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Use Cases for Medical Summaries

Explore the various use cases for medical summaries in patient care coordination, including coordination across providers, patient problems, and time. Learn how to structure free text and identify relevant sections and documents.

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Use Cases for Medical Summaries

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  1. Use Cases for Medical Summaries Lawrence McKnight, MD Siemens Medical Solutions Co-Chair IHE-PCC Planning Committee Use Cases for Medical Summaries

  2. Patient Care Coordination • Coordination of Care • Across Providers • Across Patient Problems • Across Time • Building on Success of XDS • Mix of Data types • Currently unstructured text primarily • +/- mix of structured data. Use Cases for Medical Summaries

  3. What's In a Document H&P Chief Complaint HPI Problems Labs Meds Allergies ROS Exam VitalSigns Etc… Use Cases for Medical Summaries

  4. What's In a Document H&P Discharge Summary Chief Complaint Chief Complaint HPI Problems HPI Problems Labs Problems Meds Labs Labs Meds Meds Allergies Allergies ROS ROS Exam VitalSigns Hospital Course Etc… Etc… Use Cases for Medical Summaries

  5. Where to Begin? • Given: Much of the most clinically relevant data in EMR's are stored as free text. • Given: Structured/Unstructured must live together. • Where to begin/end structuring of free text? • View • Import / Reconcile • Decision Support • What are the most relevant sections? • What are the most relevant documents? Use Cases for Medical Summaries

  6. Domain Experts • Practicing Physicians • Specialty Groups • ACP, AMA, AFP, ACEP • Standards Groups • SNOMED, HL7 • Consultants, Industry Analysts • Hospital Systems / Institutions • Health Care IT Companies • Large • Small • Ambulatory • Acute Use Cases for Medical Summaries

  7. Areas to Focus • Roadmap • Transfer of Care • Start with Medical Summary • More than simple Transfer of Information • Explicit Transfer of Responsibility Use Cases for Medical Summaries

  8. What's in a Medical Summary? Broad Permanent Care Episode Care Collaborative Care Problem Scope Focused Focused Broad Intended Audience Use Cases for Medical Summaries

  9. Medical Summary • Episode Care • Purpose to summarize an episode • Author participation in care continues (generally) • Scope is problems involved in episode • Ex: Admit H&P, Discharge Summary, Procedure Note • Collaborative Care • Purpose is request help in Patient Management • Scope involves focus on a problem • Broad Audience is a side effect • Ex: Referral, admit to long term care • Permanent Care: • Purpose is Transfer Care • Author participation in care does not continue • Scope involves all aspects of care • Ex: discharge from military, patient relocation Use Cases for Medical Summaries

  10. Storyboarding • A process to help define the Use Case story. • Time • Pre-conditions • Events • Post-conditions • Interactions • Actors Use Cases for Medical Summaries

  11. UC1: Referral • Outpatient PCP  Specialist • "Collaborative Care" Medical Summary • Preconditions: • Referring Physician Office with EMR • Specialist Office with EMR • Data elements available • EMR's connected in RHIO environment Use Cases for Medical Summaries

  12. UC1: Events for PCP • Pick Specialist • Create Request • Select Data Elements • Review / Sign • Give request to Staff:Alternate flows • Staff obtains Consent • Obtain Payer Authorization Number • Create Copies • Attach additional paperwork Use Cases for Medical Summaries

  13. UC1: Events for Specialist • Office Staff Review Request • Physician Views Information • Optional Import • Optional Query for more info Use Cases for Medical Summaries

  14. UC2: Discharge • Inpatient  PCP • "Episode" Medical Summary • Preconditions: • Hospital and PCP with EMRs • Data elements available defined • EMR's connected in RHIO Use Cases for Medical Summaries

  15. UC2: Events for the InPatient Author • Select Data Elements • Review / Sign Use Cases for Medical Summaries

  16. UC2: Events for PCP Office • Office Staff Review Request • Physician Views Information • Optional Import • Optional Query for more info Use Cases for Medical Summaries

  17. Activity Diagram Profile Use Cases for Medical Summaries

  18. Referral-Reason Chief-Complaint HPI Active-Problems Current-Medications Allergies Past-Medical-History ROS Vital-Signs Physical-Exam Relevant-Procedures Relevant-Tests Administrative-Identifiers Insurance Major Sections:Referral Note Use Cases for Medical Summaries

  19. Admit-Date Discharge-Date Roles Chief-Complaint HPI Hospital-Course Discharge-Diagnosis Active-Problems Resolved-Problems Discharge-Medications Meds-Administered Allergies Discharge Diet ROS Vital-Signs Physical-Exam Functional-Status Relevant Procedures Relevant Tests Plan Of Care Administrative-Identifiers Insurance Major Sections:Discharge Summary Use Cases for Medical Summaries

  20. Discussion Outcomes • 3 Common Sections – Always relevant • Problems • Meds • Allergies • UC1: Referral • Reason for Referral • UC2: Discharge Summary • Hospital Course Use Cases for Medical Summaries

  21. ? Use Cases for Medical Summaries

  22. More information…. • IHE Web sites: www.ihe.net • Technical Frameworks, Supplements • Fill in relevant supplements and frameworks • Non-Technical Brochures : • Calls for Participation • IHE Fact Sheet and FAQ • IHE Integration Profiles: Guidelines for Buyers • IHE Connect-a-thon Results • Vendor Products Integration Statements Use Cases for Medical Summaries

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