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Care Theme: Transitions of Care. Supporting the Medical Home Model of Primary Care. Us Case 5. Interoperability Showcase In collaboration with IHE. Use Case 10. Care Theme: Transitions of Care Use Case 10: Supporting the Medical Home Model of Primary Care.

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Care Theme: Transitions of Care

Supporting the Medical Home Model of Primary Care

Us Case 5

Interoperability Showcase

In collaboration with IHE

Use Case 10


Care Theme: Transitions of Care

Use Case 10: Supporting the Medical Home Model of Primary Care

  • 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 – including PIX, XDS, XCA, XPHR, ARR, DSUB, XDS-MS and others, 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.

  • Demonstration of how care givers get latest notification for health document subscription.

  • Meaningful Use (MU) Relevance:

    • Improving quality, safety, efficiency, and reducing health disparities

    • Engage patients and families in their healthcare

    • Improve care coordination

  • Clinical Workflow:

  • A Patient Centered Medical Home contract has been signed between a primary care practice and a payer. Per the terms of this Medical Home agreement, each patient is required to use a Personal Health Record/PHR system to maintain its patient demographics, family history and information regarding adherence to the care plan. As a result of this agreement, the PCP establishes a clinical notification subscription with the community HIE to be informed of and gain access to any medical treatment or encounters for his target patient population.

  • A diabetic patient who is part of this target population has had a recent encounter at the PCP office and a local emergency room due to complications stemming from this diabetic condition. The medical summaries for all the encounters are registered with the community HIE which then are available for retrieval. The PCP retrieves the clinical summaries and documents the care plan for this patient. The PCP having retrieved and reviewed the complete patient history and summary of recent encounters, shares the care plan which includes guidance regarding diet and exercise with the patient and updates the PHR for mutual progress tracking and reporting.


A Patient Centered Medical Home contract has been signed between a primary care practice and a payer.

Per the terms of this Medical Home agreement, each patient is required to use a Personal Health Record/PHR system to maintain health data regarding her adherence to the care plan.

  • Medical Home Agreement

Health Information Exchanges

(HIE1 /HIE2)

EMR

  • PCP Office

As a result of this agreement, the PCP establishes a clinical notification subscription with the community HIE to gain access to any medical treatment or encounters for the patients included in this target patient population.

2. Patient Home

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 ER case manager coordinates the immediate discharge plan.

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.

3. ED

PHR

Florida Blue receives the electronic discharge summary and continues ongoing care coordination with the PCP and patient/member.

Prior to the patients 10 day follow-up appointment the PCP retrieves the prior office visit and discharge summary for review. The patient sees their PCP and the PCP updates the plan of care to help achieve the patients care goals. The PCP shares the office visit/care plan, which includes education regarding diet and exercise with the patient and sends it to the HIE which updates the patients PHR for mutual progress tracking and reporting.

4. ED

Services: Secure Transport Infrastructure, Content Creator, Content Consumer, DSUB, XCA.

Data Stores: Document Registry, Document Repository, Audit Repository, MPI, EMR, PHR

5. Infrastructure


Care Theme: between a primary care practice and a payer. Transitions of Care

Use Case 10: Supporting the Medical Home Model of Primary Care

IHE Profiles & Domains:

Visit the IHE Product Registry at: ihe.net/registry


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