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UseCases

Page history last edited by PBworks 14 years, 8 months ago

Use Cases

 

Our overall goal is to develop a reference set of use cases that can support needs of multiple stakeholders.

 

 

    1. Personal Health Communication
      1. Acute Care Summary of Care to Personal Health Record
      2. Family provides Health Summary to Adult Day Care Center
      3. Personal Health Advocacy and Management(completed by R. Scichilone)
      4. Lifespanning Health Records Kept by Individuals (Completed)
      5. Nursing Home to Personal Health Record(J. Stutesman)
      6. PT or OT to Personal Health Record
      7. CCRC to Personal Health Record for Personal Wellness
    2. Transfer of Care
      1. Nursing Home to Home Health(completed by K. Steele)
      2. Home Health to Acute Care(completed by C. Lundberg)
      3. Nursing Home to Emergency Room(completed by M. White)
      4. Hospital to Nursing Home(completed by M. White)
      5. Hospital to Home Health(completed by K. Steele)
      6. Assisted Living to Nursing Home(completed by K. Steele)
      7. Nursing Home to Assisted Living(completed by J. Stutesman)
      8. PAC LTC to Hospital
      9. Nursing Home to Nursing Home(initiated by J. Stutesman)
      10. Nursing Home to Hospital(initiated by J. Stutesman)
      11. Home Care to Home Care
      12. Home Care to Nursing Home
      13. Home Care to Assisted Living
    3. Coordination of Care
      1. Attending Physician in a Nursing Home Setting(completed by J. Stutesman)
      2. Nursing Home Resident Regularly Visits Dialysis(Completed by M. White)
      3. Home Care Communication with Family Physician
      4. Home Health Care delivered to an Assisted Living Resident
      5. Coordination of Care - Cancer
      6. Home Care to Acute Care
    4. Health Management
      1. Acute Care informs Family Physician(Completed by A. Richard)
      2. Chronic Care Management Over Time
    5. Interdisciplinary Care
      1. Physical Therapist Charts to Nursing Home or Home Health Health Record(completed by J. Stutesman)
      2. Interdisciplinary Care: Cancer Treatment Center(completed by R. Scichilone)
      3. PT or OT to Nursing Home
      4. PT or OT to Home Health
      5. Rehab to Home Health
    6. Orders/Consultations
      1. Physician Requests Nutrition Consultation(completed by Knight Steele)
    7. Administrative Uses
      1. Managed Care Pre-Certification Request
      2. Part D Pre-Certification
      3. Billing Attachments
      4. Nursing Home Data Reporting
      5. Home Care Data Reporting
    8. System Uses
    9. Research Uses
      1. De-identified Health Record Summary provided to Researcher(Completed by A. Richard)
      2. Nursing Home to research
      3. Home Care to research
    10. Addendum, to be incorporated above

 

Personal Health Communication

 

For example, Care Record Summaries provided to Person or Person's agent (i.e. health record bank). Perhaps should incorporate RHIO's as intermediaries for Person.

 

Acute Care Summary of Care to Personal Health Record

Family provides Health Summary to Adult Day Care Center

Personal Health Advocacy and Management(completed by R. Scichilone)

Lifespanning Health Records Kept by Individuals (Completed)

Nursing Home to Personal Health Record(J. Stutesman)

PT or OT to Personal Health Record

CCRC to Personal Health Record for Personal Wellness

 

 

Transfer of Care

 

Transition between care settings and/or care providers

 

Nursing Home to Home Health(completed by K. Steele)

Home Health to Acute Care(completed by C. Lundberg)

Nursing Home to Emergency Room(completed by M. White)

Hospital to Nursing Home(completed by M. White)

Hospital to Home Health(completed by K. Steele)

Assisted Living to Nursing Home(completed by K. Steele)

Nursing Home to Assisted Living(completed by J. Stutesman)

PAC LTC to Hospital

Nursing Home to Nursing Home(initiated by J. Stutesman)

Nursing Home to Hospital(initiated by J. Stutesman)

Home Care to Home Care

Home Care to Nursing Home

Home Care to Assisted Living

 

Coordination of Care

 

Coordination of Care across multiple providers, i.e. shared care

 

Attending Physician in a Nursing Home Setting(completed by J. Stutesman)

Nursing Home Resident Regularly Visits Dialysis(Completed by M. White)

Home Care Communication with Family Physician

Home Health Care delivered to an Assisted Living Resident

Coordination of Care - Cancer

Home Care to Acute Care

 

Health Management

 

Chronic Care Management, Health Monitoring, longitudinal care coordination

 

Acute Care informs Family Physician(Completed by A. Richard)

Chronic Care Management Over Time

 

Interdisciplinary Care

 

Sharing of information across interdisciplinary care teams within a care network or provider.

 

Physical Therapist Charts to Nursing Home or Home Health Health Record(completed by J. Stutesman)

Interdisciplinary Care: Cancer Treatment Center(completed by R. Scichilone)

PT or OT to Nursing Home

PT or OT to Home Health

Rehab to Home Health

 

Orders/Consultations

 

Provision of health record summaries in context of requesting tests, evaluations and other orders. distinguished from transfer and coordination of care because service request does not assume transfer or shared oversight of care. Should we rename as Request Consultation/Prescription?

 

Physician Requests Nutrition Consultation(completed by Knight Steele)

 

Administrative Uses

 

Attachments (Billing), Pre-certification

 

Managed Care Pre-Certification Request

Part D Pre-Certification

Billing Attachments

Nursing Home Data Reporting

Home Care Data Reporting

 

System Uses

 

Synchronize health information across an organization's systems

Present views and summaries of health information to caregivers

 

Research Uses

 

Communication of deidentified health information for research purposes.(Completed by A. Richard)

 

De-identified Health Record Summary provided to Researcher(Completed by A. Richard)

Nursing Home to research

Home Care to research

 

 

Addendum, to be incorporated above

 

 

Issues to Address

 

How to organize?

How many specific "representative use cases" do we need for an area.

Incorporation of boomerang

 

Comments:

1. The "Personal Health Advocacy and Management" use case is not populated. This seems to be a unique use case in comparison to the other use cases on the list. For example, the exchange of assessments or specific functional status assessment results from providers to a PHR would enable to the individual to create and maintain what could effectively become the longitudinal patient record.

 

2. The specific use case for “Transfer from Nursing Home to Hospital Use Case” about Mrs. L describes a person with some chronic problems and an acute/emergent event that requires hospitalization. It is unclear to me what the relationship is between the assessments in the catalogue and this use case.

 

For example, in this use case there is no reference to the completion of date of the MDS. In this instance, transfer of an entire MDS assessment that may have been completed as long as 88 days earlier, may not reflect information about Mrs. L’s current health, functional, and cognitive status. Further, in a study on HIE, receiving ERs indicate that they do not want or need complete assessment forms. Instead they want/need only pertinent clinical data. ERs indicate that receiving “superfluous” information does not fit into the ER workflow.

 

Is this use case about populating the CCD with pertinent (and current) health and functional status observations extracted from clinical/progress notes in an EHR?

 

3. The list of use cases does not include a use case on transfer from nursing home to home with home health. This would be a different use case than those otherwise included. In this instance, both providers are required to use different assessment instruments that contain similar, but not comparable content. The receiving setting would like to receive the complete assessment from the referring/sending provider. Exchanging standardized assessments would enable (i) standardized information exchange (including use of CCD), and (ii) re-use of assessment content (e.g., assisting in the production of the assessment in receiving setting), and could improve continuity and quality of care, and increase efficiencies.

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