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S&I Framework
Transition of Care (ToC) Initiative
Use Cases:
Closed Loop Referral
Origin PCP’s Office
Setting: PCP’s office
Activity: PCP Physician is in the middle of an encounter (office visit) with a patient and determines that
the patient needs to be referred to a specialist. The PCP has documented the encounter in the EHR and
within the EHR prepares the consultation request message to the specialist (alternatively, within the
EHR, assigns this task to support staff, who complete the task). Depending on the EHR system
functionality some of the process may be semi-automated (addition of standard data set from EHR and
potentially the variable data set). Once the message is prepared it can be reviewed in human readable
format, the message is addressed to the appropriate specialist (or specialty practice) and is sent to the
specialist’s EHR via Direct Messaging. The message arrives in the specialist’s EHR (or Direct Messaging
account) before the patient has left the PCP’s office. A copy of the message is retained in the PCP’s EHR.
The prepared consultation request message can also be addressed and sent to the patient’s PHR via
Direct Messaging.* (Please see description for this activity at the end of the document).
Direct HISP retains message transfer log per their Service Level Agreement.
Additional referral activities may occur depending on the practice. E.g. checking patient’s insurance
relative to proposed specialist, scheduling the appointment for the patient with the specialist.
Message Contents: Both minimal standard data set and referral context relevant data set
Message always includes standard minimal data set:
 Demographic information, active medication list (with doses and sig), allergy list, problem list,
reason for referral, etc.
Message contains variable data set relevant to the context of the request:
 Examples:
o Cover note describing the clinical impetus for the referral
o For a cardiologist consultation request: cardiology relevant tests and results such as
Cardiac Echo results, Holter Monitor results, etc.; cardiology pertinent family, social
histories, procedures, PE findings, etc..
o For a dermatologist consultation request: dermatology relevant tests and results such as
skin biopsy path report, image of lesion, dermatology pertinent family, social histories,
procedures, PE findings, etc..
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Specific example:
 PCP has worked up a patient who has a working diagnosis of Thyroid Cancer and
is referring the patient to an Endocrine Surgeon.
 Message includes standard minimal data set as above as well as the PCP
selected referral specific variable data set. E.g.:
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Pertinent PE finding and history of present illness: 3 month history of a 2 cm R
sided, hard thyroid nodule
Pertinent results and diagnosis: FNA done 2/28/11 significant for medullary
carcinoma, Calcitonin 2700, CEA 7, TSH, T3 Free T4 all normal
Pertinent Additional Diagnoses Medical /Surgical Hx: significant only for 3 year
history of mild obesity, current BMI 30
Pertinent Family History: significant for Thyroid cancer mother (unknown type).
No history of MEN Syndromes. No History of radiation exposure.
PCP referral request and determination of responsibility: Please evaluate for
possible MEN II syndrome, surgery, post operative care, and any special
recommendations. I will assume full care status post the procedure.
Reference to shared information with Patient: I have reviewed all of the above
information with the patient and his wife.
Patient did/did not understand what was communicated
Message Transfer: From PCP to Specialist via Direct Messaging
Receipt in Specialty Office
Setting: Specialist’s office
Activity: Message received into Specialty practices’ EHR. If patient is known to the system an
automated match may occur. New patients can be directed to a front desk staff EHR Work Queue for
pre-registration (depending on the practices’ workflow). Additional practice variable activities may
occur such as verifying that the patient has an appointment and, if not, checking patient’s insurance and
contacting the patient to schedule the appointment with the specialist.
Front desk staff can then promote the message to the specialists EHR document review task list.
Depending on practice workflow, and EHR system functionality, specialist may review the document and
order additional tests to be performed for the patient prior to the office visit, enhancing the efficiency of
care. Discrete data elements from within the message can be promoted to the specialist’s EHR system
date, time and source stamped; eliminating the need for redundant testing, and data transcription with
its inherent error risk. The information in the message may allow the clinician to appropriately assure
that the correct amount of time is blocked for the patient visit.
The patient comes for the encounter and the specialist documents the encounter in the EHR and
prepares the consult message to the PCP. Depending on the EHR system functionality some of the
process may be semi-automated (addition of standard data set from EHR). Once the message is
prepared it can be reviewed in human readable format, the message is addressed to the appropriate
PCP (this may be automated in some EHR systems based on the data element PCP of record) and is sent
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to the PCP’s EHR via Direct Messaging. The message arrives in the PCP’s EHR before the patient has left
the specialist’s office. A copy of the message is retained in the specialist’s EHR.
The prepared consultation message can also be addressed and sent to the patient’s PHR via Direct
Messaging. ** (Please see description of this activity at the end of the document).
Direct HISP retains record of message transfer and delivery success/failure to recipient(s) per their
Service Level Agreement.
Message Contents: Both minimal standard data set and referral context relevant data set
Message always includes standard minimal data set:
 Demographic information, specialist reconciled active medication list (with doses and sig),
allergy list, specialist reconciled problem list, specialist recommendations, etc.
Message contains variable data set relevant to the context of the referral:
 specialist recommendations, pertinent findings, test or study results, procedures or operations
and reports, indication of any specialty ongoing follow up responsibilities, what has been
communicated to the patient, patients level of understanding of what was communicated,
Message Transfer: From Specialist to PCP via Direct Messaging
Receipt in PCP’s Office
Setting: PCP’s office
Activity: Message received into PCP practices’ EHR (or Direct Messaging account). Patient generally will
be known in the EHR system in which case an automated EHR match will occur, patient without an
automated match can be reconciled, new patients can be registered in the EHR. If the message is
received into the EHR, additional practice variable activities may occur: patient’s message can be
directed to a front desk staff EHR Work Queue for appropriate distribution to additional staff EHR work
queues as appropriate to the practice workflows. For example, the front desk staff may schedule a
follow-up visit with the patient and add the patient’s consultation message to the PCP’s document task
list. If the patient has an assigned Care Manager that follows the patient at an advanced practice care
facility (such as a Patient-Centered Medical Home), the consultation message may be directed to both
the PCP and the Care Manager. The care Manager may be aware that the patient becomes confused
when medications are altered and call the patient to ensure the patient is taking the correct
medications.
Discrete data elements from within the message can be promoted to the PCP’s EHR system date, time
and source stamped; eliminating the need for data transcription with its’ inherent error risk. The PCP
can review and promote to the EHR the new reconciled active medication and problem lists, any new
procedures can be accepted into the EHR, and any other new discrete data elements. The consultation
message can be retained in its entirety as a permanent part of the patient’s EHR record.
The patient comes for the encounter with the PCP and the PCP documents the encounter in the EHR.
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* Message Transfer: From PCP to Patient’s PHR via Direct Messaging
Receipt in Patient’s PHR
Setting: Patient’s Home
Activity: Message received into Patient’s PHR via Messaging. Depending on the specific PHR, patient
may receive a notification to access their PHR as there is new information available. Patient (or patient’s
authorized proxy) can access the PHR and review the consultation request message. Patient (or their
proxy) may respond with confirmation or questions. Again, depending on the PHR’s functionality the
patient may be able to select sections with of the consultation request message (that are discrete data
elements) to automatically populate the appropriate fields in the PHR. For example, the patient can
upload any new problems to the problem list. Other PHR’s may have “all or none” functionality allowing
the patient to simply determine if they would like to retain to the PHR or delete from the PHR the
consultation request message.
** Message Transfer: From Specialist to Patient’s PHR via Direct Messaging
Receipt in Patient’s PHR
Setting: Patient’s Home
Activity: Message received into Patient’s PHR via Direct Messaging. Depending on the specific PHR,
patient may receive a notification to access their PHR as there is new information available. Patient (or
patient’s authorized proxy) can log on to the PHR and review the specialist’s consultation message.
Patient (or their proxy) may respond with confirmation or questions. Again, depending on the PHR’s
functionality the patient may be able to select sections with of the consultation request message (that
are discrete data elements) to automatically populate the appropriate fields in the PHR. For example,
the patient can upload any new problems to the problem list. Other PHR’s may have “all or none”
functionality allowing the patient to simply determine if they would like to retain to the PHR or delete
from the PHR the specialist’s consultation message.