Care Theme: Transitions of Care
description
Transcript of Care Theme: Transitions of Care
Care Theme: Transitions of CareUse Case: Optimizing Cardiac Care Oversight by Leveraging Home-based Devices and Remote Monitoring Care Regimens
Primary Goal: To demonstrate how the use of remote monitoring of home-based medical devices following a syncopal episode at home will improve the follow-up care for the patient by the Cardiologist and Home Nursing Service specialized in Geriatric care.Key Points: • The demonstration will use the IHE Cross-enterprise Document Sharing profile for exchange of medical summary
information between electronic health record (EHR) Systems and Remote Monitoring Management Systems (RMMS). • Helps with the transition of the patient’s care plan from the hospital setting to the home setting.• Allows device data to be captured automatically in EHR systems which reduces workflow complexity.Meaningful Use Relevance: • Improving Care Coordination – Exchanging key information among authorized care providers • Improving Quality, Safety, Efficiency, and Reducing Health Disparities
IHE Profiles & Actor
s
Domain Profile Vendors Actors
Patient Care Coordination (PCC)XDS NextGen, Content Creator, Content Consumer
XDS Alere ACS, Truven Content Consumer
Personal Health Monitoring Record (PHMR) PHMR LNI/Continua Content Creator
IT Infrastructure (ITI)
XCA AEGIS, Infor Cloverleaf Initiating Gateway, Responding Gateway
XDS.b Truven Registry, Repository
XDS.b Acuo Registry, Repository
Use Case 9
1. A patient visits with his PCP following an episode at home. The PCP refers the patient to a cardiologist.
2. The cardiologist reviews the information from the PCP and prescribes home monitoring and follow-up with the home monitoring specialist
3. At home, a home nurse service has assisted the patient with the setting up of the remote monitoring equipment. The physiological monitoring information is captured regularly and forwarded to the Remote Monitoring Management Service (RMMS) engaged for the patient.
4. The RMMS creates and publishes a patient summary of the monitoring information to the community HIE making it available for access by the EP office in accordance with the home monitoring regimen.
5. The Cardiologist reviews the results of the study and adjusts the medication regimen and continues home monitoring.
6. The Geriatric specialist reviews the data from the RMMS.
1 – PCP 3- Home Setting
6 – Specialist
2 – Cardiologist
4 – Remote Monitoring Management Service
Clinical Workflow:
Care Theme: Transitions of CareUse Case: Optimizing Cardiac Care Oversight by Leveraging Home-based Devices and Remote Monitoring Care Regimens
5 – Cardiologist
3a – Monitoring Devices
5a – Monitoring Devices
HIE1| HIE2
HIE2| HIE1
Visit the IHE Product Registry at: ihe.net/registry
HIE1| HIE2