Use Case Table of Contents
FHIR Write Use Cases
Meducation Write PDF Back to EMR and Access from Patient Portal
When Meducation materials are printed out for the patient, those materials (i.e., PDF) could be stored in the patient record via storage of 1) electronic PDF file, 2) scanned PDF printout, or 3) unique Meducation identifier code can be link to the PDF. Hospitals require a record of any materials that were provided to a patient. Any document provided to patients should be tagged as "patient materials" so that they are automatically posted to the patient portal (this is how many EHRs work – if a document is tagged as being for patient use, then that document is automatically accessible from the patient portal).
Meducation transactions increment the Patient Ed Numerator for MU
When Meducation materials are printed out for the patient, or a video demonstration is played, the numerator for Meaningful Use needs to be incremented. This will help hospitals meet their MU requirements for "patient education" .
Pediatric Growth Chart Write Back of Z-Score
When a clinician sees a pediatric patient and views the pediatric growth chart, the clinician documents Z% score to be stored as part of the patients longitudinal record inside the EHR using the Pediatric Growth Chart Application.
Bilirubin Chart Writes a Transcutaneous Bilirubin Observations
To assess the risk of hyperbilirubinemia in new borns, a clinician uses a transcutaneous bilirubinometer to read the serum bilirubin levels. The clinician then documents the reading to be stored as part of the patients longitudinal record inside the EHR using the Bilirubin Chart Application.
Bilirubin Monitor Writes an Alert/Notification
When the Bilirubin Monitor sees that a bilirubin observation has not been stored for a new born within a certain amount of time after birth, it needs to raise an alert to relevant clinicians reminding them to do a serum bilirubin reading.
When the Bilirubin Monitor sees a bilirubin observation with serum bilirubin levels that exceed a certain threshold, it needs to raise an alert to relevant clinicians providing advice on how to intervene and treat the patient along with a link so the Bilirubin Chart Application can be opened directly from the Alert/Notification.
Ideally, the Bilirubin Monitor would raise alerts inside of the EHR in the way that is standard for that EHR. The goal being that alerts generated by the Bilirubin Monitor are treated the way all alerts generated by EHR are treated.
Eventing Use Cases
Bilirubin Monitor Responds to 'Baby Born' & Bilirubin Observations
When a baby's birth is documented in the EHR, the Bilirubin Monitor is notified by the EHR with an event containing enough relevant information so that the Bilirubin Monitor can query the EHR through it's FHIR services to collect relevant details about the patient.
When ever a serum bilirubin is stored in the EHR, the Bilirubin Monitor is notified by the EHR. (This could be handled by an implementation of the FHIR Subscription resource).
Work is underway to support this in the HSPC Reference Implementation.
MeducationPMI: User, On-Demand Trigger:
Clinicians can print MeducationPMI sheets (detailed instructions for a medicine) for use at bedside, prior to med reconciliation, to explain meds to patients at the time a medicine is administered – while in the hospital. An important HCAHPS measure is “Percent of patients who reported that staff "Always" explained about medicines before giving it to them.” This will help hospitals improve their performance score.
MeducationPMI: “New Med” Trigger:
When a new medicine is ordered for the patient, MeducationPMI could be automatically generated for the patient.
MeducationRS: “Ready for Discharge” Trigger:
When the patient is flagged as “Ready for Discharge” or “Initiating Patient Discharge”, Meducation should be automatically invoked, the final home-going med list sent to Meducation, and the Meducation screen populated with the discharge medication regimen summary presented to the discharge Nurse.
Backend Service Use Case
Bilirubin Monitor Is Authorized to subscribe to certain clinical event published by the EHR
The Bilirubin Monitor needs to authorized to listen to relevant events happening inside of the EHR. Such as: Baby is born, bilirubin observation written/updated. It also needs to be authorized to read patient demographics, observations, and write alerts/notifications.
Clinical Decision Support Scenario
Proposed: Comprehensive scenario demonstrating a multitude of different CDS use cases.
This scenario and its constituent uses cases are being developed by the CDS Collaboratory, a "joint venture" between the OpenCDS, Socratic Grid that will soon include other open source HSPC participants.
"A VA patient with essential hypertension is traveling in the Phoenix area and is involved in a severe car accident that leaves him severely injured and comatose. He is admitted to a local intensive care unit and is being treated, among other things, with drug XXX for hypertension. His vital signs and arterial blood pressure are displayed on a bedside CR Monitor. A Clinical Decision Support System (CDSS) monitors the patient's care and advises the clinical staff as they treat the patient for his injuries.
Use Case #1: Several days into the hospitalization, the system detects that the patient is experiencing a transient, but clinically significant (suboptimal) drop in systemic blood pressure. These dips, however, are still within the patient monitor's configured parameters and so no alarm is triggered. the dips are correlated with with each XXX administration, Typically, these transient events would be managed by a dose and/or interval adjustment if there is no risk of infection. However, the hospital is a NwHN participant and has access to the patient's VA medical history and genome profile. It determines that the patient is genetically predisposed to unpredictable responses to his XXX medication. After determining alternative therapies, the system checks a drug-allergy knowledge base, evaluates the possibilities in light of the patient's VA allergies, recommends a suitable substitute and generates the corresponding provider recommendation.
Use Case #2: When the provider fails to acknowledge the medication alert within a mandated period of time, the system escalates the message to the provider's cell phone. Upon receiving an appropriate HIPAA compliant text, the provider logins in, opens the alert, reviews several InfoButton provided references, and ultimately accepts the recommendation. The system then retrieves the corresponding orderable from an Order Catalog and the provider completes and signs the order.
Use Case #3: Several days later the patient begins to experience blood pressure dips that are not temporally related to medication administrations. The system determines that these events should be evaluated by a third party sepsis screening system to investigate a possible infectious etiology. This system responds with an appropriate alert notifying the provider that a sepsis work up is recommended.
Use Case #4: Upon recovering from his injuries, and as the patient is preparing to be discharged, the system prompts the provider to complete a suicide risk assessment as recommended for all former combat veterans. Upon completing the survey, the system scores the completed screening tool and determines that the patient is a high risk. In response, the discharging physician makes a mental health follow-up appointment and personally calls the receiving physician to ensure appropriate transition of care."
Architecture
Patient physiologic waveforms (created by a patient simulator) are displayed by bedside medical devices. These devices output data to a C4MI service that normalizes the structure and semantics of the data before passing these "real-time" events to the rest of the architecture.
The patient monitor data is analyzed by an Event Processor (providing complex event processing of waveform data) that extracts a variety of features from the event stream and publishes those features (facts) to an HL7 compliant Event Publication and Subscription Service.
The CDS system is a subscriber to the Medical Device topic in the EPS topic tree. The system also subscribes to many other topics that publish clinical events being recorded in the EMR. One of these topics is Medication Administration.
The CDS system can make requests to non-self knowledge bases to augment its own analytic capabilities - our use case illustrates an HL7 DSS call to OpenCDS to evaluate whether the patient may have sepsis. These systems can either publish their return "advice" to an appropriate EPS topic or can directly communicate back to the original CDS system.
The CDS system analyzes the data available, including any derived facts from third-party services, and publishes its final "advice" to EPS. An HL7 compliant Unified Communication Services is a subscriber to the EPS Advice topic. It is responsible for communicating advice to recipients and managing any required re-routing or escalation.
The EMR manages provider visualization of advice in part by using a Smart-On-FHIR CDS "Inbox". The Inbox is a Smart On FHIR component that plugs in to a CareWeb bedside GUI. When the provider fails to acknowledge the alert within a mandated period of time, the system escalates the message to the provider's cell phone. Upon receiving an appropriate HIPAA compliant text, the provider logins in, opens the alert, reviews several InfoButton provided references, and ultimately accepts the recommendation.
The CDS system can process and display HL7 HeD compliant structured documents, order sets and simple rules. In our use case, the provider is presented with a Suicide Risk assessment. The system can evaluate a completed form/survey using an HeD provided rule, and notifies the provider that the patient is at high risk.
