1.0 Overview

The Sirona Unified Collaboration Portal framework (UCP) is a modular platform that helps health care providers communicate and collaborate with their patients on health care matters. It provides access to clinical data, documents, diagnostic guidance, risk analysis, decision support, and planning tools that help providers assess their patients' medical data, their relative risk for specific diseases and to leverage rules and workflows during their diagnostic workups. Medical facility administrators can use a resource-capacity simulator to optimize resources (staff, rooms, equipment, and so on) needed to care for their patients. Such optimization increases capacity and improves access to care.

Sirona allows patients to access many of the same tools and clinical resources used by providers. Sirona also provides a range of opportunities to educate patients on a broad spectrum of health care topics, and through its collaboration services, facilitates active participation in their treatment and recovery. Through use of the Sirona patient tools, patients can better understand their conditions, their treatment plans, and can collaborate with their health care providers to fashion and implement a coordinated plan for achieving and sustaining health.

1.1 System Description

Sirona is a web-based application divided into three groups of general functionality, accessible to both providers and patients according to their status and role.

• General Education: Both unauthenticated and authenticated users can access certain portal resources without logging in. Users can browse general help topics and news, request an account, take a feature tour, and other tasks appropriate to site navigation.

• Patient Functionality: Only authenticated patients can access this layer of Sirona, which provides access to their medical record (PMR), a Patient Inbox for receiving and sending messages related to their health care, and management tools, such as a unified calendar and health care address book.

• Provider Functionality: Only authenticated health care providers can access this layer. It contains tools to review patient medical records through the Electronic Medical Record (EMR) application, send emails/alerts/documents to patients and colleagues, and receive Clinical Decision Support alerts. Additional clinical tools include capabilities to assess a patient risk for disease and determine a diagnosis. The portal allows authorized providers to access a CDS workbench to author rules that support clinical decision-making, and a simulator to optimize resources at their medical facilities.

Both providers and patients log in on the same page. Sirona, based on user type, directs the user to the appropriate portal application, Patient Portal (PMR) or Provider Portal (EMR). While each application has its own theme colors, layout, and functionality, the intent behind the common login is to re-enforce that patient and providers are a team collaborating on a common goal.

1.3 About This Document

This document describes the functional requirements for the Sirona portal framework. It provides a high-level understanding of the features available to all users, both authenticated and unauthenticated.

1.3.1 Audience

The following stakeholders are the audience for this document:

• Business analysts and users

• Architects looking for a broad description of the Sirona Unified Care Portal and its applications

• Developers

1.3.2 Document Organization

Section 1.0 describes the audience, scope, relevant terminology, reference documents, and documentation for the Unified Collaboration Portal.

Section 2.0 provides a description of the Sirona Home and site navigation pages that introduce the main portal application and the other modules comprising the system. It also describes the functional requirements defining account access and site navigation.

Section 3.0 describes the Patient Portal and the functional requirements governing the patient Universal Inbox and Patient Medical Record, as well as patient organizing tools, such as the Calendar and Personal Info features.

Section 4.0 describes the Provider Portal and the tools that authenticated providers can use to monitor patient medical records, analyze risk for disease, support clinical decision-making, and run disease probability and diagnostic processes. This section provides functional requirements for the Medical Records, Clinical Analytics, and Diagnostic Guide tools. The tools that facilitate clinical decision support and resource capacity optimization, also accessed through the Provider Portal, are described in separate documents referenced below.

1.3.3 Reference Documents

• Resource Capacity Simulator functional requirements are described in Requirements - Resource

Capacity Simulator

• Clinical Decision Support Workbench functional requirements are described in Requirements - Clinical Decision Support Workbench

• The functional scenarios that provide examples of how to use the Sirona Unified Care Portal are described in Requirements – Scenarios

2.0 General Portal Functionality

A major goal of the Sirona system is to create a collaborative health care team that includes the patient and his or her circle of medical professionals. To that end, the Sirona Unified Collaboration Portal platform provides a broad base of general information on treating disease and establishing a healthy lifestyle that unauthenticated users can access. After perusing the information provided on general health and well being, users can request that accounts with greater access and functionality be established for them.

Accounts require specific security measures and access-control procedures. Although a potential user can request an account online, actual account creation typically requires an in-person meeting with a System Administrator at the relevant medical facility. Patients requesting access must have been enrolled in the Healthcare Plan and must have a Primary Care Manager who serves as guide and mentor when patients have questions or concerns regarding the data they can now access.

This section describes the functional requirements for account creation and access, and for unauthenticated site navigation. The following figure provides a screenshot of the home login page, showing the three main tabs and the site navigation footer: Log In, About, and Medical News:

2.2 Log In Tab

The Sirona Unified Collaboration Portal platform is a controlled environment that meets HIPAA security and privacy regulations. New users must establish accounts in person, using any administrative process approved by their medical facility. Once enrolled in the Sirona system, patients and providers both use the standard user name /password log-in procedure on the Portal Home Page, or for convenience, a Common Access Card (CAC). Although the enrollment process must be completed in person, patients and providers can request an account online using the UCP user interface to expedite the onsite enrollment process. For authenticated users who lose their password, UCP provides a tool for resetting passwords.

The Log In tab contains the UCP user interface that allows patients and providers to request accounts, reset passwords, and log in.

2.2.1 Account Access

Accounts require security measures and specific access procedures. New users must establish accounts in person. Once a user has established an account, he or she can access the Sirona system by entering the authenticated account user name and password and clicking Log In, or using a Common Access Card. All users log in at the same page.

2.2.2 Request Account

To ensure HIPAA security and privacy regulations, new account registration typically follows these, or similar, steps:

1. User requests account online using the Sirona interface.

2. System Administrator of user's medical facility contacts user to schedule time to enroll in person.

3. Following in person identity confirmation, the System Administrator creates the account.

4. System Administrator notifies user of completion and availability of account via email.

Users can begin the enrollment process by requesting an account online via the Home Log In Page. They click Request An Account, and submit the initial account information, which includes first and last name, email address, complete street address, Social Security number, username, and policy number (the ID associated with the chosen health care facility). The Request Account button allows users to send their requests to the specified medical facility. By clicking Request Account, the user agrees that he or she has read the Terms of Service available on that screen.

New users must complete the enrollment process in person at their medical facility. System Administrator specifies roles and access level at time of manual account creation.

2.2.3 Request New Password

If users forget their password or wish a new one, they click Request New Password on the Home Log In page. On the screen that appears, they enter their full email address that they use to sign into their account, and click Submit. Sirona subsequently sends a temporary system-generated password to the user's email address.

2.3 About Tab

Sirona currently includes four main applications, described in general terms on the About navigation tab, with more detail provided in application-specific information pages:

• Patient Portal is a patient-focused application that improves collaboration between patients and health care professionals by providing patients with their personal medical records, a patient inbox for receiving communications, articles, and documents that educate a patient on health concerns, and other health care management tools.

• Provider Portal similarly is focused on the professional, who needs less education. Provider Portal tools are more sophisticated, designed to facilitate the health care provider's decision-making process. Provider Portal provides clinical analytics and diagnosis tools, in addition to EMR.

• Resource Capacity Simulator provides tools for the health care administrator to optimize the allocation of resources for treatment.

• Clinical Decision Support (CDS) Workbench provides tools that help the enterprise expert or health care provider to write CDS rules and interact with Sirona rule engine to execute decision support.

2.3.1 Patient Portal Page

This page contains introductory information about the Patient Portal application, similar to the following: “Patient Portal is a patient-focused application that improves collaboration between patients and health care professionals by providing patients with their personal medical records, a patient inbox for receiving communications, articles, and documents that educate a patient on health concerns, and other health care management tools. Also called the Patient Medical Record component, Patient Portal enables patients to participate actively in their treatment through email and scheduling tools. It allows them to review their medical data, with item-specific supporting material appropriate for the layperson, and manage their health care much as they now manage their business affairs through other online resources. It provides patients with tools to exchange emails with their providers, receive recommendations and alerts related to their care, and complete the tasks requested by their health care provider team. Sirona decision support and workflow capabilities provide additional personalized services and guide patients in making better choices about their health and well-being. As informed partners collaborating dynamically with their health care providers, patients have the opportunity to engage fully in a lifelong educational program that empowers them to control their own health care actively.”

2.3.2 Provider Portal Page

This page contains introductory information about the Provider Portal application, similar to the following: "Provider Portal similarly is focused on the professional, who needs less education. Provider Portal tools are more sophisticated, designed to facilitate the health care provider's decision-making process. Provider Portal provides clinical analytics and diagnosis tools, in addition to EMR. Through the Provider Portal web-based user interface, health care professionals manage their patients’ care and to collaborate with patients in deciding the best course of treatment. Provider Portal provides a wealth of advanced, state-of-the- art tools that support health care professionals in risk assessment, disease probability analysis and diagnosis, and creation of rules and workflows to store in the rule engine for clinical decision support. This version of the product focuses on improving health care outcomes for patients diagnosed with PTSD.

Provider Portal provides clinical analytics and predictive models to support the clinician's decision-making process in managing risk, diagnosing, and treating patients. Sirona, via its rule engines, decides what to do, its dynamic and iterative diagnostic capabilities automate the needed tasks, and its notification capabilities communicate with patients and providers to result in the most efficient and timely use of resources."

2.3.3 Resource Capacity Simulator Page

This page contains introductory information about the Resource Capacity Simulator application, similar to the following:

"The Resource Capacity Simulator provides tools for the health care administrator to optimize the allocation of re- sources for treatment. It helps health care administrators to predict the number of new cases of a particular disease to expect when a specified population deploys. The application determines the maximum number of patients that the cur- rent health care facility resources can accommodate, based on definitions contained in a specified constraint set. The Resource Capacity Simulator adjusts schedule, resources, and other variables to provide the best recommendation for resource allocation, including staff, hospital beds, and equipment. It determines additional resources required to care for new patients after available resources have been optimized. This version of the product focuses on optimizing re- sources in the treatment of post-traumatic stress disorder (PTSD)."

2.4.4 CDS Workbench Page (Future Addition)

A future version of Sirona incorporates the Clinical Decision Support Workbench, which is currently a standalone application. Once integrated, a page with introductory information about the workbench will include text similar to the following:

"The Clinical Decision Support (CDS) Workbench provides tools that help the enterprise domain expert or health care provider to write CDS rules and interact with the Sirona rule engine to execute decision support. This web-based Sirona interface provides the clinical domain expert and other authenticated health care professionals with an intuitive graphical tool to author knowledge modules containing rules, guidelines, and other logic. Once created, this logic can be saved along with its defining metadata to the knowledge module repository to allow a diverse community of medical groups or individuals to share their expertise and standards of excellence with others."

2.4 Medical News Tab

The Medical News navigation tab provides ready access to general and summary information on fitness, exercise, nutrition and other topics, allowing Sirona to guide and inform patients about topics important to well being and recovery. Patients may select topic-specific pages to access detailed information in each area. The goal is to provide a holistic approach to educating patients and providers.

2.4.1 Wellness Page

The Wellness detail page provides patients and health care professionals with resources and services that in- spire physical, social, and psychological health. On this page, users find articles on physical wellness and how to achieve and maintain it through better hygiene, sleep patterns, and environmental safety. This page addresses social and psychological wellness, including educational information on stress management, building friendships and social alliances, and problem-solving and time management skills. It also lists educational programs and services available in neighborhood centers or at medical facilities. Information on education classes and services might include volunteer groups, behavioral health specialists, animal therapy programs, and social networking organizations. All articles include publishing dates. Available services and classes are described with location and schedule information.

2.4.2 Exercise & Fitness Page

The Exercise and Fitness detail page provides articles on the latest in exercise and fitness news. Articles support the user in beginning an exercise program and maintaining fitness while limiting risk of injury. This page lists educational programs and services available in the vicinity or at medical facilities. Popular educational and article topics might include Back Pain and Stretching, Dog-Walking and Fitness, Cardiovascular Training Through Community Sports, and Dance and Fitness. Services might include local gyms, yoga centers, physical therapists, personal trainers, walking clubs, and community centers offering enjoyable classes and activities. All articles include publishing dates. Available services and classes are described with location and schedule information.

2.4.3 Diet & Nutrition Page

The Diet and Nutrition detail page provides the latest news on diet and nutrition and how they impact the development of major diseases such as diabetes, high blood pressure, and cancer. This page lists educational programs and services available in neighborhood centers or at medical facilities. Popular educational and article topics might include Foods and Supplements to Reduce Depression, Healthy Diets for Weight Loss, Gluten-Free Cooking, Diet for Improved Energy and Motivation, Effects of Alcohol on Health, and Managing Low Blood Sugar. Local services might include nutritionists, dieticians, health food stores, alternative medicine, and support groups for weight loss or gain and addictive substance behaviors. All articles include publishing dates. Available services and classes are described with location and schedule information.

2.4.4 Your Provider Page

The Your Provider detail page contains background information on the providers available at the medical facility, their areas of specialization and subspecialties, and the services that they provide. This page also includes the programs and services offered at the medical facility.

2.4.5 Family Page

The Family detail page provides articles related to building strong family ties, and involving all family members in the creation of wellness in the family. This page addresses the challenges that family members manage when one member is physically ill, or suffering from mental and psychological stress and lists educational programs and services available n neighborhood centers or at medical facilities. Popular educational topics might include Health Issues of Caregivers, When Your Loved One Returns From Deployment, How to Integrate Back Into the Family After Deployment, and the Importance of Family Life in Health. Family services might include family therapists and child counselors, community centers offering family activities, after-school programs for children, support services at local churches, and 12-step support groups. All articles include publishing dates. Available services and classes are described with location and schedule information.

2.4.6 Veterans Page

The Veterans detail page provides articles that help returning veterans adjust to civilian life and reintegrate with their loved ones and community. Articles on this page might cover topics such as Reintegration Into Civilian Life, Returning Veterans and the Job Market, Managing Mixed Feelings Upon Educational Re- Entry, and Physical and Emotional Challenges of Returning Vets. This page also describes the services available to returning military personnel, including financial aid, special programs, educational re-entry, and support in many areas of daily living. These services are available at the medical facility, in the local community, at the Veterans Administration, and other appropriate venues. All articles include publishing dates. Available services and classes are described with location and schedule information.

2.5 Navigation Footer

The Sirona Navigation Footer displayed at the bottom of the portal for unauthenticated users provides access to the functionality available in the Log In, About, and Medical News tab navigation bar. It also pro- vides additional, less commonly accessed information. The Support/Help component provides various ways of getting answers to the questions that patients and providers may have. A Getting Started feature includes frequently asked questions and their answers; a Preferences feature provides a way to configure and personalize the portal experience; a Feedback tool allows users to contact the proper personnel and provide feed- back on their experience of the product.

As with all organizations and products, information on terms of service, copyright, security, and privacy must be provided to users. The Sirona Legal/Security feature provides this information. Finally, the Sirona Site Navigation Footer provides a Contact Us page with company contact information.

2.5.1 Get Started Page

The Get Started page of the Support/Help feature provides some introductory tips to using the Unified Collaboration Portal and answers frequently asked questions, including how to get account, who might find Sirona helpful, and how health is achieved collaboratively within a patient and provider team.

2.5.2 Preferences Page

The Preferences page of the Support/Help feature provides ideas about how the user can personalize his or her experience of the Unified Collaboration Portal. This page is available only after a user has logged in.

2.5.3 Help Page

The Help page of the Support/Help feature shows how to search through the broad base of Sirona help topics. This page provides a Search field that allows the user to enter help keywords. A Search Results box displays the resulting information available on the specified topic.

2.5.4 Feedback Page

The Feedback page of the Support/Help feature shows how to submit written suggestions and comments to Sirona support. On this page, authenticated or unauthenticated users can enter their email address in the specified field and then write their suggestions or comments in the text box provided. A Submit button sends the information to Sirona Support.

2.5.5 Terms of Service Page

The Terms of Service page of the Legal/Security feature provides a text description of the conditions governing use of the Sirona website. This page gives information about site content and how users are and are not permitted to use it. The conditions described on the Terms of Service page address how to protect the site and sets the expectations for user participation.

2.5.6 Privacy Policy Page

The Privacy page of the Legal/Security feature provides the Sirona privacy practices, including policies on information collection, use, and sharing, as well as access to and control over information.

2.5.7 Copyright Page

The Copyright page of the Legal/Security feature Sirona provides the year(s) of deployment of the Sirona system and includes the name of the owner of the copyright, not necessarily the author or creators of the system. It includes the conditions under which parts of the Sirona site can be copied and used in various environments and how to acknowledge the legal owner of the copyright and the Sirona creators.

2.5.8 Security Page

The Security page of the Legal/Security feature describes the precautions taken to protect information and prevent unauthorized access to the Sirona system. It describes how links to other websites and cookies are managed to protect the personal information that a user may provide.

2.5.9 Contact Us Page

The Contact Us page of the Sirona website contains public contact information for the medical facility's public facilitators, patient representatives, legal department, and portal administrative help and support teams, including street addresses, phone numbers, and email addresses. This page provides the capability to determine public email addresses, street addresses, and phone numbers for common services.

3.0 Patient Portal

The Patient Portal application provides additional web-based functionality for authenticated patients.

Patient Portal continues the general education that the patient began with the UCP Navigation tool. It allows patients to review their medical data, with item-specific supporting material appropriate for the layperson, and manage their health care much as they now manage their business affairs through other online resources. It provides patients with tools to exchange emails with their providers, receive recommendations and alerts related to their care, and complete the tasks requested by their health care provider team. Sirona decision support and workflow capabilities provide additional personalized services and guide patients in making better choices about their health and well being. As informed partners collaborating dynamically with their health care providers, patients have the opportunity to engage fully in a lifelong educational program that empowers them to control their own health care.

3.1 Patient Application Menu

The Portal Application Menu provides access to functionality within the portal. It is common to both the Patient Portal and the Provider Portal described in Section 4. User role and privilege defines the degree and depth of each portal capability. Access to the following general functions is provided:

Function Name

Further Details

Organizer

• Send and receive emails.

* Receive and respond to health-related alerts and recommendations from the Sirona

Clinical Decision Support system.

* Request and receive health care summaries from outside organizations via the

Nationwide Health Information Network.

* View and use a controlled medical address and contact book.

* Manage medical appointments and schedules.

* Access and update personal information.

Medical Records

* Provides access to patient's medical record data, including documents, labs, diagnostic images, allergies, and so on.

3.2 Organizer

Patient Portal provides patients with several organizational aides that help them manage their health-related tasks and remain accountable to the health care team to which they belong.

• Messages provides general emailing functionality, the ability to receive and respond to CDS alerts, and to request NwHIN documents.

• Calendar allows the patient to view and change medical appointments using a standard calendar tool that lays out the month and its commitments. This feature also allows the patient to learn the available education times and learn details on the curriculum of all education classes.

• Contacts provides the medical address book, a directory of contact information for health care entities committed to the progress of the authenticated patient.

• Personal Info contains the database of information on a patient's circle of family and legal support and contains information that the patient has provided the medical facility.

Each of these organizing tools is described in detail in the subsections below.

3.2.1 Messages

The Unified Collaboration Portal platform uses the Universal Inbox as its mailbox. The Universal Inbox is similar to other well-known email clients, and is able to manage more than just email. In the current version of Sirona, messages include CDS alerts, with or without associated tasks, or NwHIN documents from other health care organizations. The Universal Inbox is used to display and manage patient and provider messages throughout the Unified Collaboration Portal. In Provider Portal, two inboxes are available to a provider: a Desktop Inbox for messages sent directly to or from the provider, and an EMR inbox, for messages sent to or from a selected patient to health care providers contributing to his or her care. In Patient Portal, only one mailbox is supported, the Messages Inbox; it provides a patient with a dedicated client for communicating only with their health care providers.

3.2.1.1 Email

The Messages Inbox can receive standard email correspondence and alerts from contacts listed in the Medical Address Book accessed via Organizer > Contacts, described later.

3.2.1.2 Alerts

The Messages Inbox can display alerts. An alert is any message that the Clinical Decision Support system sends, and can be a simple notification of information of interest, or an important reminder to complete a survey or schedule a visit with the patient's Primary Care Manager. An Alert may be associated with a task that the patient is asked to perform; common tasks include scheduling appointments, filling out surveys, and delivering documents. Alerts can have different priority levels, currently the following: Normal, HIGH, or Critical.

Because Sirona emphasizes collaboration between patient and provider, Inbox alerts may ask a patient to perform associated tasks. Tasks include scheduling appointments, filling out surveys, and delivering documents. As timely completion of tasks is critical to the collaborative delivery of health care services, the Universal Inbox provides a mechanism for completing these tasks from within the tool, allowing patients to respond to, discard, or reject an alert message. Sirona then sends the patient's decision or response to the appropriate provider or system responsible for executing the task.

3.2.1.3 NwHIN Documents

To ensure patients have access to all their health information, regardless of the custodial organization, patients can request that NwHIN Summary of Care documents be forwarded to them. NwHIN provides standards, services, and policies enabling health information exchange over the Internet and provides the security the confidentiality required for the transfer of medical information. Sirona provides the capability of broadcasting a patient request to all NwHIN affiliated institutions and automatically submits document requests to any facility with new data not previously downloaded. Through the Sirona Patient Portal inter- face, patients and providers can request that NwHIN send pertinent documentation to them, receive them in their Inbox, and review them. A copy of that document is automatically included in the patient's Sirona Medical Record.

Currently, this document is self-contained. Future iterations of the tool will parse the in- formation and seamlessly integrate it with the local organization's data into a single comprehensive view so that distributed health information can be aggregated and is readily available for clinical decision making. Sirona also sends the received document to its rule engine for analysis.

3.2.2 Calendar

Calendars in the patient Organizer help patients keep track of their medical appointments, such as checkups with their Primary Care Manager, consults with medical specialists, and their scheduled diagnostic tests. Each patient has a medical calendar that aggregates all his or her booked appointments throughout the system, regardless of clinic or specialty. This integrated view ensures that they have a comprehensive collection of all their scheduled clinic visits. In addition, the patient may elect to register any iCal-based (for example, Google) personal calendar with the Sirona portal and automatically import their private appointments into their Organizer. These calendars can be individually viewed or super-imposed on top of their medical calendar, thereby ensuring that they can efficiently review both their private and clinical obligations. In addition to standard booked appointments, Sirona can display a configurable list of general calendars such as the schedule for available education classes, common screening services, or meetings of community interest.

The Sirona calendars are currently read only. Future versions allow patients to book or reschedule appointments. The standard calendars also are supplemented by additional schedules exposed by the CDS engine. Based on patient diagnoses, consult orders, and so on, additional calendars might be appropriate for a given patient. For example, if a patient has an un-booked neurology consult request, the CDS engine can make the clinic's open appointment schedule visible to patients, allowing them to book a convenient time slot themselves. Once the order is booked, the view is automatically removed, and the booked appointment is displayed in the patient's standard medical calendar. Rule-based calendar exposure ensures a highly individualized and personal patient experience, while at the same time providing for the appropriate degree of control by the responsible clinic.

3.2.3 Contacts

The Contacts option of the Organizer menu provides a Medical Address Book for patients. The Contacts list includes the title, first and last names, and organizational affiliation of every health care professional that have contributed to the patient's recent medical care. Patients can search for a health care contact, select one, review public telephone numbers, and send a corresponding email if desired, among other functions. To maintain an accurate and useful list of the health care professionals involved in the patient's treatment, while not exposing contact information unnecessarily, Sirona does not allow patients to delete, add, or change entries in their Contacts list. Instead, Sirona always displays the current Primary Care Manager, the contact information of any provider seen within the past two years, and will automatically include information for any provider with which the patient has a future booked appointment; Sirona automatically re- moves that entry if the appointment is subsequently cancelled or the patient does not keep the appointment. Patients can access the Contacts medical address book through the Organizer menu or when composing email in the Messages Inbox tool.

3.2.4 Personal Info

The Personal Info option of the Organizer menu allows patients to provide demographic information to their health care provider and update it, when necessary. The organization's subsequent processing and validation of this information is not specifically configured in Sirona, but can be managed by the Rule and Workflow engines as appropriate for each facility. This information includes photos and demographic information, data on members of the family, emergency contact information, HIPAA releases, powers of attorney, and address and contact information.

3.3 Medical Records

The Patient Portal provides authenticated patients access to their entire medical record created and stored by their primary health care organization. It includes information on admissions, allergies, documentation and encounters, immunizations, medications, problems, vital signs, and diagnostic test results. PMR pro- vides exactly the same information that is accessible to the patient's health care professionals, who access the patient record through the Electronic Medical Record (EMR) in the Provider Portal.

The Sirona PMR module provides valuable health care education content integrated directly into the portal. When a patient is reviewing a lab, for example, they can optionally access additional information on the test, how it is done, and what the results may mean. Most of the information is textual, although the system can optionally include images, podcasts, and videos related to the topic if the organization has the appropriate license. This integrated information capability is called the Educational Content Service and is optimally configured to display its information in the user-specified language and reading level.

3.3.1 General Functionality

The following subsections describe the general and specific display requirements for the main medical record modules supported by Sirona, including Admissions, Allergies, Demographics, Documentation (including encounters), Immunizations, Medications, Problems, Results, and Vital Signs.

3.3.2 Admissions

The Admissions Module of the medical record contains the patient's history of admissions into the hospital. This record includes admitting and discharge dates, admitting, discharge, and follow-up doctors, diagnosis, and data source (organization) providing the information.

3.3.3 Allergies

The Allergies Module of the medical record contains the patient's history of allergies and drug sensitivities. This record includes the allergy or intolerance conditions, severity, and any associated adverse conditions that the patient has experienced. An adverse condition might be in relation to food, medication, environment, or a product.

3.3.4 Documents

The Documents Module of the medical record includes documents related to encounters and interactions between the patient and health care providers. Interactions include in-person visits and other forms of communication, such as faxes or telephone consults (Telcons). This module might also include copies of consents, advanced directives, progress notes, summaries of communications, letters and other documents related to the treatment of the patient, such as the existence of a living will, health care proxies, and CPR and resuscitation status.

3.3.5 Immunizations

The Immunizations Module of the medical record provides a history of the patient's immunizations, and whether the patient was offered but refused a specific vaccine. Data include vaccine name, date and time of administration, facility, administering provider, dosage, dose number, any reactions, date to re-administer, lot number, route and anatomic site of administration. This module also includes educational content on the vaccine and the diseases that the immunization is intended to prevent.

3.4.6 Medications

The Medications Module of the medical record contains information on the prescription and non-prescription medications that the patient is now taking or has taken in the past and educational content on the medication and its side effects. It includes a history of prescriptions, fulfillment, and medication administration activities, such as locations where the prescriptions were filled and the managing pharmacist. Side effects noted might include reactions to medications, such as rash, nausea, or increased heart rate.

3.4.7 Problems

The Problems Module of the record contains information on relevant clinical problems, complaints, and conditions for which the patient is receiving care. Data include onset, severity, and names of providers treating the problem. This module also includes educational content on each disease, its treatment, prevention, and long-term outcomes.

3.4.8 Results

The Results Module of the medical record contains the results of the laboratory and other diagnostic tests performed on the patient. Test data are organized according to micro, cytology, pathology, imaging, surgical, and procedures, among others. This module of the medical record reports historical and current result observations for the patient and also includes educational content on each test, risks, and so on.

3.4.9 Vital Signs

The Vital Signs module of the medical record contains historical and current data on vital signs for the patient. Vital signs are considered a subset of results, but are displayed separately to follow the clinical conventions of the medical facility recording them. Clinical context determines the vital signs recorded, which include temperature, height, weight, blood pressure, and so on.

4.0 Provider Portal

The Provider Portal application provides a web-based user interface that health care professionals use to manage their patients’ care and to collaborate with patients in deciding the best course of treatment. In addition to standard EMR functionality, the Provider Portal provides a wealth of advanced, state-of-the-art tools that support the clinician's decision-making process in managing risk, diagnosis, and treatment. Although this version of the product focuses on improving health care outcomes for patients diagnosed with PTSD, the Sirona platform provides generalized capabilities that are equally applicable to other diseases and conditions.

4.1 Portal Navigation Menu

The Portal Navigation Menu provides access to individual applications within the portal. It is common to both the Provider Portal and the Patient Portal described in Section 3. User role and privileges define what tabs are visible for a given user. The navigation tabs for a fully-privileged provider include the following:

• Desktop

• Patient Records

• Simulator

• Workbench (future version)

Note: The Resource Capacity Simulator and the Clinical Decision Support Workbench are advanced stand- alone clinical decision support and resource optimization tools accessed from the Provider Portal interface and described in other documents.

4.2 Provider Desktop

Provider Portal Desktop provides health care providers with several organizational aides that help them manage their health-related tasks and remain accountable to the health care team to which they belong:

• Messages provides general emailing functionality and the ability to receive and respond to CDS alerts.

• Calendar allows the provider to view and change medical and personal appointments using a standard calendar tool that lays out the month and its commitments.

• Contacts provides the personal address book and a complete directory of contact information for all organizational entities.

• Personal Info contains the database of information on a provider's circle of family and legal support and contains information that the provider has at the medical facility.

Each of these tools is accessible form the Organizer Menu and is described in detail in the subsections below.

4.2.1 Messages

The Provider Desktop Organizer uses the Universal Inbox as its mailbox that can be access by the link Messages in the Desktop navigation menu. It is similar to other well-known email clients, but manages more than email. In the current version of Sirona, messages can be also be CDS alerts, with or without associated tasks, or NwHIN documents from other health care organizations.

The following figure shows how health care professionals access their Organizer Messages from the

Provider Desktop:

4.2.2 Email

The Desktop Inbox can receive standard email correspondence and alerts from contacts listed in the Medical Address Book accessed via Organizer > Contacts, described later. When viewing messages in the Desktop, all emails sent directly to or from the provider are displayed, regardless of the patient they concern. In contrast to the Patient Portal, the NwHIN document request functionality is not available at the desktop level and can only be accessed from within a patient record as described below.

4.2.3 Alerts

The Desktop Inbox can display alerts. An alert is any message that the Clinical Decision Support system sends, and can be a simple notification of information of interest, or an important reminder to complete a survey or schedule a visit, or review a critical lab result. An alert may be associated with a task that the provider is asked to perform. Alerts can have different priority levels, currently: Normal, Important or Critical.

Because Sirona emphasizes collaboration between patient and provider, Desktop Inbox alerts may ask a provider to perform an associated task, including scheduling appointments, filling out surveys, and reviewing critical lab results. As timely completion of tasks is critical to the collaborative delivery of health care services, the Desktop Inbox provides a mechanism for completing these tasks from within the tool, allowing providers to respond to, discard, or reject an alert message. Sirona then sends the decision or response to the appropriate system responsible for executing the task.

4.2.5 Calendar

Calendars in the Provider Desktop Organizer help providers keep track of their medical appointments. Each provider has one or more medical calendars that display all their booked appointments throughout the sys- tem, regardless of clinic or specialty. This integrated view ensures that they have a comprehensive collection of all their scheduled clinic visits. In addition, the provider may elect to register any iCal-based (such as Google) personal calendar with the Sirona portal and automatically import their private appointments into their Organizer. These calendars can be individually viewed or super-imposed on top of their medical calendar, thereby ensuring that they can efficiently review both their private and clinical obligations. In addition to standard booked appointments, Sirona can display a configurable list of general calendars such as the schedule for available education classes, common screening services, or meetings of community inter- est. The Sirona calendars are currently read only, but future versions allow providers to book or reschedule patient clinic appointments, manage clinic appointment templates for future schedules, and change appointment slot duration, type, or both. Provider or clinic rule-managed calendars can display a configurable list of general calendars, such as the schedule for available education classes, common screening services, or meetings of community interest.

4.2.6 Contacts

The Contacts option of the Organizer menu provides the global Medical Address Book of the medical facility. The Contacts list includes the title, first and last names, and health care entity affiliation of all health care professionals associated with the provider's medical facility. When the Desktop is active, Contacts pro- vides the global medical facility professional contacts. Providers can search for a health care contact, select one, and send an email to him or her. Providers can access the Medical Address Book both through the Organizer menu and through the Desktop Provider Inbox when composing an email.

4.2.7 Personal Info

The Personal Info option of the Organizer menu allows providers to provide and edit the contact information used by their organization for managing a variety of business processes, including Human Resources, LDAP accounts, and so on. The organization's subsequent processing, validation and use of this information is not specifically configured in Sirona, but can be managed by the rule and workflow engines as appropriate for each facility. This information includes photos and demographic information, data on members of the family, emergency contact information, HIPAA releases, powers of attorney, and address and contact information.

5.0 EMR Medical Records

The Electronic Medical Record module of Provider Portal allows authenticated providers access to a patient's entire medical record. It includes information on admissions, allergies, documentation (including en- counters), immunizations, medications, problems, vital signs, and diagnostic test results. EMR provides exactly the same information that authenticated patients access through the Patient Portal Medical Records feature.

The Sirona EMR modules provide valuable health care education content integrated directly into the portal. When a provider is reviewing a lab, for example, they can optionally access additional information on the test, how it is done, and what the results may mean. Most of the information is textual, although the system can optionally include images, podcasts, and videos related to the topic if the organization has the appropriate license. This integrated information capability is called the Educational Content Service and is optimally configured to display its information in the user-specified language.

5.1 Patient Search

The Patient Search capability allows providers to search for a patient record using predefined parameters, including the patient's last name, first name and middle initial, date of birth, gender, social security number, and medical record number. Sirona provides further fine-tuning of the patient search by allowing providers to specify the type of organization in which to search for the patient, as broad as the Nationwide Health In- formation Network, or as specific as a medical center or clinic.

To view a patient's records, the provider must first perform a patient search, as shown in the following figure:

Once the provider has found the patient, he or she can review the medical record on the selected patient.

5.2 Admissions

The Admissions Module contains the patient's history of admissions into the hospital. This record includes admitting and discharge dates, admitting, discharge, and follow-up doctors, diagnosis 1 and 2, status, and data source, such as the VA or IHS.

5.3 Allergies

The Allergies Module contains the patient's history of allergies and drug sensitivities. This record includes the allergy or intolerance conditions, severity, and any associated adverse conditions that the patient has experienced. An adverse event might be in relation to food, medication, environment, or a product.

5.4 Appointments

The Appointments Module provides a view of the selected patient's medical appointments, such as check- ups with a Primary Care Manager, consults with medical specialists, and scheduled diagnostic tests. This medical calendar aggregates the patient's booked appointments throughout the system, regardless of clinic or specialty. This integrated view ensures a comprehensive collection of all past and future clinic visits and is visible by default to the reviewing provider.

In addition to standard booked appointments, Sirona can display open slots in a configurable list of general calendars, such as available education classes, common screening services, or meetings of community interest. Sirona also displays the reviewing provider's clinic schedules and the open slots in each. These calendars can be individually viewed or super-imposed on top of the patient's medical calendar, thereby ensuring that providers can efficiently review them all.

The Sirona calendars are currently read only. Future versions allow providers to book the selected patient into an open slot or reschedule an existing booked appointment. The standard calendars might also be supplemented with additional schedules exposed by the CDS engine, upon evaluating the patient diagnoses, consult orders, and so on, which might be appropriate for a given patient. For example, if a patient has an un- booked neurology consult request, the CDS engine can make the clinic's open appointment schedule visible to the reviewing provider, allowing him or her to book a convenient time slot for the patient. Once the order is booked, the open schedule view is automatically removed, and the booked appointment is displayed in the patient's standard medical calendar. Rule-based calendar exposure ensures a highly individualized experience, while at the same time providing for the appropriate degree of control by the responsible clinic.

5.5 Communications

The Communications Module is similar to other well-known email clients, but it manages more than email. In the current version of Sirona, message types also include CDS alerts, with or without associated tasks, and NwHIN documents from other health care organizations. The Communications Module always dis- plays its message list from the perspective of the patient.

5.5.1 Email

The Communications Module displays a filtered view of patient emails exchanged between the selected patient and the authenticated provider. It is a historical view of communications that has medical and legal value; providers may not edit, delete, or otherwise modify the displayed contents. The module does, however, allow a provider to compose a new message to the patient using his or her own account credentials. When sending a new message from within the Communications module, the patient is automatically included in the To: field, the provider also has access to the patient's Global Contacts list to include another agent, if desired. Once delivered, the newly composed message is automatically stored in the provider's Sent box, and the copy that the patient receives appears in the Communications Module as an Inbox message.

5.5.2 Alerts

The Communications Module also displays alerts received by the patient. An alert is any message that the Clinical Decision Support system sends, and can be a simple notification of information of interest, or an important reminder to complete a survey or schedule a visit with the patient's Primary Care Manager. An alert may be associated with a task that the patient is asked to perform; common tasks include scheduling appointments, filling out surveys, and delivering documents. Alerts can have different priority levels, currently the following: Normal, HIGH, or Critical.

Although an alert provides a mechanism for patients to complete tasks from within the message, allowing them to respond to, discard, or reject an alert message, an alert is read only to a provider reviewing them from within the EMR.

5.5.3 NwHIN Documents

The Communications Module also displays Nationwide Health Information Network (NwHIN) documents requested by a patient or by any provider.

NwHIN provides standards, services, and policies enabling health information exchange over the Internet and provides the security and confidentiality required for the transfer of medical information. Sirona pro- vides the capability of broadcasting a patient request to all NwHIN affiliated institutions and automatically submits document requests to any facility with new data not previously downloaded. Through the Sirona Patient Portal interface, patients and providers can request that NwHIN send pertinent documentation to them, receive them in their Inbox, and review them. A copy of that document is automatically included in the patient's Sirona Medical Record. Currently, this document is self-contained. Future iterations of the tool will parse the information and seamlessly integrate it with the local organization's data into a single comprehensive view so that distributed health information can be aggregated and is readily available for clinical decision making. Sirona also sends the received document to its rule engine for analysis.

5.6 Demographics

The Demographic Module provides information that patients have provided representatives of their chosen medical facility and allowed to be added to their records. This database includes photos and demographic information, data on members of the family, emergency contact information, HIPAA releases, powers of attorney, and address and contact information.

5.7 Documents

The Documents Module of the medical record includes documents related to encounters and interactions between the patient and health care providers. Interactions include in-person visits and other forms of communication, faxes or telephone consultation reports. This section might include copies of consents, advanced directives, progress notes, summaries of communications, letters and other documents related to the treatment of the patient, such as information about the existence of a living will, health care proxies, and CPR and resuscitation status.

The following figure shows the Documentation section of the selected patient's medical record, detailing the clinical notes on the patient:

5.8 Immunizations

The Immunizations Module of the medical record provides a history of the patient's immunizations, and whether the patient has refused the immunizations. Data include vaccine name, date and time of administration, facility, provider administering, dosage, dose number, any reactions, date to re-administer, lot number, route and anatomic site of administration. This module also includes information on the diseases that the immunization is intended to prevent.

5.9 Medications

The Medications Module of the medical record contains information on the prescription and non-prescription medications that the patient is now taking or has taken in the past. It includes a history of prescriptions, fulfillments, and medication administration activities, including the locations where the prescriptions were filled, and the managing pharmacist. It may include reactions to medications, such as rash, nausea, or in- creased heart rate.

5.10 Problems

The Problems Module of the record contains information on relevant clinical problems, complaints, and conditions for which the patient is receiving care. Data include onset, severity, and names of providers treating the problem. The Problems module includes diagnosis history and all concerns that patient and providers have noted in the course of treatment.

5.11 Results

The Results Module of the medical record contains the results of the laboratory and other diagnostic tests performed on the patient. Test data are organized according to micro, cytology, pathology, imaging, surgical, and procedures, among others. This module of the medical record reports historical and current result observations for the patient.

5.12 Vital Signs

The Vital Signs module of the medical record contains historical and current data on vital signs for the patient. Vital signs are considered a subset of results, but are displayed separately to follow the clinical conventions of the medical facility recording them. Clinical context determines the vital signs recorded, which include temperature, height, weight, blood pressure, and so on.

5.13 Clinical Analytics Drawer

The Electronic Medical Record (EMR) interface of Provider Portal Provides two important clinical decision support tools to assist the provider: Clinical Analytics Drawer and Diagnostic Guide. Together, these tools ensure that providers are made aware of a particular patient's relative risk for developing common diseases, and that they have all the information required to ensure a cost-effective and efficient diagnostic workup.

The Sirona Clinical Analytics Drawer displays information regarding a patient's relative risk for developing one or more diseases. This analysis is done automatically using patient information that Sirona retrieves from the EMR system. For example, when the patient checks into a clinic for a visit with his or her provider, the system initiates an analysis of the clinical record, feeding relevant information to the predictive models that assess risk for a variety of common medical conditions. By the time the provider sees the patient, the results of that analysis are available within Provider Portal. The Clinical Analytics Drawer dis- plays a patient's relative risks to the provider in a way that is sensitive to the provider's workflow.

The predictive models used to calculate a patient's relative risk are determined by the organization deploying the Sirona system. This base collection of models are used to evaluate every patient whose medical record is accessed and, therefore, provides the organization with the ability to screen their population ac- cording to enterprise requirements. If other, optional, models are available, the provider has the elective capability to choose other models that may be appropriate for the patient population that they treat. For example, all patients can be screened with diabetes, asthma, or both models, while behavioral health providers can optionally screen for Post-traumatic Stress Disorder, as well.

The Clinical Analytics Drawer is generally closed and opens only when a patient's relative risk for a particular disease exceeds a predetermined threshold. The organization or optionally the individual provider sets this threshold. When one or more disease thresholds are exceeded, the drawer slides open and displays the calculated risk profiles for each disease currently being monitored. For each model, the calculated risk and confidence interval are displayed. Any model that exceeds the configured threshold is displayed using a graded color scheme to draw attention, and visually indicate, the relative risk.

Predictive models are trained under the assumption that one or more data sources are available to provide the required information for calculating relative risk. In the real world, some of these inputs may not be present for a particular patient. When a model is run using incomplete data, the clinical analytics drawer indicates which sources are missing, and provides, as appropriate, a mechanism for the provider to supply the data required. For example, if a PTSD model requires the number of operational deployments in which a soldier has been involved, and that information is lacking, the drawer allows the provider to ask the question and record the answer. Any manually provided input data that are added to the patient's record in the form of laboratory results or other diagnostic tests, trigger an automatic recalculation of the relative risk and update the clinical analytics drawer, as appropriate,

The clinical analytics drawer is located at the right margin of any medical record screen within Provider Portal. The drawer automatically opens when the record is initially opened, and at any subsequent time when new medical information triggers an analysis that results in a change in the patient's relative risk pre- diction. At all other times, if the drawer has been closed, it remains so unless the provider manually opens it. The intent of the drawer is to ensure that important risk information is communicated appropriately before the clinic visit gets underway, while being low profile and unobtrusive at all other times so as not to in- appropriately interrupt provider cognitive workflow.

The following figure shows how the calculation of relative risk progresses as the clinician provides further details about the patient's history. In Drawer 1 in the figure below, the clinician has answered the question about trauma history, but has not submitted it; relative risk is unavailable, as the drawer notes: PTSD: Risk N/A. In Drawer 2, the clinician submits the information on trauma history and answers the question about physical abuse history; the drawer notes: PTSD: Risk 70% +/-20, where +/-20 is the Confidence Interval. In Drawer 3, the clinician specifies the number of deployments; the drawer recalculates the relative risk as follows: PTSD: Risk 80% +/-10.

5.14 Diagnostic Guide

The Clinical Analytics Drawer communicates a patient's relative risk for developing one or more diseases. A high relative risk score with a narrow confidence interval, however, should not be misinterpreted as diagnostic. In other words, a patient with a 90% probability of developing Post-traumatic Stress Disorder may fortunately not actually have the disease. To facilitate an appropriate workup for a condition in question, a provider can access the Diagnostic Guide functionality provided by the Unified Collaboration Portal. This clinical decision support tool, launched by clicking the Start Diagnostic Guide button available in the drawer, uses a predictive model tool to facilitate diagnostic decision-making.

When launched, the Diagnostic Guide replaces the center canvas area of the portal with a graphical depiction of the steps and choices available to a provider while making decisions regarding a diagnostic workup. In the PTSD use case, the tool initially displays the Disease Certainty Score (current probability of disease), the calculated confidence interval, and a select list of diagnostic tests and interventions that might be appropriate during the workup. For example, options may include performing a psychometric assessment, obtaining relevant imaging studies, completing survey questionnaires, or ordering laboratory tests. For each of these, the Diagnostic Guide calculates a utility score that reflects the model's estimation of the contribution to diagnosis that a particular option provides. A utility score is a reflection of the benefit an intervention might have for achieving a particular clinical goal. Diagnostic utility, the benefit afforded to making a diagnosis, is the most prevalent and relevant utility score. However, for a particular patient, cost-effectiveness or patient comfort might be the principal goal. In such situations, the predictive model calculates Financial Utility or Pain Utility respectively. Only diagnostic utility is now in scope for Sirona, but the requirement for calculating and displaying alternative utility scores is anticipated.

The Diagnostic Guide displays explicitly the three to five choices with the highest utility to the provider. Other tests or interventions that might be appropriate are available via the Low Utility Options function. Additionally, the provider has access to the entire repertoire of the EMR ordering system when he or she selects the Other Diagnostic Choices button, even if the predictive model does not recognize these interventions as relevant to the diagnostic workup.

When a provider selects one of the options presented, the system displays a summary describing the intervention, its potential relevance for the workup, and whether the choice is available at the local facility, the local community, or both. After reviewing this information, the provider can accept the choice and trigger the subsequent workflow. For example, if the option is a laboratory test, the system places the appropriate order and electronically activates it on the provider's behalf. Alternatively, if the choice is to complete a survey questionnaire, the survey form is immediately displayed for the provider to complete. Finally, if the option recommends a particular physical exam, the system allows the provider to record the result after the human task has been completed.

When the provider has finished selecting the desired options, the Diagnostic Guide displays the current status of each choice and whether the results are available or pending. Because tasks cannot be expected to be completed at the same time, or even the same day, the system retains the current Diagnostic Guide state at all times, allowing providers who leave the tool for any reason to resume where they left off when they return.

When all chosen interventions have provided results, the Diagnostic Guide then allows the provider to advance to the next iteration. Using the newly resulted information, the guide will recalculate the patient's diagnostic certainty score, re-analyze the diagnostic utility of the remaining options, and display the next three to five choices that have the highest utility.

After one or more iterative cycles, the patient's diagnostic certainty score will be 100%, or high enough that further workup has little clinical benefit, a common decision that must be made with diagnoses of exclusion. At this point, the provider can choose to end the Diagnostic Guide session, and select from a tailored list an appropriately coded diagnosis to record in the medical record. The provider may, alternatively, cancel the guide session at any time without recording a new condition.

Diagnostic Guide sessions are patient based and not unique to a particular provider. This means that when one or more providers access a patient record, each of them may see and interact with any active guide session. A guide workflow, therefore, is a powerful collaboration and coordination tool for aligning the diagnostic efforts of the clinical team, communicating workup strategy, and reducing unnecessary duplicative efforts.

Unlike traditional clinical pathway tools, or similar structured prescriptive diagnostic aids, the Diagnostic Guide focuses on providing the qualitative information, expressed as utility scores, which a provider needs when considering interventions required to attain a particular goal. Reflecting the process commonly found in clinical medicine, the guide supports a semi-structured, iterative cognitive workflow with frequent re- assessments. It is a goal-oriented approach that encourages evidence-based decision-making while retaining provider flexibility and autonomy in delivering individualized patient care.

The Diagnostic Guide provides an additional benefit for clinical quality improvement initiatives in that it records through every iteration the patient's disease risk, the utility scores at every stage of the workup, and the choices that were eventually made. At any time during the diagnostic workup, providers can review the decision-making history and critically review their choices. Alternatively, institutional process improvement teams can aggregate Diagnostic Guide logs to evaluate provider performance, workflow impediments, or institutional barriers to quality care. The Diagnostic Guide offers a powerful tool for collecting information relevant to clinical operations into meaningful quality improvement analysis.

5.15.1 Diagnostic Guide Interface

When the Diagnostic Guide is launched, the center canvas area of the screen displays the Disease Certainty Score, the calculated Confidence Interval, and a list of diagnostic tests and interventions that might be suitable during the workup:

The choices available to the provider are ranked by utility – in the above example, the Guide displays the top 4 choices with diagnostic utility in the work-up for PTSD. The provider is not limited only to those options explicitly displayed. He or she has can access the entire order set available at their facility using the “Other Diagnostic Choices” option, which is essentially an entry point into the CPOE system. Alternatively, they may select “Lower Utility Options”, which makes available other choices that the predictive model has identified as useful, but did not score high enough to make the top four.

In the figure below, the clinician has chosen the recommended ‘Number of Deployments’ option, which has the highest diagnostic utility score of the four options originally displayed. The Diagnostic Guide displays a description of the test and provides the justification for the recommendation. At each step of the workup, the tool attempts to provide the supporting data, references, and context that provide need to make evidence based decisions. Over time this information helps develop confidence in the system’s recommendations and provides for innumerable teaching opportunities.

If the choice is a test or procedure, the display indicates whether the local facility offers the study, and if not, which local facility or contract partner does. Again, the system attempts to provide unbiased information that the provider may utilize to help them individualize their care to the particular patient and clinical situation at hand.

If the provider choices to start the “workflow” recommended by the Guide, the tool displays a task appropriate interface. In the above example, a deployment survey is displayed and the user is asked to enter the requested answers. A Submit button sends the entered data to the CDS system for processing.

After the clinician has chosen and committed to one or more diagnostic options, the system displays the current status of those tasks. In our current example, the Number of Deployments was completed, and a Domestic Violence Screen and Order for Serum Alcohol Level are in process.

Once all the options have completed, as shown in the Stage 1 Status box below, the clinician can choose to move to Stage 2, by clicking Move Forward.

The Diagnostic Guide re-tabulates Disease Certainty scores to reflect the results of the tasks chosen and completed during each round of diagnostic testing and evaluation. This cycle repeats itself until the Disease Certainty score reads “CERTAIN” with a narrow Confidence Interval, or the provider is satisfied that diagnosis can be made. At this point, further diagnostic interventions are unnecessary, as indicated by the Diagnostic Utility scores near zero in the figure below.

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