Care Theme: Transitions of Care

1. Use Case 10 Care Theme: Transitions of Care Use Case: Promoting Medical Home Care Team Coordination via Timely Data Access and Sharing • Primary Goal:To demonstrate the exchange of patient health data among multiple systems belonging to a single or to multiple organizations including electronic medical record (EMR) systems, Health Information Exchanges (HIEs), Personal Health Record (PHR) systems, and other stakeholder systems for medical home care. • Key Points: • Using a host of IHE profiles this demonstration illustrates how a patient’s health data is shared across providers in multiple communities for medical home care agreement. • Recent health data is exchanged in an accurate and secure manner between HIEs in two different regions. IHE Profiles & Actors

2. Use Case 10 Care Theme: Transitions of Care Use Case: Promoting Medical Home Care Team Coordination via Timely Data Access and Sharing Clinical Workflow: 4 – Health Plan / Payer 1 – Medical Home agreement 3 – Emergency Room 2 – PCP 6 – Patient Home 5 – PCP A Patient Centered Medical Home contract has been signed between a primary care practice and a payer. As a result of this agreement, the PCP establishes a relationship with the community HIE to gain access to any medical treatment or encounters for the patients included in this target patient population. Patient is being seen by their PCP and is found to be non-compliant with their home medical management and is referred to the Emergency Room (ER) for emergency medical treatment of Hyperglycemia. The physician office note is registered with the community HIE. The ER physician retrieves the PCP office visit from the community HIE. Patient is evaluated and treated in the ER. Patient is anticipated to be discharged home and it is determined that discharge planning is required because the patient has been non-compliant with their established plan of care. The medical summary for this encounter is registered with the community HIE and is available for retrieval. The ER sends Florida Blue the Discharge Summary electronically. The patient is discharged home. Prior to the patients 10 day follow-up appointment the PCP retrieves the prior office visit and discharge summary for review. Patient data is available on the patient’s portal and available to view. Visit the IHE Product Registry at: ihe.net/registry