14.  Transitions of Care
EPs/EHs/CAHs provide a summary of care record during transitions of care
Types of transitions:
Transfers of care from one site of care to another (e.g.. Hospital to: PCP, hospital, SNF, HHA, home, etc)
Consult (referral) request (e.g., PCP to Specialist;  PCP, SNF to ED) [pertains to EPs only]
Consult result note (e.g. consult note, ER note)
Summary of care may (at the discretion of the provider organization) include, as relevant:
A narrative (synopsis , expectations , results of a consult) [required for all transitions]
Overarching patient goals and/or problem-specific goals
Patient instructions (interventions for care )
Information about known care team members

Discussion questions:
a.  Are standards available to support these data elements such as patient goals or problem-specific goals?
b.  Are there closed loop workflows required i.e. tracking of completed referrals?

15.  Notifications
Eligible Hospitals and CAHs send electronic notifications of significant healthcare events in a timely manner to known members of the patient’s care team (e.g., the primary care provider, referring provider, or care coordinator) with the patient’s consent if required
Significant events include:
Arrival at an Emergency Department (ED)
Admission to a hospital
Discharge from an ED or hospital
Death

Discussion questions:
a.  Do we have a sufficient vocabulary (NPI, direct address etc.) to identify members of the care team and the means to notify them electronically?
b.  Are standards sufficiently mature to support each of these communications as structured data?

16.  Immunizations
CEHRT functionality provides ability to receive and present a standard set of structured, externally-generated immunization history and capture the act and date of review within the EP/EH practice

Discussion questions:
a.  Are standards sufficiently mature to support query/response of this data?
b.  Do public health departments plan to support this functionality?

17.  Case Reporting
CEHRT is capable of using external knowledge (i.e., CDC/CSTE Reportable Conditions Knowledge Management System) to prompt an end-user when criteria are met for case reporting. When case reporting criteria are met, CEHRT is capable of recording and maintaining an audit for the date and time of prompt.

CEHRT is capable of using external knowledge to collect standardized case reports (e.g., structured data capture) and preparing a standardized case report (e.g., consolidated CDA) that may be submitted to the state/local jurisdiction and the data/time of submission is available for audit.

Discussion questions:
a.  Is the CCDA the appropriate standard to support case reporting?
b.  Do state/local jurisdictions plan on implementing such workflows?
c.  Do the appropriate standards and rules for defining reportable conditions exist?

18.  Registry Reporting
Reuse CEHRT data to electronically submit standardized (i.e., data elements, structure and transport mechanisms) reports to one registry
Reporting should use one of the following mechanisms:
Upload information from EHR to registry using standard c-CDA
Leverage national or local networks using federated query technologies

Discussion questions:
a.  Is the CCDA the appropriate standard to support registry reporting?
b.  As with other "OR" criteria, will EHR vendors have to implement upload AND federated query approaches?

Once we answer these questions, we can weigh the impact on clinician workflow, the burden on development resources, and the balance of federal directives versus competing local organizational priorities.

Let the discussion begin!