Cardiac Episode with PCP referral to Cardiologist with Remote Monitoring & Follow-up Care

Care Theme: Transitions of Care

Use Case 9

Interoperability ShowcaseIn collaboration with IHE

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 (MU) Relevance:

• Improving Care Coordination – Exchanging key information among authorized care providers

• Improving Quality, Safety, Efficiency, and Reducing Health Disparities

Clinical Workflow: A patient has a syncopal episode at home and visits his PCP. The PCP refers the patient to a Cardiologist. The Cardiologist orders home monitoring. The patient monitors themselves at home and the Remote Monitoring Management System provides the results to the Cardiologist. The Cardiologist reviews the studies, adjust the medication and continues the home monitoring. Based on the new results the Cardiologist refers the patient to a Geriatric specialist who will continue to leverage the home monitoring care regimen.

Care Theme: Transitions of CareUC 9: Cardiac Episode with PCP referral to Cardiologist with Remote Monitoring & Follow-up Care

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

specialist3. 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 Home Setting

6 – Specialist

2 – Cardiologist

4 – Remote Monitoring Management Service

Clinical Workflow:

Care Theme: Transitions of CareUC 9: Cardiac Episode with PCP referral to Cardiologist with Remote Monitoring & Follow-up Care

5 – Cardiologist

3 – Monitoring Devices

5a – Monitoring Devices

Domain Profile Vendors Actors

Patient Care Coordination

(PCC)

XDS NextGen, Content Creator, Content Consumer

XDS Wellogic, 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 Repository

XDS.b Acuo Registry

IHE Profiles & Domains:

Care Theme: Transitions of CareUC 9: Cardiac Episode with PCP referral to Cardiologist with Remote Monitoring & Follow-up Care

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