Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Transition of Care Initiative
Elements in Transition of Care Use Case
8/1/2011
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Version Control
Date
04/08/11
Version
Owner
v1.0
UCR Support Team
05/24/11
v1.1
UCR Support Team
Source
ToC Workgroup
Consensus
Dr. Thomas Caruso,
Dr. Holly Miller
Description of Changes
Dr. Caruso: Addressed and resoluted
all comments brought forth by ToC
Harmonization Workgroup Members
Dr. Miller: Update to scope to
include “Other Providers”.
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Table of Contents
List of Figures ................................................................................................................................................ 4
List of Tables ................................................................................................................................................. 4
1.0 Preface and Introduction ........................................................................................................................ 6
2.0 Overview and Scope................................................................................................................................ 6
2.1 In Scope ............................................................................................................................................... 7
2.2 Out of Scope........................................................................................................................................ 7
2.3 Background ......................................................................................................................................... 7
2.4 Policy Issues ........................................................................................................................................ 8
2.5 Regulatory Issues ................................................................................................................................ 8
2.6 Communities of Interest ................................................................................................................... 10
3.0 Challenge Statement ............................................................................................................................. 11
4.0 Value Statement ................................................................................................................................... 14
5.0 Use Case Assumptions .......................................................................................................................... 14
6.0 Pre-Conditions....................................................................................................................................... 15
7.0 Post Conditions ..................................................................................................................................... 16
8.0 Actors and Roles ................................................................................................................................... 16
9.0 Use Case Diagram ................................................................................................................................. 17
10.0 Scenario 1: The Exchange of Clinical Summaries from Provider to Provider...................................... 19
10.1 User Stories of Scenario 1 ............................................................................................................... 19
10.1.1 Base Flow of Scenario 1 ........................................................................................................... 28
10.1.2 Activity Diagrams for Scenario 1 .............................................................................................. 30
10.2 Functional Requirements of Scenario 1 .......................................................................................... 32
10.2.1 Information Exchange Requirements of Scenario 1 ................................................................ 32
10.2.2 System Requirements of Scenario 1 ........................................................................................ 32
10.3 Sequence Diagrams of Scenario 1 ................................................................................................... 33
11.0 Scenario 2: The Exchange of Clinical Summaries between Provider to Patient in Support of
Transitions of Care ...................................................................................................................................... 35
11.1 User Stories of Scenario 2 ............................................................................................................... 35
11.1.1 Base Flow of Scenario 2 ........................................................................................................... 37
11.1.2 Activity Diagrams of Scenario 2 ............................................................................................... 39
11.2 Functional Requirements of Scenario 2 .......................................................................................... 41
11.2.1 Informational Interchange Requirements of Scenario 2 ......................................................... 41
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
11.2.2 System Requirements of Scenario 2 ........................................................................................ 41
11.3 Sequence Diagrams of Scenario 2 ................................................................................................... 42
12.0 Issues and Obstacles ........................................................................................................................... 44
13.0 Dataset Considerations ....................................................................................................................... 44
APPENDICES .............................................................................................................................................. 61
Appendix A: Related Use Cases............................................................................................................... 61
Appendix B: Previous Work Efforts Related to Clinical Information Exchange ..................................... 61
Appendix C: Privacy and Security Assumptions ...................................................................................... 62
Appendix D: Glossary .............................................................................................................................. 63
Appendix E. References .......................................................................................................................... 65
List of Figures
Figure 1: Use Case Diagram ........................................................................................................................ 17
Figure 2: Context Diagram .......................................................................................................................... 18
Figure 3: Activity Diagram of Scenario 1 User Story 1 ................................................................................ 30
Figure 4: Activity Diagram of Scenario 1 User Story 2 ................................................................................ 31
Figure 5: Sequence Diagram of Scenario 1 User Story 1............................................................................. 33
Figure 6: Sequence Diagram of Scenario 1 User Story 1............................................................................. 34
Figure 7: Activity Diagram of Scenario 2 User Story 1 ................................................................................ 39
Figure 8: Activity Diagram for Scenario 2 User Story 2 ............................................................................... 40
Figure 9: Sequence Diagram for Scenario 2 User Story 1 ........................................................................... 42
Figure 10: Sequence Diagram of Scenario 2 User Story 2........................................................................... 43
List of Tables
Table 1: Communities of Interest ............................................................................................................... 11
Table 2: Actors and Roles of Use Case ........................................................................................................ 16
Table 3: Actors and Roles for Scenario 1 User Story 1 ................................................................................ 25
Table 4: Actors and Roles for Scenario 1 User Story 2 ................................................................................ 26
Table 5: Base Flow of Scenario 1 User Story 1 ............................................................................................ 29
Table 6: Base flow of Scenario 1 User Story 2 ............................................................................................ 29
Table 7: Information Exchange Requirements of Scenario 1 ..................................................................... 32
Table 8: System Requirements of Scenario 1 ............................................................................................. 32
Table 9: Actors and Roles of Scenario 2 User Story 1 ................................................................................. 35
Table 10: Actors and Roles of Scenario 2 User Story 2 ............................................................................... 36
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Table 11: Base Flow of Scenario 2 User Story 1 .......................................................................................... 37
Table 12: Base Flow of Scenario 2 User Story 2 .......................................................................................... 38
Table 13: Informational Exchange Requirements of Scenario 2 User Story 1 ............................................ 41
Table 14: System Requirements of Scenario 2 ........................................................................................... 41
Table 15: Dataset for Discharge Instructions .............................................................................................. 47
Table 16: Dataset for Discharge Summary.................................................................................................. 51
Table 17: Dataset for Clinical Summary ...................................................................................................... 56
Table 18: Dataset for Clinical Summary for Specialist Notes ...................................................................... 61
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
1.0 Preface and Introduction
To fully realize the benefits of health IT, the Office of the National Coordinator for Health Information
Technology (ONC), as part of the Standards and Interoperability (S&I) Framework is developing Use
Cases that define the interoperability requirements for high priority health care data exchange;
maximize efficiency, encourage rapid learning, and protect patients’ privacy in an interoperable
environment. These Use Cases address the requirements of a broad range of Communities of Interests
including; patients, their significant others and family members, providers, vendors, standards
organizations, public health organizations, and Federal agencies.
These Use Cases describe:




The operational context for the data exchange
The stakeholders with an interest in the Use Case
The information flows that must be supported by the data exchange
The types of data required in the data exchange
The Use Case is the foundation for identifying and specifying the standards required to support the data
exchange and developing reference implementations and tools to ensure consistent and reliable
adoption of the data exchange standards.
2.0 Overview and Scope
The Initiative, Elements in Transition of Care, defines the electronic communication and data elements
necessary for clinical information exchange to support transfers of care between providers and to
inform patients.
This Use Case addresses multiple scenarios. The first scenario focuses on the exchange of patient
information between providers to accomplish a successful transition in care from one care environment
to another. This includes transitions between acute, long-term care, nursing facility, rehabilitation, home
healthcare, as well as discharges to home with follow up by primary care or specialty care provider(s).
Transitions within the same care setting are not included in the scope of this Initiative. The Use Case
includes referrals for the purpose of consultations.
The second scenario focuses on the sharing of electronic clinical information from providers to their
patients, including the data interchange required to support the needs of a patient -during these
transitions of care. In this scenario, the patient has the ability to access and incorporate their available
clinical information into their PHR.
For both scenarios, it is important to have common transport standards for the secure and interoperable
exchange of electronic health information in the context of Elements in Transition of Care.
Successful outcomes and metrics of this Use Case include: [This needs to be updated, once the Success
Metrics Committee has completed their work – HM]
1. The number of providers sharing Transitions of Care summaries
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
2. The number of organizations who have been certified to produce valid specifications (Software
development/Tools organizations)
3. The time reduction for creation of new minimal unstructured summaries and structured
summaries
4. Cost reduction for creation of core elements within Transitions of Care
5. Improvement in ability to achieve MU criteria
6. Process improvement efforts related to transfer patterns in a health information technology
environment
7. Enhanced patient clinical outcomes secondary to self-awareness and involvement in their care
8. Identifying best practice IT standards to promote the interoperability of systems to successfully
exchange clinical information safely and securely and to enable the recipient to view the clinical
information in a human readable format.
2.1 In Scope



Clinical Summary information and its basic dataset(s) for the Transition of Care to include the
transfer of care and the exchange of clinical information between providers and between
providers and patients
All transitions between different care settings as discussed in the overview are to be supported
within the scope of this initiative The requirements resulting from the initial ToC datasets
provides the base for these additional care transitions.
Transitions between different role groups within different sites of care.
2.2 Out of Scope






The comprehensive EHR
Financial Information, except for basic insurance information, will not be sent
While Query Transactions are out of scope, consideration of metadata necessary to tag clinical
summaries to support queries is within scope.
Sharing of clinical summaries for other purposes; e.g., claims submission
Transmission protocols are out of scope since the providers would not need to address the
transport, though the system itself (outside the scope of a use case) would have to address the
most efficient means of transport from sender to receiver.
Defining or modifying existing clinical medicine practices
2.3 Background
The Transition of Care Initiative is key to healthcare reform because its implementation will contribute
to the overall cost savings within the US health system through enhanced care coordination, improved
clinical outcomes and care efficiency, and decreased adverse events. Therefore this Transition of Care
Initiative is aligned closely with the goals of Meaningful Use Stage 1 and anticipated Stage 2 as well as
addressing various Prioritization Criteria as described next. Furthermore, the Transition of Care
Initiative supports various evidenced based medicine and research initiatives including Comparative
Effectiveness Research and other high priority research initiatives that align with the Nation’s agenda to
improve the quality of care while reducing its costs.1
1
Comparative Effectiveness Research (CER) evaluates existing health care interventions to determine which work
best for a particular patient as well as which treatments might have a deleterious effect and under what
circumstances they are most likely to cause the greatest harm. According to the Institute of Medicine: “CER assists
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
The Transition of Care Initiative addresses improvements in care coordination and patient engagement
in their own healthcare, in order that the strong foundation of Meaningful Use Stages 1and 2 can be
further strengthened with requirements for Meaningful Use Stage 3 that drive these improvements in
care coordination and patient engagement. Improving the exchange of relevant clinical information
through the specification of multi-role, multi-site datasets lays the foundation for supporting the
longitudinal care plan which will cross multiple sites of care, unvolving multiple disciplines and require
iterative exhanges among participants including the patient.
The technical feasibility of this Initiative requires and supports information exchange. The Initiative
specifically leverages existing interoperability standards; thus, many of the Healthcare Information
Technology Standards Panel (HITSP) specifications (Appendix B) apply, as well as utilizing standards such
as Health Level Seven (HL7) Continuity of Care Document (CCD and ASTM Continuity of Care Record
(CCR)) developed by existing standard development organizations. This work assumes the use of the
CCD for transitions of care. The Initiative supports data flow which can be tested as exhibited by the fact
that NIST has current test scripts available. The Transition of Care Initiative is accountable by aligning
Stakeholders’ readiness level of use as well as attempting to improve general Health IT usability.
These Prioritization criteria coupled with existing relevant Use Cases (Appendix A) have rendered the
basis for selection of the Transition of Care Initiative; thus, leveraging lessons learned that will be
applied to the formulation of this Use Case.
2.4 Policy Issues
The Use Case strives to address relevant and timely policy issues that will have downstream impacts on
the US healthcare reform agenda; specifically as related to healthcare information technology.
The Affordable Care Act mandates multiple pilots involving coordination of care, particularly at
transitions. The primary policy issue at hand is the intention of the HIT Standards Committee to
converge the clinical summary into a single standard. The Standards Committee has not confirmed that
the HITSP C32/CCD will be the Base Standard. The current rule allows both CCD and CCR to be adopted.
The CCR and CCD do not have sections for discharge diagnosis; this potentially could be included in a
transition of care [summary].
The User Story and Activity Diagrams represent a generalized flow of information exchange, but do not
represent infrastructure, architecture, or workflow requirements. They show what information needs to
go from place A to place B to achieve a clinically sound transfer of care for the patient; however, they
dictate neither the information content format, nor the specific transactions for the transfer of this
information. It is left to policy makers to determine what requirements are applied to eligible providers
for transition of care. However, the advantages of mandating a standard format for all transitions
documents are worthy of additional investigation. Standardized format not only serves as a checklist for
the sender, it makes it easier for the receiver to identify missing information.
2.5 Regulatory Issues
Implementation of the Transitions of Care Initiative supports the following regulatory requirements:
consumers, clinicians, purchasers, and policy makers in making informed decisions that will improve health care at
both the individual and population levels."
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
The Final Rule for Health Information Technology: Initial Set of Standards, Implementation
Specifications, and Certification Criteria for Electronic Health Record Technology for Meaningful Use
Stage 1 state the following:
A. Initial Set of Standards, Implementation Specifications, and Certification for Electronic Health
Record Technology (July 2010) identified the following standard for Engagement of Patients and
Families in their Healthcare:
(1) Electronic Copy of Health Information: Electronic copy of health information. Enable a user to
create an electronic copy of a patient’s clinical information, including, at a minimum: diagnostic test
results, problem list, medication list, and medication allergy list in: (1) Human readable format; and
(2) On electronic media or through some other electronic means in accordance with: (i) The standard
(and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii)
For the following data elements the applicable standard must be used:
(A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard
specified in §170.207(a)(2);
(B) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and
(C) Medications. The standard specified in §170.207(d) Electronic Copy of *Discharge Instructions:
Electronic copy of discharge instructions enable a user to create an electronic copy of the discharge
instructions for a patient, in human readable format, at the time of discharge on electronic media or
through some other electronic means.
(2) *Electronic Copy of Discharge Instructions: Electronic copy of discharge instructions. Enable a
user to create an electronic copy of the discharge instructions for a patient, in human readable
format, at the time of discharge on electronic media or through some other electronic means.
(3) Clinical Summaries for each Office Visit: Clinical summaries enable a user to provide clinical
summaries to patients for each office visit that include, at a minimum: diagnostic test results,
problem list, medication list, and medication allergy list. If the clinical summary is provided
electronically it must be: (1) Provided in human readable format; and (2) Provided on electronic
media or through some other electronic means in accordance with: (i) The standard (and applicable
implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the
following data elements the applicable standard must be used:
(1) Problems. The standard specified in §170.207(a) (1) or, at a minimum, the version of the
standard specified in §170.207(a) (2);
(2) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and
(3) Medications. The standard specified in §170.207(d).
B. Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic
Health Record Technology (July, 2010) identified the following standard for Improvement in Care
Coordination:
(1) Enable a user to create an electronic copy of a patient’s clinical information, including, at a
minimum, diagnostic test results, problem list, medication list, medication allergy list, and
procedures: (I) In human readable format, and (ii) on electronic media or through some other
electronic means in accordance with: (A) The standard (and applicable implementation
specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (B) For the following data elements
the applicable standard must be used:
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
(1) Problems. The standard specified in §170.207(a) (1) or, at a minimum, the version of the
standard specified in §170.207(a) (2);
(2) Procedures. The standard specified in §170.207(b) (1) or §170.207(b) (2);
(3) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and
(4) Medications. The standard specified in §170.207(d).
(2) Enable a user to create an electronic copy of a patient’s discharge summary in human readable
format and on electronic media or through some other electronic means
2.6 Communities of Interest
Communities of Interest are public and private stakeholders that are directly involved in the business
process or are involved in the development and use of interoperable implementation guides and in their
actual implementation. Communities of Interest may directly participate in the exchange; that is, they
are business actors; or indirectly through the results of the improved business process.
The following list of Communities of Interest and their definitions are for discussion purposes for Clinical
Information Exchange.
Member of Communities of Interest
Patient
Consumers
Care Coordinators
Clinicians
Laboratories
Pharmacies
Provider
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Working Definition
Members of the public who require healthcare services
from ambulatory, emergency department, physician’s
office, and/or the public health agency/department.
Members of the public that include patients as well as
caregivers, patient advocates, surrogates, family
members, and other parties who may be acting for, or
in support of, a patient receiving or potentially
receiving healthcare services.
Individuals who support clinicians in the management
of health and disease conditions. These can include
case managers and others.
Healthcare providers with patient care responsibilities,
including physicians, advanced practice nurses,
physician assistants, nurses, psychologists, pharmacists,
and other licensed and credentialed personnel involved
in treating patients.
A laboratory (often abbreviated lab) is a setting where
specimens are sent for testing and analysis are
resulted, and then results are communicated back to
the requestor. The types of laboratories may include
clinical/medical, and environmental, and may be both
private and/or public
Entities that exist that are experts on drug therapy and
are the primary health professionals who optimize
medication use to provide patients with positive health
outcomes
An individual clinician in a care delivery setting who
requests, submits or accepts the transfer of the clinical
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Member of Communities of Interest
Working Definition
summary for the purposes of delivering care
Provider Organizations
Organizations that are engaged in or support the
delivery of healthcare to include Hospitals, Ambulatory
Centers and Provider Practices. IDNs, ACOs
Standards Organizations
Organizations whose purpose is to define, harmonize
and integrate standards that will meet clinical, and
business needs for sharing information among
organizations and systems
Federal Agencies
Organizations within the federal government that
deliver, regulate or provide funding for health and
health care
Electronic Health Record/Personal Health
Record and HISP Vendors
Vendors which provide clinicians and consumers
specific EHR/PHR solutions such as software
applications and software services.
HISP organizations provide the technical capability to
transmit the ToC messages across diverse EHR/PHR
systems. These suppliers may include developers,
providers, resellers, operators, and others who may
provide these or similar capabilities.
Table 1: Communities of Interest
3.0 Challenge Statement
Meaningful Use Stage 1 and anticipated Stage 2 criteria require information to be exchanged in
transitions of care. Implementers are often confused about how to adopt the specifications for
exchange of the required data. The content of any exchange is only as good as its fidelity to source,
assured identity, provenance, completeness, audit/traceability, full context, along with permissions and
qualifications. Without ensuring these characteristics across information exchanges such that all are
fully evident to the receiver (and ultimate user), no exchange is valid. Furthermore, this exchange is
dependent on a secure, interoperable environment.
Different transition scenarios may require different types of artifacts (e.g. a transition from inpatient to
ambulatory may require a discharge summary; a transition from primary care provider to specialist may
require a referral summary, etc). All of these artifacts should draw from a common framework. As part
of that framework, we should allow for different data elements to be communicated as needed. In all
cases, the ToC transaction should support existing clinical workflows, and data overloading the recipient
clinician must be avoided. Ultimately, the data needs of the patient and caregivers should be
considered because it is the providers, patient (and/or their legal representative) that are the recipient
end users of the data.
The challenge of data overload cuts both ways. It is inefficient for “senders” to collect information that
provides no clinical benefit to the patient or guidance to the receiving clinician. It is also ineffient for
“receivers” to wade through extraneous information to find the relevant data elements. This challenge
can be met with two “filtering” processes, one for the sender and one for the receiver.
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Among the deliverables of this initiative are datasets specific to sending and receiving sites that are
purpose and patient specific and which contain only those data elements required by one of the
receiving clinicians. No data elements other than these will be required in the CCD+. In this way,
“senders” are protected from gathering and sending more information than is needed.
The process by which the CCD is received requires a filtering capability. This specification of this
capability is beyond the scope of this initiative but will be specified as a requirement for later
development. Receivers will be able to “filter” the CCD+ to see only those elements that they want,
even if more elements are included in the CCD+.
As noted by the ToC WG, the exchange of clinical summaries is challenged by the selection of a single
format for all transfers of care that does not support the various requirements for the data elements of
different stakeholders, and diverse ToC circumstances. The current requirements that these all be
communicated in either the CCD or CCR format may exclude data not supported by those standards. On
the other hand, the use of a variety of formats for each different type of transfer of care would make it
extremely difficult for systems to exchange and communicate the necessary data, and significantly delay
this capability.
We have chosen the CCD as the model for information exchange. The ToC WG identified a potential
solution to the dilemma of restricted format needed to assure consistency and interoperability, and the
variability of data elements required across such a diverse group of senders and receivers. They framed
a potential response to this challenge and proposed to:




Identify a “Core” data set that would be required in all ToC circumstances.
Identify the kinds of data beyond this “Core” data set needed for various transfers of care
circumstances by all the stakeholders.
To define a uniform way of how to structure commonly used information.
To provide a robust tool-set to aid in the development and validation of conforming
implementations to support widespread adoption.
The LCC SWG proposes to answer this challenge by creating a “Set of datasets” specifying the essential
clinical content based on properties of the sending and receiveing sites, the purpose and characteristics
of the transition and patient-specific charateristics. The “Set of datasets” is large but finite and able to
be reconfigured as the requirements of clinical practice change and elements added or removed. The
process by which this evolution is achieved is beyond the scope of this initiative but will need to be
robust, broadly inclusive and responsive to changing clinical needs. Furthermore, each of these site and
transition specific datasets can be futher customized with disease, medication and patient specific
datasets. In this model, the CCD+ will have the following components
1. Core data elements common to all transitions of care
2. Site-specific data elements
3. Role-specific data elements required by designated receivers (MD, RN, Therapist, etc)
4. Transition specific elements based on the characteristics of the transition
5. Patient specific data elements.
It is possible to build a “unique” CCD out of standardized components. The standardized components
include:
1. core elements: present in all transitions documents
i. ID
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
ii. Demographics
iii. Allergies
iv. Active medications
v. Contact information of the “sender”
2. Site-specific data elements
i. Senders: identify critical elements that always apply when patients leave their
site, as examples
1. ED: recent tests, tests pending, treatment, resonse, followup plan
2. Out patient testing: results of test/procedure, complications
i.
Receivers: elements they always need from this site of care
1. Details of follow-up plan
2. Name and contact information of the clinician responsible for managing
each active problem addressed during the stay
3.
Role-specific data elements
ii.
Physician
1. ED physician
2. PCP
3. Specialist
4. Rehab
5. Others
iii.
RN
1. ED
2. In patient
3. Wound care
4. Telemonitoring
5. Others
iv.
Case Manager
v.
Therapist
1. OT
2. PT
3. Speech
vi.
Administrative personnel
vii.
Technicians
viii.
Other
5. Transition-specific elements
i.
There are four broad types of transitions: 2x2 grid made up of the
combinations of Elective/Urgent and Permanent/Temporary
1. Elective/Permanent: example-discharge summary from any site
2. Elective/Temporary: example-LTPAC to Out patient for testing,
evaluation or procedure
3. Urgent/Temporary: example- LTPAC to ED for evaluation
4. Urgent/Permanent: example-admission to ACH in-patient unit after ED
evaluation
6. Patient specific data elements
i.
Conditions:
1. CHF
a. Target wgt
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
b. Labs
c. EF
d. If EF< 40 if no betablocker, ACE-i/ARB, anticoag why not
2. Others
3. Medications
a. Anticoagulation
i. Agent
ii. Duration
iii. Route
iv. Target
v. Monitoring
vi. Who manages
vii. Data needed to safely prescribe next dose
viii. Who to call with issues
b. Others
Standardized data sets currently exist or can be added using currently accepted vocabulary and
definitions for any required data element. These component parts can be assembled to create a
“unique” CCD for each patient, site and type of transfer.
4.0 Value Statement
The standardized patient clinical summary will provide timely, accurate, and structured information at
the point of care to the receiving provider as well as offering enhanced clinical information to the
patient. The accuracy and appropriate amount (the data required for the care of the patient without
data overload) of clinical information will ensure that clinicians provide high quality care and patients
will now become more involved and be informed of their care overall leading to a patient centric
approach and patient empowerment. Enhancing a patient’s ability to make well informed decisions
about their healthcare can be supported by the patient having access to their health information.
Defining the minimum data elements to be exchanged and mapping them to MU specified formats will
facilitate this functionality becoming rapidly incorporated into certified EHR vendor offerings and better
enable providers to use the specifications in a timely manner to exchange the required clinical data
between care settings and with their patients. This initiative proposes to create these interoperable
datasets to guide EHR vendors.
5.0 Use Case Assumptions
Assumptions for this Use Case are the following:


ToC to and from LTPAC are primarily “facility” to “facility” transfers, each involving the
contributions of one or more providers to complete the required dataset.. This requires another
level of organization that provides not only to capability of transferring and recei ving CCDs, but
also the capabililty to construct them from inputs from the required participants.
A provider is an individual clinician in a care delivery setting who submits or receives the
transfer of the clinical message for the purposes of delivering care. A provider organization is
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
engaged in or supports the delivery of healthcare and includes Hospitals, acute care facilities,
rehabilitation, SN facilities, and Ambulatory facilities.
 The Transferring or Referring provider or Provider Organization has an EHR system or other
software capable of producing a structured summary document using C32/CCD and/or CCR
standards and properly coded data elements; and can be exchanged with another EHR system
or PHR system.
 The EHR or PHR system is capable of ensuring that content of the Summary Record (as
exchanged) maintains its fidelity to source, as well as assured identity, provenance,
completeness, audit/traceability, full context, along with permissions and qualifications
The HISP providing the technical exchange services has established network and policy infrastructure to
enable consistent, appropriate, and accurate information exchange across clinical systems, EHRs PHRs,
data repositories (if applicable) and locator services. This includes, but is not limited to:







Methods to identify and authenticate users
Methods to identify and determine providers of care
Methods to enforce data access authorization policies
Security and privacy policies, procedures and practices are commonly implemented to support
acceptable levels of patient privacy and security; i.e. HIPAA, HITECH and EHR certification
criteria
The Patient has and uses a PHR
The transmission of data may occur via HISPs or Health Information Exchanges as data may be
transmitted to multiple EHRs, HIEs and providers
Some exchanges may require HISP to HISP connectivity
Appendix C provides more details on Privacy and Security assumptions.
6.0 Pre-Conditions
Pre-conditions are those conditions that must exist for the implementation of the ToC interoperability
Information Exchange.









To ensure the Summary Record maintains its fidelity to source, assured identity, provenance,
completeness, audit/traceability, full context, along with permissions and qualifications-both as
a pre-condition of transmittal/disclosure (source/sending EHRs/PHRs) and of receipt (receiving
EHRs/PHRs).
PHR and EHR systems are in place.
The Patient is registered in all systems.
The Provider has treated the Patient or has been requested to treat the patient by another
provider.
Relevant clinical information will be exchanged which will include at a minimum “Core”, and
may include “Variable” data.
There are methods to ensure the veracity of data.
Clinicians securely access clinical information through an EHR system.
Patients may securely access clinical information through a PHR system.
Appropriate standards protocols; patient identification methodology; consent; privacy and
security procedures; coding, vocabulary and normalization standards have been agreed to by all
relevant participants.
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
 Legal and governance issues regarding data access authorizations, data governance, and data
use are in effect.
7.0 Post Conditions
Post Conditions are those conditions that exist after the Clinical Information Exchange.



Clinical Information is successfully reported and electronically transmitted between Sending
Provider to Receiving Provider or Patient PHR and (1) is accessible by the Receiving
Provider/Patient through an EHR/PHR system and (2) is displayed in a human readable format.
Clinical Information is accessible by the Electronic Health Record application.
Clinical Information is accessible by the Personal Health Record application.
8.0 Actors and Roles
This section describes the Business Actors that are participants in the information exchange
requirements for each scenario. A Business Actor is an abstraction that is instantiated as an IT system
application that a Stakeholder uses in the exchange of data needed to complete Use Case action(s); a
Business Actor may be a Stakeholder. Furthermore, the systems perform specific roles in this Use Case
as listed below:
Actor
Provider (Person)
HISP
Patient
Provider Organization
Caregivers
System
Electronic Health Record
(EHR) System
Health Information Service
Provider
Personal Health Record
(PHR) System
Electronic Health Record
(EHR) System
Personal Health Record (PHR)
System
Role
Sender/Receiver or
Source/Destination
The “wire” across which the health
information is sent from the
sender to the receiver
Sender/Receiver or
Source/Destination
Sender/Receiver or
Source/Destination
Sender/Receiver or
Source/Destination
Table 2: Actors and Roles of Use Case
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Use Case Development and Functional Requirements for Interoperability
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9.0 Use Case Diagram
The following diagram depicts the exchange to support the Elements in Transition of Care Use Case.
1. The ability of the Electronic Health Record System to send and/or receive Clinical Information
through a HISP.
2. The ability of the Personal Health Record to send and/or receive Clinical Information through a
HISP.
Transition of Care Use Case Diagram
Figure 1: Use Case Diagram
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Transition of Care Context Diagram
Send Clinical Summary, Consultation
Request Summary Discharge Summary
and/or Discharge Instruction
st
ue
eq rge
R
n ha
c
tio
lta r Dis
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s
o
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o
C
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ry, y a
ma mar
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n
um
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cal ge S ctio
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C
I
Patient
ves Dis
cei ry,
Re ma
e)
op
Sum
f Sc
o
t
( Ou
Rs
H
rE
ide
rov
P
tes
da
Up
Transition Of Care
Provider_1
Receive Clinical Summary and
Consultation Summary
Re Rece
qu ive
est
C
Sum linic
a
or mar l Sum
Dis y D
cha isc mary
rge har , Co
Ins ge S nsu
tru um lta
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ns ry a
Sen
nd
dC
/
lini
cal
Sum
Sum mar
ma y an
dC
ry
on
su l
t
Provider_2
Figure 2: Context Diagram
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
10.0 Scenario 1: The Exchange of Clinical Summaries from Provider to
Provider
Introduction to Scenarios:
As described in the Scope section, the Use Case has two scenarios: the first focuses on the perspective
of provider to provider exchange of clinical summaries. The second focuses on the perspective of the
providers sending these clinical summaries to patients and their PHR. Both scenarios share the same
User Stories. However, the User Story in the first scenario is presented from the provider to provider
perspective and the second scenario is presented from the provider to patient perspective. Thus both
scenarios are based on the same User Stories and activities, just presented from the two perspectives.
The actual instance of any of the User Stories and activities may include both perspectives.
Assumptions:
1. The receiving facility may have provisionally accepted the patient for transfer or referral and
wants the clinical summary, but this is not necessary for the sending facility to push the ToC
information.
2. Informal negotiations between providers are out of scope and are not necessary to assure
acceptance of transfer or referral.
3. Informal agreement to receive by other provider and by patient is necessary for actual transfer
or referral of patient. Similarly informal agreement to receive the clinical information by the
other provider and by the patient is necessary for information exchange to take place, as is
traditional in current actual medical practice.
4. Scenario 1 does not describe transport or end user site activity but does include those data
elements required by transport and end users for safe and efficient transfers.
5. The information exchange can be achieved with or without intermediaries. If the information is
transferred via a HISP signed patient consent is not required. Using intermediaries such as an
HIE requires signed patient consent in most states. Same assumptions apply to Scenario 1 and 2.
6. There are several rounds of “pre-transfer” information exchange which are out of scope
including requests for bed availability, exchanges of “screening” information, final confirmation
of bed availability and transfer time.
10.1 User Stories of Scenario 1
The User Stories illustrate a combination of events in the scenario flows which are described in further
detail in the tables that follow. There are three high level user stories. These are: Acute Care Hospital
Sites to Post Acute Care Sites (ACH to LTPAC), LTPAC Sites to ACH Sites (LTPAC to ACH) and LTPAC Sites
to Other LTPAC Sites (LTPAC to LTPAC).
In these scenarios, ACH Sites include the following:
1. In patient care units (In patient)
2. Emergency Departments (ED)
3. Out patient testing, treatment and procedure areas (Out patient)
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
In these scenarios, LTPAC Sites include the following:
1. Long Term Acute Care Hospitals (LTAC)
2. In patient Rehabilitation Facilities (IRF)
3. Skilled Nursing and Extended Care Facilities (SNF/ECF)
4. Home Health Agencies (HHA)
5. Hospice Services at home or in a facility (Hospice)
6. Primary or Principal Care Physician and the Patient Centered Medical Home (PCP/PCMH)
7. Community Based Organizations providing Meals on Wheels, Respite, Homemaker services,
etc (CBO)
8. The Patient and Family at Home (Pt/Fam)
At different times, each ACH and LTPAC site can be a receiver of patients from other sites or a sender of
patients to another site. These dual roles are displayed in the following grid which lists these sites as
“senders” along the left hand column and “receivers” across the top row.
Transitions to (Receivers)
Transitions From
(Senders)
In Patient
ED
Out patient
Services
LTAC
IRF
SNF/ECF
HHA
Hospice
PCP
PCMH
CBOs
Patient/
Family
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
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Transition of Care Use Case
Of the 121 (11x11) potential transitions 48 are out of scope (in grey), 24 are low volume or low
complexity leaving 49 clinically significant ACH to LTPAC, LTPAC to ACH, LTPAC to LTPAC or LTPAC to
Patient transitions (circles).
Transitions to (Receivers)
Transitions From
(Senders)
In Patient
ED
Out patient
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
LTAC
IRF
SNF/ECF
HHA
Hospice
Services
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=L
CI = H
TV = H
V=M
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=M
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=L
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = H
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
equals
Priority
PCP
PCMH
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = M
CBOs
V=H
CI = L
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = M
TV = H
Patient/
Family
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = H
CBOs
Patient/Family
V=
Volume
CI=
Clinical
Instability
Time-Value
of information
TV=
Two
Parameters
Rated "H"
Out
of
Scope
There are other clinically significant transitions that are not included on this grid to other facility types
such as Assisted Living Facilities, Specialty Hospitals and Psychiatric Facilities. In a later phase of this
work, other senders and receivers will be added to this grid for creation of transition specific data sets.
These priority transitions are nearly divided equally among the three high level user stories: ACH to
LTPAC, LTPAC to ACH and LTPAC to LTPAC as indicated on the next figure.
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Transitions to (Receivers)
Transitions From
(Senders)
In Patient
ED
Out patient
LTAC
IRF
SNF/ECF
HHA
Hospice
Services
PCP
CBOs
PCMH
Patient/
Family
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
LTPAC
to
ACH
ACH
to
LTPAC
LTPAC
to
LTPAC
Priority
Out
of
Scope
These priority transition can be further divided in to the four basic types listed on page 13:




Elective/Permanent: example- Discharge from any site
Transfer from ED to LTPAC
Elective/Temporary: example- LTPAC to Out patient
Out patient to LTPAC
Urgent/Temporary: example- LTPAC to ED
Urgent/Permanent: example- LTPAC to In patient after ED evaluation
These, too, are distributed but not equally among the three high level user stories. The data set
associated with each of these transition is made up of a different combination of essential data
elements thereby adding yet another level of complexity.
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Use Case Development and Functional Requirements for Interoperability
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Transitions to (Receivers)
Transitions From
(Senders)
In Patient
ED
Out patient
LTAC
IRF
SNF/ECF
HHA
Hospice
Services
PCP
CBOs
PCMH
Patient/
Family
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
Elective/Permanent
Elective/Temporary
Urgent/Temporary
Urgent/Permanet
LTPAC
to
ACH
ACH
to
LTPAC
LTPAC
to
LTPAC
Priority
Out
of
Scope
The final layer of complexity arises from the participation of different role groups in both sending and
receiving sites. The specific participants also vary depending on the type of transition. The distribution
of essential “receivers” within each of these transitions is displayed in the following grid.
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Use Case Development and Functional Requirements for Interoperability
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Survey Respondants Transitions to (Receivers)
by Role Group
In Patient
ED
Out patient
Essential Receivers
Services
Admin/Scheduler
X
X
Care/Transition Manager
X
EMTs
X
X
MD/NP
X
X
X
IRF
SNF/ECF
HHA
X
X
X
X
X
X
X
X
X
X
X
X
OT
X
X
X
X
PT
X
X
X
X
X
X
X
X
X
X
X
Social Worker
X
Speech Therapy
X
Technician
Hospice
PCP
CBOs
PCMH
X
RN
X
LTAC
X
Patient/
Family
X
X
X
X
X
X
X
X
X
X
X
X
Although the matrix of sites, participants and types of transfers is very complex, fortunately data from
IMPACT supports a far simpler taxonomy based on the type of transition and the roles of the
participating receivers.
NOTE:. Transfers of patients among ACH Units (ED to In patient, ICU to Floor, etc) are out of scope for
this Use Case. However, the same data structure and principles used to identify essential clinical data
elements in ACH-LTPAC transfer scenarios apply as well to intra-hospital transfers and inter-hospital
transfers (ED to ED, In-patient to ED). The content of intra- and inter-hospital data sets can be
constructed using the same processes employed here.
User Story 1: The Exchange of Information to Support the Transfer of Patient Information from Acute
Care Hospital Site of Care to Post Acute Site of Care (ACH to LTPAC)
Actors:
Actor
Provider: Hospital In-patient, Out patient or ED
Provider: LTAC, IRF, SNF, HHA, Hospice, PCMH,
CBO *(Pt/Fam is discussed in the next section)
Providers: multidisciplinary team members as
needed to populate specific data elements
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Role
Source
Destination
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Use Case Development and Functional Requirements for Interoperability
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Actor
Role
Providers: multidisciplinary team members at
Destination
receiving sites
Table 3: Actors and Roles for Scenario 1 User Story 1
Setting 1: Hospital sites from where patient is discharged (sends discharge dataset to a PAC site of
care).
A patient is discharged from the hospital, out patient test area or ED. Discharge instructions are given to
the patient by hospital personnel at the time of discharge. The instructions may be generic, patient
specific, or disease specific depending on the facility’s practices and the patient’s needs. The patient
acknowledges that he has received the instructions from the hospital personnel (verbally, in writing, or
electronically). The acknowledgement triggers the physical discharge sequence of events and patient
transport out of the facility. Upon discharge, the discharge summary is prepared within the Hospital EHR
system. The attending physician of record (APoR) reviews the discharge summary (or instructions) and,
once she has approved it, the discharge summary is included in the discharge packet. The discharge
packet includes the discharge summary, discharge instructions and additional site, transition and
patient specific data elements). This is sent to the Post Acute Care Team This information is sent with
the patient or prior to the patient’s arrival at the PAC site to assure that the essential clinical data
required to assure a safe and efficient transition of care is available to the receiving team in a timely
manner. The summary may arrive in the PCP’s EHR system even before the patient has left the hospital.
A copy of the message may be retained in the hospital EHR per the hospital’s policies and workflow
rules.
Audit logs of the exchange are retained according to the hospitals, PCP’s, and any intermediaries’
policies, procedures, and agreements.
Setting 2: Patient's PCP or Care Team (receives discharge summary from Hospital or ED clinical
system).
Discharge summary/instructions are received into the PCP practice’s EHR system. Patient generally will
be known in the EHR system in which case an automated EHR match may occur). Discharge
summaries/instructions that are not automatically matched to a patient are reconciled manually, which
may include the process of creating a new patient record and registering the patient. Once the discharge
summary/instructions have become part of the PCP’s EHR system, additional practice variable activities
may occur: new tasks may be directed to a front desk staff EHR work queue, as well as to additional staff
EHR work queues as appropriate to the practice workflows. Follow-up/plan of care is managed
according to established PCP workflow. For example, upon receiving notification of the patient’s status,
the care manager is now aware that the patient has been discharged from the hospital. The Care
Manager may be aware that the patient becomes confused when medications are altered and calls the
patient to ensure the patient is taking the correct medications post discharge and is following the
discharge instructions.
The PCP may review and promote into the EHR the newly reconciled active medications, updated
problem lists, new procedures and other discrete data elements. The hospital (or ED) discharge
summary/instructions are retained in its entirety as a permanent part of the patient’s record.
*User Story 1 could also be applied to a specialist sending reports back to PCP for follow-up post op or
post discharge.
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
User Story 2: Closed Loop Referral
Actors
Actor
Provider; PCP's EHR System
Provider; Specialist's EHR System
Role
Referral Source
Referral Destination
Table 4: Actors and Roles for Scenario 1 User Story 2
Setting 1: PCP's office (sends consultation request clinical summary to specialist).
A PCP 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 is documenting the encounter in the EHR and within the EHR
prepares the consultation request clinical summary for the specialist. The message is addressed to the
appropriate specialist, specialty or provider organization and is sent to the specialist’s EHR system. In all
cases the message will include the “Core” data and ideally will also include selective “Pertinent” data.
Setting 2: Specialist's office (receives referral request clinical summary from PCP; send consultation
summary to PCP).
The consultation request clinical summary is processed according to the specific context of the referral.
In accordance with practice policies and workflow the specialist reviews the document and orders any
additional tests to be performed for the patient prior to the office visit. Discrete data elements from
within the summary may be promoted to the specialist’s EHR system (date time and source stamped).
When the patient arrives at the specialist’s office he is registered in accordance with practice policies
and workflow. The specialist documents the encounter in the EHR system and prepares the consultation
summary for the PCP. Once the consultation summary is prepared, it is addressed and sent to the PCP’s
EHR system. A copy of the message is retained in the specialist’s EHR system
*User Story 2 could also be applied to a specialist sending reports back to PCP for follow-up post op or
post discharge.
Return to Setting 1: PCP’s office
The consultation summary is received into the PCP practices’ EHR system. Once the consultation
summary is received into the EHR system, additional practice variable activities may occur: tasks can be
directed to a front desk staff EHR system work queue for appropriate distribution to additional staff’s
EHR system work queues, as appropriate to the practice workflows. For example, the front desk staff
may schedule a follow-up visit with the patient and alert the PCP of the availability of the consultation
summary. If the patient has an assigned Care Manager who follows the patient at an advanced practice
care facility (such as a Patient-Centered Medical Home), review alerts may be sent to both the PCP and
the Care Manager for appropriate compliance planning. Discrete data elements from within the
consultation summary may be promoted to the PCP’s EHR system. In accordance with practice policies
and EHR functionality, the PCP may review and promote to the EHR the specialist-reconciled active
medication and problem lists, any new procedures may be accepted into the EHR, and any other new
discrete data elements may become part the of the patient’s EHR 9all date/time/source stamped). The
consultation summary may be retained in its entirety as a permanent part of the patient’s EHR record.
User Story 3: Complex Series of Care Transactions
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Setting: Emergency Department
Activity: A patient is transported to the ED from home in a semi-comatose condition. Their significant
other has printed data from the patient’s PHR and has given that to the EMS to give to the ED doctor.
The patient is admitted to the ED. The ED EHR system receives the patient summary from the patient’s
PCP’s EHR system. The ED physician determines that the patient needs to be admitted to the hospital.
The patient is admitted to the hospital’s critical care unit. As the ED and the Hospital share the same
EHR system the data, once entered into the system, is available to all appropriate end users caring for
the patient.
Summary Contents: Both basic standard dataset and patient summary message context relevant
dataset-----APPLIES TO ALL Transitions of Care (Basic data set and pertinent data set to not data
overload the recipient clinicians).
Message should always include Core basic dataset:

Demographic information, active medication list (with doses and sig), allergy list, problem list,
etc.
Summary contains variable dataset relevant to the context:

Examples: Recent results, vitals, etc.
Setting: Hospital
Activity: A patient is cared for in a critical care unit. All treating clinicians have access to the information
in the Hospital EHR system. The patient’s significant other, who is the patient’s Durable Power of
Attorney for Healthcare (DPOA-HC), is staying with the patient in the hospital. The patient’s DPOA-HC
requests that copies of changes to patient’s orders be sent directly from the hospital EHR to the
patient’s PHR so that he/she can monitor the patient’s care. After several days in the intensive care unit
it is determined that the patient would benefit from intensive rehabilitation that is not available at the
hospital. The attending physician arranges a discharge from the hospital and transfer for the patient to a
Rehabilitation Facility. In accordance with the hospital’s policies and workflow a discharge summary &
instructions are prepared by the hospital EHR. The discharge summary and instructions, including
recommendations for continuation of open orders, are sent to the Rehab facility EHR. The hospital EHR
sends patient’s PCP’s EHR a copy of discharge summary/instructions.
Upon discharge from hospital, the patient is transferred to a rehabilitation facility. The TOC discharge
information is transferred via a HISP to the recipient facility prior to the patient leaving the hospital.
Summary Contents: Both basic standard dataset and Discharge context relevant dataset
Summary should always include Core basic dataset:

Demographic information, active reconciled medication list (with doses and sig), allergy list,
problem list, reason for admission, follow up/discharge instructions etc.
Summary contains variable dataset relevant to the hospitalization (selected by the clinician who
prepared the discharge message):

Examples:
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
o Procedures during hospitalization
o Relevant results, reports
o Wound care (if applicable)
o Speech, Occupational & Physical Therapy orders and Activities of Daily Living (ADL)
evaluations
o Etc.
Setting: Rehabilitation Facility
Activity: The hospital discharge summary/instructions are received in the Rehab facility's EHR system.
When the patient arrives she is admitted and the EHR is updated. The EHR system provides the patient
information for review by the hospital personnel that will be caring for the patient. Once reviewed and
approved by the clinicians in accordance with the facility’s policies, protocols and workflows, the
information is available to all of the rehab staff that will be caring for the patient. The patient’s PHR
receives copies of rehab case review notes and ADL evaluations so that the DPOA-HC can actively
monitor the patient’s progress and assist in planning patient’s discharge destination post-rehab.
Upon completion of the rehabilitation, the patient is discharged to home/PCP. At this point in time the
patient’s PCP receives a discharge summary ToC document at the time the patient is being discharged
from this facility prior to the patient physically being out the door. – see User Story 1.
Summary Contents: Both basic standard dataset and Discharge context relevant dataset
Summary should always include Core basic dataset:

Demographic information, active reconciled medication list (with doses and sig), allergy list,
problem list, reason for admission,
The Summary contains variable dataset relevant to the rehab care plan.

Examples might include:
o Therapy orders
o ADL scores
10.1.1 Base Flow of Scenario 1
User Story 1: The Exchange of Discharge Summary to Support the Transfer of Patient Information from
One Provider to another Provider.
Step #
1
Actor
Provider
2
Hospital EHR System
3
PCP EHR System or
other Provider EHR
System
Provider
4
8/1/2011
Event/Description
Trigger Generation of
Discharge Summary for
Patient A
Send Discharge summary to
PCP's EHR System or other
Provider EHR System
Receive Discharge Summary
Inputs
START
Outputs
Discharge
Instructions
Discharge
Instructions
Discharge
Instructions
Discharge
Instructions
Discharge
Instructions
Trigger Generation
of Discharge Summary for
Discharge
Summary
Discharge
Summary
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Step # Actor
Event/Description
Inputs
Outputs
Patient A
(includes Discharge
Instructions)
5
Hospital EHR System
Send Discharge summary to
Discharge
Discharge
PCP's EHR System or other
Summary
Summary
Provider /Organization
6
PCP EHR System or
Receive Discharge Summary
Discharge
Discharge
other Provider EHR
Summary
Summary
System
7
Provider
View Discharge
Discharge
END
Summary/Instructions
Summary
Table 5: Base Flow of Scenario 1 User Story 1
User Story 2: The Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient
from One Provider to Another
Step #
1
Actor
Provider
Event/Description
Trigger Generation of
Consultation Request Clinical
Summary for Patient A
Inputs
START
2
PCP EHR System
3
Specialist EHR System
4
Provider
5
Provider
Consultation
Request Clinical
Summary
Consultation
Request Clinical
Summary
Consultation
Request Clinical
Summary
START
6
Specialist EHR System
7
PCP EHR System
8
Provider
Send Consultation Request
Clinical Summary to
specialist's EHR System
Receive Consultation
Request Clinical Summary
from PCP's EHR System
View Consultation Request
Clinical Summary in
specialist's EHR System
Trigger Generation of
Consultation Summary for
patient A
Send Consultation Summary
to PCP's EHR System
Receive Consultation
Summary from specialist's
EHR System
View Consultation Summary
in PCP's EHR System
Consultation
Summary
Consultation
Summary
Consultation
Summary
Outputs
Generated
Consultation
Request Clinical
Summary
Consultation
Request Clinical
Summary
Consultation
Request Clinical
Summary
END
Generated
Consultation
Summary
Consultation
Summary
Consultation
Summary
END
Table 6: Base flow of Scenario 1 User Story 2
User Story 3: Complex Series of Care Transitions (Note: Events of this User Story are reflected in the
Simple ToC User Story)
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
10.1.2 Activity Diagrams for Scenario 1
The following are the Activity Diagrams to support the events in section 10.1.1.
User Story 1: The Exchange of Information to Support the Transfer of Patient Information from a One
Provider to Another.
Figure 3: Activity Diagram of Scenario 1 User Story 1
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
User Story 2: The Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient
from a One Provider to Another.
Figure 4: Activity Diagram of Scenario 1 User Story 2
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
10.2 Functional Requirements of Scenario 1
10.2.1 Information Exchange Requirements of Scenario 1
Initiating System
Information
Interchange
Requirement Content
Hospital/ED EHR
Send
Discharge Summary
Receives
System
(A.XFER.1)2
(A.XFER.2)
PCP EHR System
Send
Consultation Request
Receives
(A.XFER.1)
Clinical Summary
(A.XFER.2)
Specialist EHR
Send
Consultation
Receives
System
(A.XFER.1)
Summary
(A.XFER.2)
And or
Procedure/operative
note
Receiving/Responding
System
PCP EHR System
Specialist EHR System
PCP EHR System
Table 7: Information Exchange Requirements of Scenario 1
10.2.2 System Requirements of Scenario 1
System Requirement Name
Display Discharge Summary
Display Consultation Request Clinical Summary
Display Consultation Summary
System
PCP EHR System
Specialist EHR System
PCP EHR System
Table 8: System Requirements of Scenario 1
2
This identifier comes from the ONC SI-UC-Simplification spreadsheet (see References)
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
10.3 Sequence Diagrams of Scenario 1
The following sequence diagrams describe the messages and order of messages.
User Story 1: The Exchange of Information to Support the Transfer of Patient Information from a One
Provider to Another.
Figure 5: Sequence Diagram of Scenario 1 User Story 1
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
User Story 2: The Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient
from a One Provider to Another.
Figure 6: Sequence Diagram of Scenario 1 User Story 2
*********PLEASE NOTE: The downloading of Patient Information to the PHR is included in Scenario 2:
Exchange of Clinical Summaries between Provider to Patient. ***********
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
11.0 Scenario 2: The Exchange of Clinical Summaries between Provider
to Patient in Support of Transitions of Care
11.1 User Stories of Scenario 2
The visuals below depict a combination of all events described in the scenario flows which are
described in further detail in the tables that follow.
(Refer to sections highlighted in red and italicized, which are the focus of this scenario)
Assumption: Scenario 2 does not describe transport or end user site activity.
User Story 1: The Exchange of Discharge Instructions and Discharge Summary between a Provider and
Patient to Support the Transfer of a Patient from One Care Setting to Another.
Actors
Actor
Provider: Any Provider EHR System
Patient: The Patient's PHR System or Patient
Portal
Role
Source
Destination
Table 9: Actors and Roles of Scenario 2 User Story 1
Setting 1: Hospital or ED from where patient is discharged (sends discharge instructions to patient).
A patient is discharged from the hospital or ED. Discharge instructions are given to the patient by his
hospital personnel at the time of discharge. The instructions may be generic, patient specific, or disease
specific depending on the facility’s practices and the patient’s needs. The patient acknowledges that he
has received the instructions from the hospital personnel (verbally, in writing, and/or electronically). The
acknowledgement triggers the physical discharge sequence of events and patient transport out of the
facility. The discharge instructions are sent to the patient’s PHR and to the patient's primary care
physician (PCP) or Care Team (as the instructions may contain information necessary for the PCP or Care
Team to follow up with the patient before the discharge summary is available). Upon discharge, the
discharge summary is prepared within the Hospital EHR system. The attending physician of record
(APoR) reviews the discharge summary and, once approved, the discharge summary is sent to the PCP.
The summary may arrive in the PCP’s EHR system even before the patient has left the hospital. A copy of
the message may be retained in the hospital EHR per the hospital’s policies and workflow rules. The
discharge summary, or portions thereof, may also be sent to the patient’s PHR system.
NOTE: The discharge instructions described above are also part of the discharge summary. Depending
on the workflow, and the policies at the hospital or ED, the patient and patient’s PHR may receive only
the discharge instructions at discharge. The discharge summary may be provided later upon request
and within 36 hours of discharge.
Audit logs of the exchange are retained according to the hospital’s PHR systems, and any intermediaries’
policies, procedures, and agreements.
Setting 2: Patient
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
The patient discharge instructions and discharge summary are received by the patient’s PHR system.
Depending on the specific PHR application, the patient or home health agency (HHA) receives a
notification to access and review the PHR. The patient (or patient’s authorized proxy) accesses the PHR
and may review the patient discharge instructions. Again, depending on the PHR system's functionality
the patient or proxy may be able to select sections within the discharge instructions (discrete data
elements) to automatically populate the appropriate fields in the PHR. For example, the newly reconciled
medication list is selected to upload to the active medication list section of the PHR and the patient
uploads any new problems to the problem list. Some information may be selected to initiate the agency
workflow process. The PHR system may also receive the discharge summary. In that case please see the
"Closed Loop Referral" User Story about handling the receipt of a medical summary in the PHR system.
User Story 2: The Exchange of Clinical Summaries between Provider and Patients to Support the
Closed-loop Transfer of a Patient from One Care Setting to Another Consultation Referral.
Actors
Actor
Provider: Any Provider EHR System
Patient: The Patient's PHR System or Patient
Portal
Role
Source
Destination
Table 10: Actors and Roles of Scenario 2 User Story 2
Setting 1: PCP’s office
Activity: Primary Care 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 is documenting the encounter
in the EHR and within the EHR prepares the consultation request clinical summary to the specialist. The
summary is addressed to the appropriate specialist, specialty or provider organization and is sent to the
specialist’s EHR system.
The consultation request, clinical summary, or portions thereof may also be sent to the patient’s PHR
system.
Setting 2: Specialist’s office
Activity: The consultation request clinical summary is processed according to the specific context of the
referral. In accordance with practice policies and workflow the specialist reviews the document and
orders any additional tests to be performed for the patient prior to the office visit. Discrete data
elements from within the summary may be promoted to the specialist’s EHR system, date/time/source
stamped.
When the patient arrives at the specialist’s office he is registered in accordance with practice policies
and workflow. The specialist documents the encounter in the EHR system and prepares the consultation
summary to the PCP. Once the consultation summary is prepared it is addressed and is sent to the PCP’s
EHR system. A copy of the summary is retained in the specialist’s EHR system. The consultation
summary will include “Core” data, and may include “variable” data.
The consultation summary may also be sent to the patient’s PHR System.
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
NOTE: The return to PCP office is only needed in Scenario 1 for the receiving of the consultation
summary by the PCP. In Scenario 2 there is not provider/patient exchange of information as part of
Transition of Care in the return to Setting 1.
Setting 3: Patient
Activity: "Consultation summary" is received by the patient’s PHR system. Depending on the specific
PHR system, the patient may receive a notification to access his PHR as there is new information
available. The patient (or the patient’s authorized proxy) accesses the PHR and may review the
consultation request clinical summary. The patient (or his proxy) may respond with questions. Again,
depending on the PHR system's functionality the patient may be able to select sections of the
consultation request clinical summary (that are discrete data elements) to automatically populate the
appropriate fields in the PHR. For example, the patient may upload any new problems to the problem
list. Other PHR systems may have “all or none” functionality allowing the patient to simply determine if
he would like to retain or delete the consultation request clinical summary in the PHR system.
11.1.1 Base Flow of Scenario 2
User Story 1: The Exchange of Discharge Instructions between Provider and Patient to Support the
Transfer of a Patient from One Care Setting to Another.
Step #
1
Actor
Provider
2
EHR System
3
PHR System
4
EHR System
5
PHR System
Event/Description
Order/Address/Request:
Discharge Summary and
Discharge Instructions to
Patient A in EHR (and has
been acknowledged by
patient)
Generate and Send:
Discharge Instructions to
PHR
Receive: Discharge
Instructions in PHR
Generate and Send:
Discharge Summary to PHR
Receive: Discharge
Summary in PHR
Inputs
START
Outputs
Discharge
Summary and
Discharge
Instruction
Request
Discharge
Instructions
Request
Discharge
Instructions
Discharge
Summary Request
Discharge
Summary
Discharge
Instructions
Discharge
Instructions
Discharge
Summary
END
Table 11: Base Flow of Scenario 2 User Story 1
User Story 2: The Exchange of Clinical Summaries between Provider and Patients to Support the
Closed-loop Consultation Referral.
Step #
1
Actor
Provider (PCP)
2
EHR System
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Event/Description
Order/Address/Request:
Consultation request while
meeting with patient
Generate and Send:
Consultation request
summary
Inputs
START
Initiated
Consultation
Request
Summary
Outputs
Initiated
Consultation
Request
Consultation
Request
Summary
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Step # Actor
Event/Description
Inputs
Outputs
3
PHR System
Receive: Consultation
Consultation
Consultation
Request Summary in PHR
Request
Request
Summary
Summary
Note: rows 4-6 will occur for
any delivery of a Clinical
Summary
4
Provider
Order/Address/Request:
START
Initiated Clinical
Clinical Summary including
Summary
specialist’s summary
Request
5
EHR System
Generate and Send: Clinical
Initiated Clinical
Clinical Summary
Summary details
Summary
Request
6
PHR System
Receive: Clinical Summary in Clinical Summary Clinical Summary
PHR
Table 12: Base Flow of Scenario 2 User Story 2
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
11.1.2 Activity Diagrams of Scenario 2
The following are the Activity Diagrams that support the events in section 11.1.1.
User Story 1: The Exchange of Discharge Instructions and a Discharge Summary between a Provider
and a Patient to Support the Transfer of a Patient from One Care Setting to Another.
Figure 7: Activity Diagram of Scenario 2 User Story 1
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
User Story 2: The Exchange of Clinical Summaries between Provider and Patients to Support the
Closed-loop Consultation Referral.
Figure 8: Activity Diagram for Scenario 2 User Story 2
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
11.2 Functional Requirements of Scenario 2
11.2.1 Informational Interchange Requirements of Scenario 2
Initiating
Information
Interchange
System
Requirement Name
Receiving/Responding
System
Electronic
Health Record
System
Electronic
Health Record
System
Send
(A.XFER.1)3
Discharge Summary
Receives
(A.XFER.2)
Personal Health Record
System
Send
(A.XFER.1)
Discharge
Instructions
Receives
(A.XFER.2)
Personal Health Record
System
Electronic
Health Record
System
Electronic
Health Record
System
Send
(A.XFER.1)
Consultation
Request Summary
Receives
(A.XFER.2)
Personal Health Record
System
Send
(A.XFER.1)
Clinical Summary
Receives
(A.XFER.2)
Personal Health Record
System
Table 13: Informational Exchange Requirements of Scenario 2 User Story 1
11.2.2 System Requirements of Scenario 2
System Requirement Name
Display Discharge Summary
Display Discharge Instructions
System
Personal Health Record System
Personal Health Record System
Table 14: System Requirements of Scenario 2
3
This identifier comes from the ONC SI-UC-Simplification spreadsheet (see References)
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
11.3 Sequence Diagrams of Scenario 2
The following sequence diagrams describe the messages and order of messages.
User Story 1: The Exchange of Discharge Instructions and a Discharge Summary between a Provider
and a Patient to Support the Transfer of a Patient from One Care Setting to Another.
Figure 9: Sequence Diagram for Scenario 2 User Story 1
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
User Story 2: The Exchange of Clinical Summaries between Provider and Patients to Support the
Closed-loop Consultation Referral.
Figure 10: Sequence Diagram of Scenario 2 User Story 2
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
12.0 Issues and Obstacles
In general, the absence of the pre-conditions described in the previous section presents obstacles to
implementation of the Use Case.
Additional obstacles are provided below:









Variations in local, state and national security and privacy regulations, and other pertinent laws.
o There are regulations concerning the storage, transmission, or destruction of electronic
health information. These regulations are inconsistent across federal, state, and local
jurisdictions.
Lack of harmonization among data interoperability standards including vocabulary and other
messaging standards.
o Without consistent standards, the viewing, accessing, or transmitting of electronic
health information may be inhibited. Certainly the eventual ability to seamlessly upload
discrete data from one EHR system to another would be inhibited
Incomplete and or inaccurate data or proprietary-formatted information prevents information
exchange activities; Consulting Provider may not be able to receive the data
A lack of EHR and PHR adoption
A lack of a sustainable business model and pervasive infrastructure to enable electronic data
exchange.
Policies do not exist for a patient’s ability to understand and control clinical information when
using a PHR.
[We had addressed this and commented that it is out of scope and would be up to the PHR edge
vendor system]
There is limited integration of PHRs with provider workflows.
State Laws regarding laboratory results.
13.0 Dataset Considerations
The following summaries are described in the previous user stories:




Discharge Summary
Discharge Instructions
Clinical Summary including Consultation Request
Clinical Summary
The Sub-Workgroup did not describe standard content of summaries such as:




Patient identity [This was included in the Core data set under patient demographics]
Data to insure transport of the content Provider Directories
Security, auditing and other policy content
Other procedural overhead, etc.
The following tables describe the sections and data expected to be found in these clinical summaries:
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
 All of the data in the tables may not be clinically relevant in all situations. Data that is not
clinically relevant to a particular ToC circumstance would simply not be “selected” by the
sending provider – This is assuming that this would be a GUI design element in EHR systems
upon which EHR vendors would compete pertaining to this functionality.
 Some clinical situations may require additional data not included in the tables [e.g. currently not
captured in EHR systems or if captured, not captured as discrete data, but captured as free text]
 Meaningful Use may only require a subset of the data
Dataset for Discharge Instructions:
Discharge Instructions always includes standard basic dataset:

Demographic information, active medication list (with doses and sig), allergy list, problem list.
Discharge Instructions contains also dataset relevant to the discharge summary/discharge instructions
context:

This will depend on what the sending clinician deems as relevant and may include: Follow
up/plan of care (e.g., CCD/83 Plan of Care (What patient can do)): Prospective sections
(Treatment Plan), treatments, diet, activities, alerts for conditions, future visits (may include
several depending on condition) including appointment established. Patient education and
information on medication (tied to alerts), disease process, wound care, condition based special
considerations, etc.) etc.
Message contains variable dataset relevant to the hospitalization (selected by the clinician who
prepared the discharge summary):

Examples
o Procedures during hospitalization
o Selected medications administered during hospitalization
o Selected vital signs
o Emergency contact information
o Relevant results, reports
o Wound care (if applicable)
o Etc.
Ref.4
T.CC.1
Section
Personal
Information
T.CC.5
Allergies and
Other Adverse
Reactions
T.CC.6
Problem List
4
Content
Name, DOB, Next of Kin,
Address, Phone Number,
Gender, Marital Status,
Religion, Race, Ethnicity
Allergy Type; and Date
Substance intolerance
Associated Adverse Events
Current Diseases & Conditions
monitored for the patient and
Additional Notes
List of allergies which might include
allergy to what (e.g., medication. food,
environment). Sensitivity. Past and those
that have arisen
 List of problems/complaints
(what was diagnosis, complaint
This identifier comes from ONC-SI-UC Simplification spreadsheet. See references.
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Ref.4
Section
Content
Additional Notes
status
and/or descriptor of
problem/complaints, symptoms).
 How do these
problems/complaints impact
interventions, orders or
instructions.
T.CC.16
Hospital
Medications names, doses,
 Include the reconciled active
Discharge
frequency, route ordered for
medications including time of
Medications
the patient for after discharge.
last dose and whether patient
was sent with samples of the
medication(s).
 NOTES. Instructions may be
more detailed if sent to another
provider.
T.CC.18
Advance
Yes/no, whether or not these
Yes/No - Target is to trigger a
Directives
exist
conversation.
Whether a Healthcare Proxy has been
invoked
T.CC.20
Immunizations
Immunizations name, dose,
Comprehensive list of immunizations
route, date administered to
received during the hospital stay
the patient
T.CC.21
Plan of Care
Proposed interventions and
Subsections include the following (1-7)
procedures for patient
1. Goals.
2. Results yet to be received and
procedures to be followed up on.
3. Active and scheduled interventions
and orders (short term direct instructions
[e.g. Vital sign checks, labs, etc.] - in the
long run as validated by the patient and
those contributed by the
patient/caregiver).
4. Education Resources/Materials Patient education needed. To include
classes, educational sessions, and printed
materials along with steps to a specific
need.
5a. Diet and Diet/Fluid Restrictions: All
instructions that describe the expected
diet.
b. Restrictions: List of limitations being
placed on the diet
6a. Fluids Management (C/N): All
instructions that describe the expected
fluids and method of administration.
b. Restrictions: List of limitations being
placed on fluids
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Ref.4
Section
Content
Additional Notes
7. Activity/Exercise
NOTES. Instructions may be more
detailed if sent to another provider.
- Yes/No - has the discharge instruction
been reviewed with the patient?
- Yes/No - has the discharge instruction
been accepted by the patient, if no then
how addressed
T.CC.22
Medical
Implanted and External Medical
 List of devices and where the
Equipment Devices; Dates
device is to be
includes
secured/prescribed/embedded.
assistive
 Duration of medical devices.
devices and is
 History of devices (recalls, S/N,
related to
etc.)
functional
 Includes reading glasses, hearing
status
aids, dental appliances, etc.
ADDED
Patient Risks
Falls, Elopement, etc
 Strategies to mitigate patient
risks
ADDED
Risks to Others Contagion, Violent behavior
 Isolation Requirements, etc
ADDED
Electronic Links
Links to provider or other computer
applications for patient results,
summaries, etc.
ADDED
Patient
List of facility dependent patient
Oriented
oriented items (e.g., pain scale at
Embarkation
discharge, last ECG, etc.)
Checklist
ADDED
Functional
End state/goal expressed/Projected
Status (O/N) change in functional status (will relate to
the goals identified)
Table 15: Dataset for Discharge Instructions
Dataset for Discharge Summary:
Discharge Summary Contents: Both basic standard dataset and discharge context relevant dataset are
determined by the discharging provider organization in accordance with the discharging provider, local
policy, regulations and law. The receiving provider through its EHR system may determine how to
incorporate and present the Discharge Summary.
Notwithstanding the Discharge Summary should always include the core dataset. At discharge the
summary might include content for the Discharge Instruction as well as Discharge Summary. Discharge
Summary content includes:

Demographic information, active reconciled medication list (with doses and sig), allergy list,
problem list, and reason for admission.
Message contains variable dataset relevant to the hospitalization (selected by the clinician who
prepared the discharge message). Examples:
8/1/2011
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



Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Procedures during hospitalization
Relevant results, reports
Wound care (if applicable)
Etc.
Hospital and ED discharge is also the focus of several other efforts including individuals and institutions
involved in ToC. For instance, the HIE Challenge Grants, Improving Massachusetts Post-Acute Care
Transfers (IMPACT). Input was provided by Keith Boone;
(http://motorcycleguy.blogspot.com/2010/11/circle-never-ends.html). Consideration was given to
HITSP C32 Version 2.5, Meaningful Use EHR certification requirement and CDA Consolidation. Along with
input from the Use Case Simplification and Discharge Instruction Sub Workgroups the following
recommended sections and data are included in the Discharge Summary. The sections with a
are also
found in the HITSP C48 Encounter Document Using IHE Medical Summary (XDS-MS) Component.
Ref. 5
T.CC.1
Section
Personal
Information
T.CC.2
Contact
Information
Insurance
Information
T.CC.3
T.CC.4
T.CC.5
T.CC.6
T.CC.7
T.CC.8
5
Healthcare
Provider
Allergies and
Other Adverse
Reactions
Problem List
Active Problems
(R/N)/Chief
Complaint
(overriding
problem at the
time of
discharge) chronic illness
and congenital
problems
History of Past
Illness
Chief Complaint
Content
Additional Notes
Name, DOB, Healthcare Power
of Attorney, Address, Phone
Number, Gender, Marital
Status, Religion, Race, Ethnicity
Contact Name, Contact Number
Insurance Name, Phone #,
Group #, Type, Member #,
Subscriber Name, Financial
responsibility
Provider Name, Address, Phone
Number, Type
Allergy Type; and Date
Current Diseases &
Conditions monitored for the
patient and status
List of allergies which might include
allergy to what (e.g., medication. food,
environment)
 List of problems/complaints
(what was diagnosis, complaint
and/or descriptor of
problem/complaints, symptoms).

Diseases & Conditions Patient
has suffered in the past
Description of Patient's
This identifier comes from the ONC SI-UC-Simplification spreadsheet (see References)
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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Ref. 5
Section
Content
Additional Notes
(see change in
Complaint (narrative)
T.CC.6 Problem
List)
T.CC.9
Reason for
Reason Patient is being
Transfer
referred
T.CC.10
History of
Sequence of events proceeding
Present
patient's disease/condition
Illness
T.CC.11
List of Surgeries List of types of surgeries and
dates
T.CC.12
Hospital
List of Hospital Diagnosis and
Admission
dates
Diagnosis
T.CC.13
Discharge
Conditions/Diseases identified
during hospital stay and dates
Diagnosis
T.CC.14
Medications
List of Current Medication
 Include the reconciled active
Names ; date, route, dose,
medications
frequency
T.CC.15
Admission
List of historical medication
Medications
names, dose, route, frequency,
date patient has taken
History
previously
T.CC.16
Hospital
Medications names, doses,
Discharge
frequency, route ordered for
the patient for after discharge
Medications
T.CC.17
Medications
Medications administered to
patient during the course of an
Administered
encounter; name, dose, route,
frequency
T.CC.18
Advance
A summary of patient's
 Yes/No, if Yes date of last known
expectations
for
care
 Yes/No if Physician Orders for
Directives
Life-Sustaining Treatment
(POLST) form returned
 Where is last known
version/original is located
T.CC.19
Pregnancy
Pregnant, Yes/NO
T.CC.20
Immunizations
Immunizations name, dose,
Comprehensive list of immunizations
route, date administered to
received during the hospital stay.
the patient
T.CC.21
Physical
Physical Findings of the Patient;
VS, Biometrics, Review of
Examination
Systems
T.CC.22
Vital Signs Patient's Vital Signs ; Heart
Including Pain Scale Assessment,
Vital Signs (R/N) rate, Resp Rate, Pulse Ox,
Smoking Status
including Pain
Temp, B/P, Pain
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Transition of Care Use Case
Ref. 5
Section
Content
Additional Notes
Scale
Assessment,
Smoking
Status
T.CC.23
Review of
Functions of various body
systems; Neuro, Derm, GI, GU,
Systems
Cardiac, Pulmonary, MS, Repro,
Nervous, Endocrine
T.CC.24
Hospital Course Sequence of (name, diagnosis
associated with) events and
dates from admission to
discharge of hospital stay
T.CC.25
Diagnostic
Results and dates of Diagnostic Corresponding results to the scheduled
Procedures
procedures and interventions
Results
T.CC.26
Assessment and Assessment of patients
Plan
conditions and
expectations/goals of care
T.CC.28
Family History
Dates with Disease Suffered,
Age of Death, other genetic
information
T.CC.29
Social History
Patient's beliefs, home life,
social/risky habits, family life,
work history
T.CC.30
Encounters
Current and historical
encounters; dates
T.CC.31
Medical
Implanted and External Medical
 List of devices and where the
Equipment Devices; Dates
device is to be
Medical Devices
secured/embedded.
(C/N) - includes
 Duration of medical devices.
assistive
 History of devices (recalls, S/N,
devices and is
etc.).
related to
functional
status
T.CC.32
Preoperative
Diagnosis (Date) assigned to
Diagnosis
patient previously to surgery
T.CC.33
Postoperative
Diagnosis (Date) assigned to
Diagnosis
patient after surgery
T.CC.34
Surgery
Particulars of Surgery
Description
(narrative) (images)
T.CC.35
Surgical
Clinically significant
Operation Note observations found during
Findings
surgery
T.CC.36
Complications
Known risks or unidentified
Section
problems
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Ref. 5
Section
Content
Additional Notes
T.CC.37
Operative Note Date and Description of
Surgical
Procedure Performed
Procedure
Discharge Diet
Part of Discharge Instructions
Functional
Part of Discharge Instructions
Status
Plan of Care
Part of Discharge Instructions
Table 16: Dataset for Discharge Summary
Dataset for Clinical Summary:
The User Stories Sub-Workgroup defined the following clinical summary content.
Clinical Summary including Consultation Request Summary
Clinical Summary always includes Core basic dataset:

Demographic information, active medication list (with doses and sig), allergy list, problem list,
reason for referral, etc.
Clinical Summary contains variable dataset relevant to the context of the request:
Examples:




Cover note describing the clinical impetus for the referral
For a cardiologist consultation request: cardiology relevant tests and results such as Cardiac
Echo results, Holter Monitor results, etc.; cardiology-pertinent family history, social histories,
procedures, PE findings, etc..
For a dermatologist consultation request: dermatology relevant tests and results such as skin
biopsy path report, image of lesion, dermatology pertinent family history, social histories,
procedures, PE findings, etc..
Specific example:
o PCP has worked up a patient who has a working diagnosis of Thyroid Cancer and is
referring the patient to an Endocrine Surgeon.
o Summary includes standard basic dataset as above as well as PCP-selected referralspecific variable dataset. E.g.:
 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 family history of MEN Syndromes. No family 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.
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
 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
Ref. 6
T.CC.1
Section
Personal Information
T.CC.2
Contact Information
T.CC.3
Insurance
Information
T.CC.4
Healthcare Provider
T.CC.5
Allergies/Other
Adverse Reactions
Content
Name, DOB, Next of Kin,
Address, Phone Number,
Gender, Marital Status,
Religion, Race, Ethnicity
Contact Name, Contact
Number
Insurance Name, Phone #,
Group #, Type, Member #,
Subscriber Name, Financial
responsibility
Provider Name, Address,
Phone Number, Type
Allergy Type; and Date
Substance intolerance
Associated Adverse Events
Additional Notes
List of allergies which might include
allergy to what (e.g., medication.
food, environment).
Yes/No/Unknown, and if Yes or
Unknown how does it affect care.
Other history that guide care
T.CC.6
6
Problem List Active
Problems (R/N)/Chief
Complaint (overriding
problem at the time
of discharge) chronic illness and
congenital problems
Current Diseases &
Conditions monitored for
the patient and status
Patient supplied information about
reaction
 List of problems/complaints
(what was diagnosis,
complaint and/or descriptor
of problem/complaints,
symptoms). Is a list, of
diagnosis, complaints some of
these may have been
resolved and some are active.
 How do these
problems/complaints impact
interventions, orders or
instructions. Discharge
instructions usually are for
the encounter just ending.
 Patient's perception or
description of
problems/complaints is
This identifier comes from the ONC SI-UC-Simplification spreadsheet (see References)
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Transition of Care Use Case
Ref. 6
Section
Content
Additional Notes
usually in notes or history.
Not part of a formal problem
list.
T.CC.7
History of Past
Diseases & Conditions
May be a list with dates onset and/or
Illness/Resolved
Patient has suffered in the
resolution
Problems
past
T.CC.8
Chief Complaint (see
Description of Patient's
If not listed, in the problem list
change in T.CC.6
Complaint (narrative)
Problem List)
T.CC.9
Reason for Transfer
Reason Patient is being
May come from Utilization Review
referred
(UR) or Medicare rules, insurance or
HMO rules or the patient may be well.
T.CC.10
History of Present
Sequence of events
Illness
proceeding patient's
disease/condition
T.CC.11
List of Surgeries
List of types of surgeries and
dates
T.CC.12
Diagnosis
List of Hospital Diagnosis
Current encounter list only
and dates
T.CC.13
Medications
List of Current Medication
 List of prescribed medications
Names ; date, route, dose,
or other medications. (Should
frequency
be the reconciled list (which
should have been done on
admission)
 If to be reconciled then list
needs to be inclusive of selfadministered medications
(herbals, over the counter)
 See notes on medication
reconciliation regarding
expectations such as
discontinued medications
from inpatient if not included
in discharge summary
 NOTES: Instructions may be
more detailed if sent to
another provider
T.CC.15
Advance Directives
A summary of patient's
expectations for care




T.CC.16
8/1/2011
Pregnancy
Yes/No, if Yes then date of
Yes/No if POLST form
returned
Where is last known
version/original is located
Going forward how the
"state" and how it affects care
Pregnant, Yes/NO
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Ref. 6
Section
Content
Additional Notes
T.CC.17
Immunizations
Immunizations name, dose, Comprehensive list of immunizations
route, date administered to (have - patient reported, got,
the patient
need):* list of immunizations
necessary to get after discharge.* list
of education or information about
immunizations they received while
hospitalization
T.CC.18
Physical Examination Physical Findings of the
Patient; VS, Biometrics,
Review of Systems
T.CC.19
Vital Signs
Patient's Vital Signs ; Heart
Instructions regarding the capture of
Vital Signs (R/N)
rate, Resp Rate, Pulse Ox,
vital signs at points along the care
including Pain Scale
Temp, B/P, Pain
plan and any special instructions
Assessment, Smoking
regarding how to capture
Status
T.CC.20
Review of Systems
Functions of various body
systems; Neuro, Derm, GI,
GU, Cardiac, Pulmonary,
MS, Repro, Nervous,
Endocrine
T.CC.21
Diagnostic Results
Results and dates of
Corresponding results to the
Diagnostic Procedures
scheduled procedures and
interventions.
T.CC.22
Plan of Care
Proposed interventions and
 Goals.
Plan of
procedures for patient
 Results yet to be received and
Treatment/Treatment
procedures to be followed up
Plan/Care Plan (R/N) on.
Covers the
 Active interventions and
considerations that
orders (short term direct
encompass a range of
instructions - in the long run
scopes and/or
as validated by the patient
timeframe (could be
and those contributed by the
a description of a
patient/caregiver).
single encounter or
across multiple
encounters
Education
Diet/Diet Restrictions
Diet:
(R/N)
- All instructions that describe the
ordered diet.
Fluids Management
(Conditional/No)
8/1/2011
Restrictions:
- List of limitations being placed on
the diet
Fluids:
- All instructions that describe the
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Section
Content
Additional Notes
expected fluids and method of
administration.
Restrictions:
- List of limitations being placed on
fluids
Yes/No-has the plan been reviewed
with the patient?
Yes/No-has the plan been accepted
by the patient, if no then how
addressed
T.CC.23
Family History
T.CC.24
Social History
T.CC.25
Encounters
T.CC.26
Medical Equipmentincludes assistive
devices and is related
to functional status
Preoperative
Diagnosis
T.CC.27
T.CC.28
T.CC.29
T.CC.30
T.CC.31
T.CC.32
T.CC.33
Diagnosis (date) assigned to
patient previously to
surgery
Postoperative
Diagnosis (date) assigned to
Diagnosis
patient after surgery
Surgery Description
Particulars of Surgery
(narrative) (images)
Surgical Operation
Clinically significant
Note Findings
observations found during
surgery
Complications Section Known risks or unidentified
problems
Operative Note
Date and description of
Surgical Procedure
Procedure Performed
Electronic Links
ADDED
Functional Status
(Optional/No)
ADDED
Relevant Diagnostic
8/1/2011
Dates with Disease Suffered,
Age of Death, other generic
information
Patient’s beliefs, home life,
social/risky habits, family
life, work history
Current and historical
encounters; dates
Implanted and External
Devices; dates
List of devices and where the device is
to be secured/prescribed/embedded.
Duration of medical devices.
History of devices (recalls/S/N, etc.)
How to get future results, summaries,
etc
Baseline, current and desired:
Functional Status
End state, Goal Expressed, Projected
change in functional status (will relate
to the goals identified)
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Ref. 6
Section
Content
Additional Notes
Surgical
Procedures/Clinical
Reports and Relevant
Diagnostic Test and
Reports
ADDED
Patient
Administrative
Identifiers
Table 17: Dataset for Clinical Summary
Consultation Summary for specialist notes:
Summary always includes Core dataset:

Demographic information, specialist-reconciled active medication list (with doses and sig when
known), allergy list, specialist-reconciled problem list, specialist recommendations, etc.
Summary contains variable dataset relevant to the context of the referral:

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,
patient’s level of understanding of what was communicated, etc.
Ref.7
Section
Content
T.CC.1
Personal Information
Name, DOB, Next of Kin,
Address, Phone Number,
Gender, Marital Status,
Religion, Race, Ethnicity
T.CC.2
Contact Information
Contact Name, Contact
Number
T.CC.3
Insurance Information
Insurance Name, Phone
#, Group #, Type,
Member #, Subscriber
Name, Financial
responsibility
T.CC.4
Healthcare Provider
Provider Name, Address,
Phone Number, Type
T.CC.5
Allergies and Other Adverse
Reactions
Allergy Type; and Date
Substance intolerance
7
Notes by Sub-Workgroup
List of allergies which might
include allergy to what (e.g.,
This identifier comes from the ONC SI-UC-Simplification spreadsheet (see References)
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Ref.7
Section
Content
Notes by Sub-Workgroup
Associated Adverse
Events
medication. food,
environment)
Yes/No/Unknown, and if Yes
or Unknown how does it
affect care.
Other history that guide care.
Patient supplied information
about reaction
T.CC.6
Problem List
Current Diseases
List of problems/complaints
by patient to specialist and
what was diagnosis,
complaint and/or descriptor
of problem/complaints,
symptoms
Active Problems (R/N)/Chief
Complaint (overriding
problem at the time of
discharge) - chronic illness
and congenital problems
Conditions monitored for
the patient and status
How do these
problems/complaints impact
interventions, orders or
instructions.
Patient's perception or
description of
problems/complaints - was
there discussion with patient?
T.CC.7
History of Past Illness
Diseases & Conditions
Patient has suffered in
the past
Optional if relevant new
discovery - resolved problems
T.CC.8
Chief Complaint (see change
in T.CC.6 Problem List)
Description of Patient's
Complaint (narrative)
If patient tells specialist
different complaint than was
reported by PCP
T.CC.9
8/1/2011
Reason Patient is being
referred
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Ref.7
Section
Content
Notes by Sub-Workgroup
T.CC.10
History of Present Illness
Sequence of events
proceeding patient's
disease/condition
If different or in addition to
PCP history
T.CC.11
List of Surgeries and
Procedures
List of types of surgeries
and procedures with date
If any performed by specialist
T.CC.14
Medications
List of Current
List of prescribed medications
Medication Names ; date, or medications administered
route, dose, frequency
by specialist
If to be reconciled then list
needs to be inclusive of selfadministered medications
(herbals, over the counter)
T.CC.17
Medications Administered
Medications
administered to patient
during the course of an
encounter; name, dose,
route, frequency
If relevant to referral
T.CC.18
Advance Directives
A summary of patient's
expectations for care
Yes/No (Optional in context of
Consultation)
T.CC.19
Pregnancy
Pregnant, Yes/NO
Only if relevant
T.CC.20
Immunizations
Immunizations name,
dose, route, date
administered to the
patient
Immunizations administered
or recommended by specialist
T.CC.21
Physical Examination
Physical Findings of the
Patient; VS, Biometrics,
Review of Systems
Pertinent positive or negative
finding only
T.CC.22
Vital Signs
Patient's Vital Signs ;
Heart rate, Resp Rate,
Pulse Ox, Temp, B/P, Pain
Pertinent positive or negative
findings only
Vital Signs (R/N) including
Pain Scale Assessment,
Smoking Status
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Ref.7
Section
Content
Notes by Sub-Workgroup
T.CC.23
Review of Systems
Functions of various body
systems; Neuro, Derm,
GI, GU, Cardiac,
Pulmonary, MS, Repro,
Nervous, Endocrine
Pertinent positive or negative
findings only
T.CC.25
Diagnostic Results
Results and dates of
Diagnostic Procedures
Corresponding results to the
scheduled procedures and
interventions.
T.CC.26
Assessment and Plan
Assessment of patients
conditions and
expectations/goals of
care
See Plan of Care in regards
discussions with patient
T.CC.27
Recommended Plan of Care
Proposed interventions
and procedures
Goals. Details for follow-up,
expectations, as needed.
Plan of Treatment/Treatment
Plan/Care Plan (R/N) - Covers
the considerations that
encompass a range of scopes
and/or timeframe (could be a
description of a single
encounter or across multiple
encounters
Active interventions and
orders (short term direct
instructions - in the long run
as validated by the patient
and those contributed by the
patient/caregiver).
Yes/No - has the specialist
findings, recommendations
and instruction been
reviewed with the patient.
Yes/No - Have these
instruction been accepted by
the patient, if no then how
addressed
Yes/No - Has patient been
involved in formulation of
plan of care
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Ref.7
Section
Content
Notes by Sub-Workgroup
Education
Patient education
provided or needed. To
include classes,
educational sessions, and
printed materials.
If relevant
Fluids Management
(Conditional/No)
All instructions that
describe the expected
fluids and method of
administration.
If relevant
T.CC.28
Family History
Dates with Disease
Optional if relevant
Suffered, Age of Death,
other genetic information
T.CC.29
Social History
Patient's beliefs, home
life, social/risky habits,
family life, work history
Optional if relevant
T.CC.31
Medical Equipment
Implanted and External
Medical Devices; Dates
List of devices and where the
device is to be
secured/prescribed by
specialist.
Medical Devices
(Conditional/No) - includes
assistive devices and is
related to functional status
Optional if implanted or
applied or with special
instructions by specialist
History of devices for this
patient.
Functional Status
(Optional/No) -scales, scores
8/1/2011
SHOULD be present
when any assessments of
functional status are
performed on the patient
If relevant - Baseline, current
and desired:* Functional
status* End state/goal
expressed/Projected change
in functional status (will relate
to the goals identified)
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Transition of Care Use Case
Ref.7
Section
Content
Notes by Sub-Workgroup
Electronic Links
How to get to future
results, summaries, etc.
Table 18: Dataset for Clinical Summary for Specialist Notes
APPENDICES
Appendix A: Related Use Cases









AHIC Consultations and Transfers of Care
AHIC Consumer Empowerment; Consumer Access to Clinical Information
AHIC Common Data Transport
AHIC Clinical Notes Detail
AHIC Personalized Healthcare
NHIN Direct Primary care provider refers patient to specialist including summary care record
NHIN Direct Primary care provider refers patient to hospital including summary care record
NHIN Direct Specialist sends summary care information back to referring provider
NHIN Direct Hospital sends discharge information to referring provider
Appendix B: Previous Work Efforts Related to Clinical Information Exchange



Health Information Technology Standards Panel Specification IS03: The Consumer
Empowerment and Access to Clinical Information via Networks Interoperability Specification
defines specific standards needed to assist patients in making decisions regarding care and
healthy lifestyles (i.e., registration information, medication history, lab results, current and
previous health conditions, allergies, summaries of healthcare encounters and diagnoses). This
Interoperability Specification defines specific standards needed to enable the exchange of such
data between patients and their caregivers via networks.
Health Information Technology Standards Panel Specification IS09: The Consultations and
Transfers of Care Interoperability Specification describe the information flows, issues and
system capabilities that apply to a provider requesting and a patient receiving a consultations
from another provider.
HITSP Information Technology Standards Panel Specification C32: The Summary Documents
Using HL7 Continuity of Care Document (CCD) Component describes the document content
summarizing a consumer's medical status for the purpose of information exchange. The content
may include administrative (e.g., registration, demographics, insurance, etc.) and clinical
(problem list, medication list, allergies, test results, etc) information. This Component defines
content in order to promote interoperability between participating systems such as Personal
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Health Record Systems (PHRs), Electronic Health Record Systems (EHRs), Practice Management
Applications and others.
 Health Information Technology Standards Panel Specification C83: The CDA Content Modules
Component defines the content modules for document based HITSP constructs utilizing clinical
information. These Content modules are based on IHE PCC Technical Framework Volume II,
Release 4. That technical framework contains specifications for document sections that are
consistent with all implementation guides for clinical documents currently selected for HITSP
constructs. View the most current version as HTML
 Health Information Technology Standards Panel Specification IS107: This Interoperability
Specification consolidates all information exchanges and standards that involve an EHR System
amongst the thirteen HITSP Interoperability Specifications in place as of the February 13, 2009
enactment of the American Recovery and Reinvestment Act (ARRA). This Interoperability
Specification is organized as a set of HITSP Capabilities, with each Capability specifying a
business service that an EHR system might address in one or more of the existing HITSP
Interoperability Specifications (e.g., the Communicate Hospital Prescriptions Capability supports
electronic prescribing for inpatient prescription orders)
 Health Level 7: The CDA Release 2.0 provides an exchange model for clinical documents (such as
discharge summaries and progress notes) - and brings the healthcare industry closer to the
realization of an electronic medical record. By leveraging the use of XML, the HL7 Reference
Information Model (RIM) and coded vocabularies, the CDA makes documents both machinereadable - so they are easily parsed and processed electronically - and human-readable - so they
can be easily retrieved and used by the people who need them. CDA documents can be
displayed using XML-aware Web browsers or wireless applications such as cell phones. While
Release 2.0 retains the simplicity of rendering and clear definition of clinical documents
formulated in Release 1.0 (2000), it provides state-of-the-art interoperability for machinereadable coded semantics. The product of 5 years of improvements, CDA R2 body is based on
the HL7 Clinical Statement model, is fully RIM-compliant and capable of driving decision support
and other sophisticated applications, while retaining the simple rendering of legallyauthenticated narrative.
Appendix C: Privacy and Security Assumptions
Security attributes includes capabilities needed to establish trust between systems, provide
confidentiality while in-transit, ensure authenticity of the data, and ensure that only authorized
individuals have access to the data.
Feature
Audit Logging
Authentication (Person)
Authentication (System)
Data Integrity Checking
Error Handling
HIPAA De-Identification
8/1/2011
Feature Applicability
X
X
X
X
X
X
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Feature
Feature Applicability
Holding Messages
Non-repudiation
Pseudonymize and Re-Identify
Secure Transport
Transmit Disambiguated Identities
User Login
X
X
X
X
Table 19: Common Transactions (not displayed as part of the sequence diagram)
Appendix D: Glossary
These items are included to clarify the intent of this use case. They should not be interpreted as
approved terms or definitions but considered as contextual descriptions. There are parallel activities
underway to develop specific terminology based on consensus throughout the industry.
Access Logs: An integrated view of who has accessed the consumer/patient’s health information for the
purposes of direct or indirect patient care.
Acute Care: Treatment for a short period of time in which the patient is treated for a brief episode of
illness. Acute Care is generally associated with care in a short term facility which is usually a nonemergency department setting.
AHIC: American Health Information Community; a federal advisory body chartered in 2005, serving to
make recommendations to the Secretary of the U.S. Department of Health and Human Services in
regards to the development and adoption of health information technology.
Ancillary Entities: Organizations that perform auxiliary roles in delivering healthcare services. They may
include diagnostic and support services such as laboratories, imaging and radiology services, and
pharmacies that support the delivery of healthcare services. These services may be delivered through
hospitals or through free-standing entities.
Care Coordination: Functions that help ensure that the patient’s needs and preferences for health
services and information sharing across people, functions, and sites are met over time.
Care Coordinators: Individuals who support clinicians in the management of health and disease
conditions. These can include case managers and others.
Clinical Support Staff: Individuals who support the workflow of clinicians.
Clinicians: Healthcare providers with patient care responsibilities, including physicians, advanced
practice nurses, physician assistants, nurses, psychologists, pharmacists, and other licensed and
credentialed personnel involved in treating patients.
Consultation: Meeting of two or more clinicians to evaluate the nature and progress of disease in a
particular patient and to establish diagnosis, prognosis, and therapy.
Consumers: Members of the public that include patients as well as caregivers, patient advocates,
surrogates, family members, and other parties who may be acting for, or in support of, a patient
receiving or potentially receiving healthcare services.
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Electronic Health Record (EHR): An electronic, cumulative record of information on an individual across
more than one healthcare setting that is collected, managed, and consulted by professionals involved in
the individual's health and care. This EHR description encompasses similar information maintained on
patients within a single care setting (a.k.a., Electronic Medical Record (EMR)).
Electronic Health Record (EHR) System Suppliers: Organizations which provide specific EHR solutions to
clinicians and patients such as software applications and software services. These suppliers may include
developers, providers, resellers, operators, and others who may provide these or similar capabilities.
Geographic Health Information Exchange/Regional Health Information Organizations: A multistakeholder entity, which may be a free-standing organization (e.g., hospital, healthcare system,
partnership organization) that supports health information exchange and enables the movement of
health-related data within state, local, territorial, tribal, or jurisdictional participant groups. Activities
supporting health information exchanges may also be provided by entities that are separate from
geographic health information exchanges/Regional Health Information Organizations including
integrated delivery networks, health record banks, and others.
Health Information Exchange (HIE): An electronic network for exchanging health and patient
information among healthcare delivery organizations, according to specific standards, protocols, and
other agreed criteria. These functional capabilities may be provided fully or partially by a variety of
organizations including free-standing or geographic health information exchanges (e.g., Regional Health
Information Organizations (RHIOs)), integrated care delivery networks, provider organizations, health
record banks, public health networks, specialty networks, and others supporting these capabilities. This
term may also be used to describe the specific organizations that provide these capabilities such as
RHIOs and Health Information Exchange Organizations.
Healthcare Payers: Insurers, including health plans, self-insured employer plans, and third party
administrators, providing healthcare benefits to enrolled members and reimbursing provider
organizations.
HITSP: The American National Standards Institute (ANSI) Healthcare Information Technology Standards
Panel; a body created in 2005 in an effort to promote interoperability and harmonization of healthcare
information technology through standards that would serve as a cooperative partnership between the
public and private sectors.
Laboratories: A laboratory (often abbreviated lab) is a setting where specimens are sent for testing and
analysis are resulted, and then results are communicated back to the requestor. The types of
laboratories may include clinical/medical, environmental, and veterinarian, and may be both private
and/or public.
ONC: Office of the National Coordinator for Health Information Technology; serves as the Secretary’s
principal advisor on the development, application, and use of health information technology in an effort
to improve the quality, safety, and efficiency of the nation's health through the development of an
interoperable harmonized health information infrastructure.
Patients: Members of the public who receive healthcare services. For hospice providers, the patient and
family are considered a single unit of care. Synonyms used by various healthcare fields include client,
resident, customer, patient and family unit, consumer, and healthcare consumer.
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Use Case Development and Functional Requirements for Interoperability
Transition of Care Use Case
Personal Health Record: A health record that is initiated and maintained by an individual. An ideal PHR
would provide a complete and accurate summary of the health and medical history of an individual by
gathering data from many sources and making this information accessible online to anyone who has the
necessary electronic credentials to view the information.
Pharmacies: Entities that exist that are experts on drug therapy and are the primary health professionals
who optimize medication use to provide patients with positive health outcomes
Provider: An individual clinician in a care delivery setting who requests or accepts the transfer of the
clinical summary for the purposes of delivering care.
Provider Organizations: Organizations that are engaged in or support the delivery of healthcare. These
organizations could include hospitals, ambulatory clinics, long-term care facilities, community-based
healthcare organizations, employers/occupational health programs, school health programs, dental
clinics, psychology clinics, care delivery organizations, pharmacies, home health agencies, hospice care
providers, and other healthcare facilities.
Registries: Organized systems for the collection, storage, retrieval, analysis, and dissemination of
information to support health needs. This also includes government agencies and professional
associations which define, develop, and support registries. These may include emergency contact
information/next of kin registries, patient registries, disease registries, etc.
Appendix E. References
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American Health Information Community; AHIC;
www.hhs.gov/healthit/healthnetwork/background
The American National Standards Institute (ANSI) Healthcare Information Technology Standards
Panel; HITSP; www.HITSP.org
Health Level Seven; HL7; www.HL7.org
Meaningful Use Final Rule; Dept of Health and Human Services;
www.edocket.access.gpo.gov/2010/pdf/2010-17207.pdf
Nationwide Health Information Network; NHIN;
www.hhs.gov/healthit/healthnetwork/background
The ONC-SI-UC-Simplification Spreadsheet (Current Version)
http://wiki.siframework.org/Cross+Initiative+-+Use+Case+Simplification+SWG
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