PCC TF-1/PPHP

PPHP Integration Profile

Patient Care Coordination relating to same day procedures or ambulatory procedures that require anesthesia generates an extensive collection of data that must be available prior to the procedure to evaluate and / or ameliorate risk. This same data is required on the day of the procedure to adequately prepare the peri-operative and post-procedure teams for any special needs a patient may require. Medical Diagnoses, proposed procedure, authorizations, laboratory and imaging studies, and the pre-procedure History & Physical, and other data gathering must all be performed in the ambulatory environment prior to scheduling a procedure in order to pre-operatively evaluate the risk of both the anesthesia and the procedure itself. A procedure risk assessment must be present and evaluated by the operative and after-care teams before the patient is allowed to have the procedure. Missing information is frequently a reason for canceling the procedure for the day, which leads to expensive underutilization of resources and dissatisfied patients. Further, incomplete information about the patient's clinical or home status may create a situation where a procedure is performed that ultimately results in an injury, inadequate aftercare or other undesirable outcome.

Actors/Transaction

There are two actors in the PPHP profile, the Content Creator and the Content Consumer. Content is created by a Content Creator and is to be consumed by a Content Consumer. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE profiles described below, and is out of scope of this profile. A Document Source or a Portable Media Creator may embody the Content Creator Actor. A Document Consumer, a Document Recipient or a Portable Media Importer may embody the Content Consumer Actor. The sharing or transmission of content or updates from one actor to the other is addressed by the use of appropriate IHE profiles described in the section on Content Bindings with XDS, XDM and XDR.

PPHP Actor Diagram

Options

PPHP Options

Actor	Option
Content Consumer	View Option (1)
	Document Import Option (1)
	Section Import Option (1)
	Discrete Data Import Option (1)

Note 1: The Actor shall support at least one of these options.

Content Consumer Options

View Option

This option defines the processing requirements placed on Content Consumers for providing access, rendering and management of the medical document. See the View Option in PCC TF-2 for more details on this option.

A Content Creator Actor should provide access to a style sheet that ensures consistent rendering of the medical document content as was displayed by the Content Consumer Actor.

The Content Consumer Actor shall be able to present a view of the document using this style sheet if present.

Document Import Option

This option defines the processing requirements placed on Content Consumers for providing access, and importing the entire medical document and managing it as part of the patient record. See the Document Import Option in PCC TF-2 for more details on this option.

Section Import Option

This option defines the processing requirements placed on Content Consumers for providing access to, and importing the selected section of the medical document and managing them as part of the patient record. See the Section Import Option in PCC TF-2 for more details on this option.

Discrete Data Import Option

This option defines the processing requirements placed on Content Consumers for providing access, and importing discrete data from selected sections of the medical document and managing them as part of the patient record. See the Discrete Data Import Option in PCC TF-2 for more details on this option.

Cross Enterprise Document Sharing, Media Interchange and Reliable Messaging

Actors from the ITI XDS, XDM and XDR profiles embody the Content Creator and Content Consumer sharing function of this profile. A Content Creator or Content Consumer may be grouped with appropriate actors from the XDS, XDM or XDR profiles to exchange the content described therein. The metadata sent in the document sharing or interchange messages has specific relationships or dependencies (which we call bindings) to the content of the clinical document described in the content profile.

The Patient Care Coordination Technical Framework defines the bindings to use when grouping the Content Creator of this Profile with actors from the IHE ITI XDS, XDM or XDR Integration Profiles.

Preprocedure History and Physicals Bindings

Content	Binding	Actor	Optionality
Preprocedure History and Physical Content Module	Medical Document Binding to XD*	Content Creator	R
		Content Consumer	R

PPHP Document Content Module

A Pre-procedure History and Physical content document is a type of medical document, and incorporates the constraints defined for medical documents found in section PCC TF-2: 5.1.4.2 Medical Document above. In addition, the PPHP content profile includes additional information to support the reasons for the procedure as well as the assessments of procedure risk and anesthesia risk.

PPHP Process Flow

This use case involves a sequence of events leading up to the patient's admission to the operating room in a surgical center. Included in these events is the creation and communication of the pre-procedure history and physical document required by quality review organizations prior to most surgeries.

Precondition: The patient's primary care physician sees the patient for a problem that may require or benefit from an interventional modality (procedure). That patient is given a diagnosis related to a possible beneficial procedure and referred to a specialist for consultation. A surgical specialist sees a patient, determines the patient requires surgery, obtains pre-authorization from the payer, orders lab and imaging, schedules the surgery with the surgical coordinator, and refers the patient back to the primary care physician for pre-surgical H&P to be done in the primary care physician's office. The surgical consultation results, including the proposed procedure to be performed to address medical diagnosis, duration of procedure, estimated blood loss, and any special positioning required for the procedure, are available electronically to the primary care physician at the time of the H&P.

Events: The patient is seen in the primary care physician's office where a complete medical and relevant social history are taken by the nurse and recorded in the office EHR, incorporating data from the surgeon's consultation report as appropriate. Laboratory and imaging reports ordered by the surgeon as well as the surgeon's consultation report are displayed electronically to the primary care physician. The physician reviews the consultation report from the surgeon's office and pre-operative studies ordered by the surgeon along with data recorded by the nurse. Physical exam reveals some abnormalities. The physician orders additional laboratory, and the patient leaves the office. When the laboratory results return, the physician completes the pre-surgical H&P, Allergies, Medications, includes the data prepared or ordered by the surgeon, and makes it available to the surgeon and surgical center. This data includes an assessment of the patient's health status compared to the risk of the type of anesthesia planned and the the procedure itself. The surgical coordinator documents that the complete collection of documents needed for surgery is available and administratively certifies that the patient is ready for surgery. The Surgical Center discharge planning is notified and assures that there is a suitable environment with appropriate support for post-procedure after-care .

Postcondition: The Pre-surgical H&P with appropriate relationships to the Surgical Consultation and all the pre-operative laboratory and imaging are available to the surgeon and the surgical center personnel for incorporation into their respective EHR's. The H&P is also available to the patient for viewing and incorporation into the patient's PHR.

Potential Stakeholders: Patient, primary care physician, pre-procedure physician (if different), surgeons, anesthesiologist, schedulers, insurance authorization, bed control, supply procurement, pre-op/OR/post-op care teams, discharge planning and billing personnel.