A patient-designated caregiver monitors and coordinates care among 3 domains

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State: Draft

Perspective: A patient's designated caregiver monitors and coordinates care among 3 domains.

Story: An 83y/o man with severe emphysema has become bedridden. Over months, he is cycled between home, hospital and rehab. Each setting has a different provider and a different EHR.

Each EHR meets meaningful use requirements, produces a standard CCR on demand and has a patient portal.

The patient has designated a family caregiver with health care proxy rights and power of attorney.

The providers in the three separate settings do not typically communicate with each other. They do, however answer questions from the caregiver and consult her prior to ordering invasive procedures or changing the treatment plan.

The caregiver creates an account with an NHIN Direct compliant Health Services Provider (HSP). The HSP issues the caregiver an NHIN Direct ID to be used as the destination of health information messages. The HSP also takes the caregiver's email and SMS address for notification of incoming messages.

NHIN Direct Information Exchange:

The caregiver signs into a provider's patient portal using credentials that were issued by the provider based on the patient's directive and the health care proxy document.

The caregiver navigates to the patient portal page, enters the NHIN Direct ID and requests that all meaningful use patient communications be sent to the designated ID until further notice.

The patient checks the connection by clicking the Send Clinical Summary Now button on the patient portal. 10 seconds later, a text message from her HSP alerts her to a new message with a link to her secure web site.

The CCR she sees has all of the data elements as mandated by meaningful use requirements.

The caregiver repeats this registration and test process for the other two provider settings.

The caregiver compares the three meaningful use CCRs from the three providers and notices that the rehab where her father is has not been giving him thyroid medication. She calls the PCP.

A week later, the caregiver is called with news that her father is in the emergency room and has abnormal lab results. She asks the physician to send her the lab results along with the current medications and problem list. The ER doc pushes the Send Clinical Summary to Patient button on the EHR.

Her text message points to a CCR that includes labs, problems, current medications as well as the ER doctor's name and contact information.