Care Theme: Transitions of Care

1. Use Case 9 Care Theme: Transitions of Care Use 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

2. Care Theme: Transitions of Care Use Case: Optimizing Cardiac Care Oversight by Leveraging Home-based Devices and Remote Monitoring Care Regimens Clinical Workflow: HIE1| HIE2 3a – Monitoring Devices 1 – PCP 2 – Cardiologist 3- Home Setting HIE1| HIE2 HIE2| HIE1 4 – Remote Monitoring Management Service 5a – Monitoring Devices 5 – Cardiologist 6 – Specialist A patient visits with his PCP following an episode at home. The PCP refers the patient to a cardiologist. The cardiologist reviews the information from the PCP and prescribes home monitoring and follow-up with the home monitoring specialist 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. 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. The Cardiologist reviews the results of the study and adjusts the medication regimen and continues home monitoring. The Geriatric specialist reviews the data from the RMMS. Visit the IHE Product Registry at: ihe.net/registry