UC-02 Query and Retrieve Document

Description

This use case supports the query and retrieval of clinical documentation by a Health Care Provider at the point of care, or by a Patient seeking access to their personal health information.

Scenario

The following examples illustrate common scenarios and do not represent an exhaustive list of implementations across Canadian jurisdictions.

1. A Health Care Provider queries and retrieves a patient’s clinical document during a care encounter to support point-of-care decision-making
   A patient visits a health care provider outside their Medical Home with symptoms of dizziness and earache. The patient reports having a regular provider within their Medical Home and notes that their high blood pressure is being monitored at home. The provider gathers relevant information and uses their Clinical Solution (e.g., EMR) to search the network for clinical documentation previously shared by another provider. Upon retrieving a clinical document for the patient, the provider reviews its contents and uses the information to inform care during the encounter.

2. A Patient accesses their personal health information to stay informed and obtains a copy for personal use
   A patient, or their designated caregiver, accesses their personal health information through a clinical system or patient portal to stay informed and, if desired, retrieve a copy to support care coordination or personal recordkeeping.

Triggers, Pre-conditions, Post-conditions

This section outlines example triggers, pre-conditions, and post-conditions for querying and retrieving clinical documents from the Clinical Data Repository. These examples do not represent all workflows implemented across Canadian jurisdictions.

Triggers

Scenario 1:

• A patient visits a Health Care Provider for care.
• If subscribed, the Health Care Provider receives a notification that new clinical information is available for the patient.

Scenario 2:

• A patient, or their authorized caregiver, accesses personal health information to stay informed.
• The patient retrieves a copy of their health information to carry while travelling.
• The patient retrieves a copy of their health information to share with another care provider.

Pre-conditions

Scenario 1:

• The Health Care Provider is authenticated within their Clinical Solution (e.g., EMR).
• The Clinical Solution is connected to or integrated with the Clinical Data Repository network.

Scenario 2:

• Where required, the patient has applied consent directives, and the Health Care Provider adheres to jurisdictional privacy policy.
• A jurisdictional clinical system that supports patient access is available.
• If applicable, the patient has authorized a caregiver to access their personal health record on their behalf.

Post-conditions

Scenario 1:

• The Health Care Provider reviews the clinical documents and applies the information to support patient care.

Scenario 2:

• The patient, or their authorized caregiver, accesses their personal health information and optionally prints a copy for personal use.
• The patient, or their authorized caregiver, shares this information with another health care provider to support continuity of care.

Use Case Participants & Diagram

The participants involved in this use case are:

• Data Consumer: A system that initiates the retrieval of clinical documents from the Clinical Data Repository. This includes Clinical Solutions (e.g., EMRs used by Health Care Providers) and Patient Portals (used by Patients or Subjects of Care to access their own health information).
• Data Responder: A Health Records System that serves as the Clinical Data Repository, enabling access to clinical documents and responding to queries from Data Consumers.

This use case diagram represents the participants and their role in the use case with a high-level view of the flow of information.

Use Case – Primary Flow

The following provides a textual description corresponding to the use case diagram:

1. The participant (Health Care Provider or Patient) identifies a need to access clinical information.
2. The participant queries the Clinical Data Repository through their clinical system.
3. The Clinical Data Repository enforces access control and business rules (e.g., credential validation, consent enforcement).
4. The Clinical Data Repository returns a FHIR Bundle containing document references or embedded clinical documents, based on the query.
5. The participant reviews the returned documents and uses the information to support care delivery or personal health management.

Use Case – Alternate Flow

The following alternate flows are out of scope for this release. Stakeholder feedback on their prioritization is welcomed for future updates.

• Step 3: Patient Consent Services are not currently supported in the CA:FeX specification. Consent is identified as a roadmap item and will be addressed in a future use case where patients have defined consent directives that Health Care Providers must evaluate prior to accessing clinical information. Some jurisdictions have implemented their own consent services, and these should be taken into account during local deployments.