IHE Patient Care Coordination Technical Framework Vol I

PCC Technical Framework V3.0, vol. 1
________________________________________________________________________
1595
1600
1605
1610
1615
1620
1625
1630
the medical summary document related to this transfer of care. A variety of EMR
implementations and usage by clinicians may result in some variability in the content of
the medical summary. The receiving ED provider has an EDIS system with the capability
to share information.
Events: A provider sees a patient, or has spoken with the patient or a family member, and
has decided to refer the patient to an ED. The provider creates an ED Referral summary
document, and shares it. The detailed content of the medical summary to support this use
case is detailed as part of the document content profile specification.
Post conditions: The ED specialist physician retrieve the Documents and views them,
optionally importing data. Import assumes the specialist has an EDIS system with the
capability for managing those discrete data elements.
Steps to identify the ED and obtain insurance preauthorization have been placed out of
scope for this Integration Profile.
3.5 PPHP Integration Profile
The PPHP Profile is not being released for public comment this cycle. Compents of this
profile have been incorporated into the technical framework for use with other content
profiles, and these remain in Volume II.
3.6 Antepartum Summary (APS)
Obstetric patients in labor and admitted to Labor and Delivery must have a complete
summary of their antepartum ambulatory care available at the time of admission to
evaluate and / or ameliorate risk. This same data is required at any visit to Labor and
Delivery for any other problems or special needs a patient may require.
As the patient is seen over a finite period in the office, aggregation of specific relevant
data is important to the evaluation of the obstetric patient upon presentation to Labor and
Delivery. During the 40 weeks of a typical pregnancy duration, the patient will have an
initial History and Physical Examination, followed by repetitive office visits with
multiple laboratory studies, imaging (usually ultrasound) studies, and serial physical
examinations with recordings of vital signs, fundal height, and the fetal heart rate. The
original New OB History & Physical, ongoing Medical Diagnoses, the Estimated Due
Date, outcomes of any prior pregnancies, serial visit data on the appropriate growth of the
uterus and assessments of fetal well being, authorizations, laboratory and imaging studies
must all be presented and evaluated upon entry to the Labor and Delivery Suite to ensure
optimal care for the patient and the fetus.
Although the patient and her care provider may plan for a vaginal (natural) method of
delivery, there is a substantive chance the delivery route may be surgical, requiring
anesthesia and post-surgical care.
_____________________________________________________________________
57
Revision 3.0 Public Comment — June 25, 2007
Copyright © 1997-2007: ACC/HIMSS/RSNA