Use Case - Submit New Patient Summary

This use case provides the capability for an authoring provider to curate and send a new patient summary for publication through the provincial Hub service.

Pre-Condition 1: HCP is registered for submission of provincial patient summaries.

Pre-Condition 2: All relevant information for inclusion on the patient summary is recorded and saved in the patient’s chart.

Basic Flow: Curate Patient Summary

1. Initiate Patient Summary Data Extract

HCP chooses to generate a patient summary extract from their patient chart.

  • Business Rule – Patient Summary Prompts and Triggers: EMR/POS systems offer any combination of the following methods to support the HCP in choosing when to produce a patient summary for a given patient:

    • Encounter trigger: All submitting EMR/POS systems are expected to provide a mechanism for the HCP to initiate a patient summary once an encounter has been charted.

    • Task trigger: EMRs may provide the ability to create a task for initiation of a patient summary at a convenient time.

    • Patient complexity prompt: EMRs may provide the ability to configure settings that will produce a patient summary prompt for matching patients. The resulting prompt may be viewed through a related query, and/or may display on the chart when appointments are booked or encounters are held. Prompt settings could include:

      • Number and/or type of conditions on the problem list
      • Number and/or frequency of ED or other acute admissions
      • Any combination of age and risk factors

      An authorized EMR user can initiate a patient summary for any/all patients where a prompt appears.

    • Referral trigger: EMRs may provide the ability to initiate a patient summary to accompany a new referral for specialist services.

  • Business Rule – Produce Draft Patient Summary for Later Curation: A patient summary that is initially generated from any prompt or trigger can be saved in a draft state for review and/or curation at any later point in time.

2. Present Standard Patient Summary Contents

POS assembles chart data into the standard patient summary, and presents to the authoring provider for review and curation as desired.

  • Business Rule – Patient Summary Chart Data: A standard patient summary contains the following information, extracted from the patient’s chart:

    • Patient identification and contact information
    • Author (submitting provider) and organization (name, contact) The author is a healthcare provider whose scope of practice covers the clinical content of the patient summary. The author is expected to have a continuing longitudinal relationship with the patient, so that consumers have confidence that the information will be kept current on an ongoing basis after initial submission.
    • Available data in each of the following categories is extracted:
      • Conditions (Problem List) This section contains a compact list of all medical conditions or diagnosed problems that are relevant to patient care and clinical decision-making. Prior conditions that are not actively treated or manifested may be included when relevant.
      • Allergies This section contains a list of allergies, intolerances and adverse reactions to any agent, allergen or class of allergens; either diagnosed by the author, or reported by the patient and acknowledged or confirmed by the author.
      • Prescribed Medications This section contains a list of current medications prescribed by the author.
      • Measured Observations This section contains quantified healthcare observations as measured and recorded by the author (or author’s organization) (e.g., height, weight, etc.).
      • Procedure History This section contains a list of past medical procedures. Detailed information is not always available for historical procedures that have been reported by the patient; therefore, this section is unstructured to accommodate any available data from the authoring provider.
      • Lifestyle / Risk Factors This section lists any relevant lifestyle factors or healthcare risks known to the author, such as smoking or alcohol consumption.
      • Family History This section contains a list of relevant medical conditions or procedures for biological relatives of the patient (e.g. parents, siblings, biological children).

3. Curate Patient Summary Data

HCP curates to include or exclude information for publication purposes, and instructs the EMR/POS to submit the finalized patient summary when curation is complete.

  • Business Rule – Remove Items from Generated Patient Summary: Authoring provider is able to remove any item(s) from the patient summary as desired. Items excluded from the patient summary are not removed from the underlying chart.
  • Business Rule – Incorporate Chart Notes: Authoring provider is able to include chart notes for any of the data categories to provide further information, or to supplement the standard extract as needed. * Data cannot be added directly to the patient summary, but must first be added or edited within the chart and then incorporated into the patient summary.
  • Business Rule – Honour Patient’s Expressed Wish for Patient Summary Confidentiality: Authoring provider is able to apply an additional level of confidentiality on a patient summary to honour an expressed wish from the patient, in accordance with related provisions of Alberta’s Health Information Act.

4. Assemble Finalized Patient Summary Data

POS assembles the finalized patient summary data with any curated inclusions and/or exclusions.

  • Business Rule – Retain Submitted Patient Summary: The curated patient summary is retained as a record within the patient’s chart.
    • Inclusions and exclusions are carried forward, and re-applied when the patient summary is updated in future.
  • Business Rule – Patient Summary Identification: The POS assigns a globally unique identifier to the patient summary, to enable traceability of all future updates to the same record (same patient, same authoring provider and same organization).
    • The unique identifier is managed within the POS such that subsequent updates to the patient summary will retain the originally assigned identifier.
  • Business Rule – New Patient Summary Submission Metadata: The following metadata is included for new patient summary submission:
    • Submission date and time
    • Submission type – patient summary (with related bundle information)
    • Submission status – ‘final’
  • Business Rule – Patient Summary Terminology: The POS performs any necessary data mapping or cross-referencing to provincially standardized code-sets and terminologies where applicable and appropriate.

5. End

Use Case ends.