Patient Care Workflow

1. Proposed Profile: Patient Care Workflow

• Proposal Editor: Kboone, TKuhn
• Profile Editor: TBD
• Date: N/A (Wiki keeps history)
• Version: N/A (Wiki keeps history)
• Domain: PCC

2. The Problem

Chronic disease care delivery requires continuous coordination of the activities of multiple healthcare providers in multiple settings. A patient may see multiple specialist doctors and other clinicians on a recurrent basis along with a Primary Care Provider (PCP). Many patients have more than one chronic problem in additional to acute episodes. In the current, fragmented health care delivery system, each of a patient’s providers may be unaware of other providers that are treating the patient. Testing and therapies are often duplicated, resulting in unnecessary costs and risks to the health of the patient. Lack of coordination can also result in failure to follow-up on the delivery of ordered services, again adding risk to the patient’s health. In some cases, multiple providers receive copies of reports of services performed, such as laboratory tests, but this can cause confusion among providers over who is primarily responsible for addressing the results.

An emerging approach to coordination of health care delivery is intended to address these problems as well as providing additional benefits to the entire system. This approach is commonly called the Patient-Centered Medical Home (PCMH). In this approach, the patient selects a provider who serves as the patient’s medical home. This provider is responsible for keeping track of all of the care a patient is receiving from all of the clinicians with which the patient deals. This model is the very kernel of the activities which the IHE Patient Care Coordination Domain aspires to facilitate.

Successful coordination of a patient’s health care can not be accomplished without IT support for the key workflow steps involved. The patient’s medical home will need the capability to track all of the patient’s providers and all of their care activities. The medical home will also have to serve as a communications hub among all of the patient’s providers, ensuring that each is aware of relevant actions by others. Finally, each provider of care to the patient will need the capability of automatically informing the medical home of actions involving the patient.

3. Key Use Case

1. Patient visits his Primary Care Provider (PCP) for a health issue. (Note: It is conceivable that patient comes in for a preventive visit and a reason for consultation is discovered.)

2. PCP evaluates the health issue, and makes a determination that the patient needs to be referred to a specialist.

3. Patient and PCP decide on a specialist based upon their preferences, insurance restrictions, etc.

4. PCP writes an order, or creates a referral letter to give to the specialist. (Note: There may be standardized referral forms from the payer or state (i.e., Maryland has a Universal Referral Form); in some cases, the referral is given to the patient, in others faxed to the specialist; if the patient schedules the visit, then he/she would need the referral)

5. Patient contacts the specialist for an appointment. (Note: Again, could be patient, office, physician (especially for an urgent/emergent referral))

6. Patient visits specialist, fills out form indicating problems, meds, allergies, reason for visit, insurance information, et cetera.

7. Front desk enters information into Specialist EHR.

8. Specialist reviews patient details, and interviews patient.

9. Specialist contacts PCP for more detail.

10. PCP faxes copy of details to specialist. (Note: Some of this information can be transmitted verbally; other information might come from lab or hospital…)

11. Specialist orders follow-up treatment with another healthcare provider.

12. Patient contacts the follow-up provider for an appointment.

13. Patient visits follow-up provider, fills out form indicating problems, meds, allergies, reason for visit, insurance information, et cetera.

14. Front desk enters information into follow-up provider EHR.

15. Patient receives treatment from follow-up provider.

16. At next visit to primary care provider, PCP asks patient for an update on referral.

Post-profile Use Case

"I am ordering something that I can’t do myself, and I what to know what happens . . ."

1. Primary Care Provider (PCP) sends order for consult and summary report to Specialist 1.
2. Specialist 1 requests additional information from PCP.
3. PCP responds with additional information.
4. Specialist 1 orders tests.
5. Specialist 1 receives results and forwards them to PCP with update note.
6. Specialist 1 sends order for consult and summary report to Specialist 2.
7. Specialist 1 sends summary report and note to PCP.
8. Specialist 2 requests additional information from Specialist 1.
9. Specialist 1 responds with additional information.
10. Specialist 2 sends report to Specialist 1.
11. Specialist 1 sends copy of report and note to PCP.

The Ultimate Use Case

Dr. Z and Mrs. Murphy

Practice Setting: Dr. Z is an internist in a small primary care practice with three internists. The practice, uses an electronic medical record (EMR) integrated with a practice management system. The EMR provides secure access to authorized external providers through a health information exchange portal.

Clinical Care: Mrs. Murphy is an 85-year-old woman with several chronic medical problems including type II diabetes mellitus, congestive heart failure, atrial fibrillation, and based on a recent assessment by Dr. Z, mild dementia. For these conditions, Mrs. Murphy takes several medications, including oral medication for diabetes, an anticoagulant (warfarin) and digoxin for her atrial fibrillation, a diuretic (“water pill”) and a beta-blocker for her congestive heart failure, and an angiotensin converting enzyme inhibitor. While Mrs. Murphy has been generally compliant with her visits, Dr. Z is somewhat concerned because she missed an appointment with him today, and as his assistant reviewed the practice management system, she noted that Mrs. Murphy also missed a telephone follow-up visit with a cardiologist and a laboratory visit, where a test for her anticoagulation status (ordered by another doctor in the practice) and a chemistry profile (ordered by the cardiologist) were to be done. Dr. Z reviews the note from the most recent cardiology visit and becomes even more concerned when he sees that the cardiologist increased the dose of Mrs. Murphy’s diuretic because of some shortness of breath, weight gain, and swelling during the last visit. Dr. Z also notes that Mrs. Murphy was seen by the on-call doctor in the practice 5 days previously with a fever and a cough and was prescribed an antibiotic. The other physician coordinated the anticoagulation test with the scheduled visit to Dr. Z because she could see the appointment in the practice system and was prompted to consider the test by the EMR’s clinical decision support program, which reminded her of the potential for antibiotics to interact with anticoagulation medication. As Dr. Z contemplates the best course of action, he receives a secure e-mail from the pharmacist managing Mrs. Murphy’s anticoagulation indicating some concern because he was aware of her visit to the on-call physician and expected Mrs. Murphy to get her laboratory test earlier that morning.

Dr. Z calls Mrs. Murphy, and after several rings, she picks up the phone. Mrs. Murphy is clearly somewhat out of breath but professes to be doing well. She indicates that her cough is better but doesn’t recall her appointment today or the scheduled laboratory tests. Dr. Z knows that the practice management system automatically calls to remind patients 1 day in advance for every appointment, including important scheduled laboratory tests, such as anticoagulation monitoring. His assistant confirms by checking the system that Mrs. Murphy was called and answered the phone yesterday afternoon. Based on his conversation with Mrs. Murphy, Dr. Z decides that rather than upset her by calling an ambulance or asking her granddaughter, who is her primary family caregiver, to take her to the Emergency Department, he will ask the home health agency nurse to make a visit this afternoon. Through a secure e-mail exchange, Dr. Z initiates an urgent referral to the affiliated home health agency to set up a visit for that afternoon to check on Mrs. Murphy. Within a few minutes, the home health agency confirms that Nurse A, with whom Dr. Z usually works, is available and will make a point to see Mrs. Murphy within the next 2–3 hours.

Dr. Z returns to seeing patients. About 3 hours later, he receives a secure e-mail notification from Nurse A indicating that she wants urgently to meet with Dr. Z . Dr. Z excuses himself from the patient he is seeing and calls his assistant into the examination room to provide some just-in-time education to his patient while he meets with Nurse A. After going to his office, Dr. Z clicks on the video link to Nurse A and simultaneously opens up the progress note already started by Nurse A. He can see immediately that Mrs. Murphy has a temperature of 101 ºF, has gained about four pounds, and has an elevated blood pressure. The whole blood glucose done by Nurse A is also recorded and is significantly higher than her usual random glucose. Nurse A joins the video call and shares that Mrs. Murphy is in moderate distress and pans the video cam to Mrs. Murphy sitting on the edge of her bed, leaning forward. Nurse A points out that Mrs. Murphy has some bruising on her arms and lower extremities and raises the potential that Mrs. Murphy may be over-anticoagulated. Dr. Z can clearly see that the mild shortness of breath he heard over the phone is either worse than he perceived, or Mrs. Murphy’s condition has deteriorated in the past few hours. Dr. Z decides that the best and safest way to quickly manage Mrs. Murphy multiple medical problems is to admit her to the hospital. Nurse A agrees to call the ambulance transport company and remain with Mrs. Murphy until they arrive. During that time she completes her assessment and contacts Mrs. Murphy’s granddaughter.

Dr. Z documents his assessment and plan in the EMR and then sends a clinical record summary to the hospital admitting department with his initial admitting orders via secure e-mail. The e-mail is also sent to the cardiologist and endocrinologist with a copy to the pharmacist to alert them that Mrs. Murphy is to be admitted and requesting that the cardiologist assist in the management of what he expects to be complications related to worsening congestive heart failure. Dr. Z is sent a secure e-mail when Mrs. Murphy arrives at the hospital. Mrs. Murphy is taken to an assessment area where laboratory tests, an electrocardiogram, and a chest x-ray are completed per Dr. Z’s orders. Shortly thereafter, Dr. Z arrives to see Mrs. Murphy and accompanies her up to the hospital room.

Mrs. Murphy is treated for pneumonia, congestive heart failure, and excess anticoagulation. The morning after her admission, a hospital discharge planner visits her and reviews her clinical record. The discharge planner notes that Mrs. Murphy lives alone and sees the recent diagnosis of mild dementia. At the multidisciplinary hospital discharge planning team meeting that afternoon, Mrs. Murphy’s case is discussed and the planners decide to recommend a new remote monitoring program to Dr. Z for Mrs. Murphy. At the time of discharge, Mrs. Murphy is accompanied home by Nurse A. When they arrive at Mrs. Murphy’s apartment, a technician from the remote monitoring program is already waiting for them. While Nurse A reviews Mrs. Murphy’s medication and self-management goals, the technician installs a wireless network hooked up to a secure internet connection. He places a scale in Mrs. Murphy’s bathroom, a docking station for Mrs. Murphy’s pill bottles, and a home glucose monitor, all connected wirelessly to the computer. Nurse A explains to Mrs. Murphy that Dr. Z will monitor her condition through the computer and that Nurse A will be helping Dr. Z. Mrs. Murphy doesn’t understand how it all works, but she agrees to weigh herself in the morning, take her pills when she hears the reminder from the pill bottle docking station, and check her sugar in the morning. Mrs. Murphy agrees that her granddaughter will be informed about these new interventions.

A couple of days later, both Dr. Z and Nurse A get an automated alert via secure e-mail that Mrs. Murphy has gained two pounds in the past 2 days. After a quick e-mail exchange, Nurse A calls Mrs. Murphy and per Dr. Z’s order, asks Mrs. Murphy to take an extra diuretic pill now and one at 6 p.m. tonight. Via the internet, Nurse A is able to reprogram the medication reminder system to prompt Mrs. Murphy to take the correct dose at the correct time. At 6:30 p.m., Nurse A receives a notification from Mrs. Murphy’s computer that the diuretic pill bottle has not been opened or moved since noon. Nurse A calls Mrs. Murphy who admits that she has been entertaining a friend and hadn’t taken her pill yet but promises to do so in the next few minutes.

4. Standards & Systems

Systems

• EHR Systems
• Practice Management Systems
• HIS Systems
• ADT Systems

Standards

• HL7 Version 2.X
• HL7 Version 3.X
• HL7 CDA Release 2.0
• ASTM/HL7 Continuity of Care Document
• Web Services
• SOAP
• HTTP
• DNS
• SMTP
• MIME
• S/MIME

5. Discussion

The interoperability requirements of patient care workflow can be thought of as support for a conversation between two or more clinicians at each step. What is needed is a simple nomenclature for the workflow steps, to serve as triggers, and specification of the payloads and communication methods that are appropriate for the steps. It is assumed that, for most steps, copying and forwarding of existing messages and documents, with appropriate “covers” will be sufficient.

The workflow for exchange of information between providers needs to address:

• Ordering
• Scheduling
• Communications between Providers
• Task Lists
• Reporting

IHE would be a good venue to solve this problem because it reflects a need to support the integration of several standards together.

Open Issues

Critical to the success of care coordination is the unambiguous identification of patients, provider organizations, and individual clinicians.

Whenever a clinician receives a copy of a report concerning a patient, it must be absolutely clear to the clinician what if any responsibility he or she has to follow-up on the details of the report.