Use Case Library

Health Information Exchange Toolkit

This toolkit contains guides, templates, and forms to help develop effective connections to a Health Information Exchange (HIE), like the Mass HIway.


 

This library contains Use Cases that improve care coordination, support Meaningful Use, and implement other HIE goals. Each Use Case provides generalized guidance and you can use the Use Case Tools to tailor a case to your organization's needs. Many Use Cases are illustrated with a real-life example from an organization that implemented the case, and/or linked to a related HIE Spotlight Story.

The Use Cases are grouped into multiple tables by HIE Use Case category, including: Closed Loop Referrals, Summaries of Care, Discharge Summaries, Care Coordination, Lab Exchange, Query HIE, and Public Health Reporting.

Transitions of Care: Closed Loop Referrals

Closed Loop Referrals

Supported Objectives

Resources

Closed Loop Referrals from Community Health Center to Orthopedic Specialist
  • Send referrals and share Clinical Summaries, Progress Notes, and Transition of Care documents
  • Improve care coordination, attain better patient outcomes, and reduce delays in closing the referral loop
Closed Loop Referrals from Community Health Center to Hospital
  • Send referrals and share CCDs
  • Enhance the coordination of care for behavioral health patients to attain better patient outcomes
  • Establish collaborative healthcare environment
  • Improve communication between organizations with different EHR systems
Closed Loop Referrals between Partnering Organizations
  • Send referrals and share CCDs and Discharge Summaries
  • Improve care coordination for patients who are seen at a hospital and its partnering healthcare organizations
Closed Loop Referrals from PCP to Specialist
  • Send referrals and share Summary of Care Documents and Consult Notes
  • Improve care coordination
  • Meet Meaningful Use HIE objective
    Closed Loop Referrals from Hospital to Behavioral Health Specialist
  • Send referrals and share Summary of Care Documents and Encounter Notes
  • Facilitate seamless transfer of patient referral and treatment information to improve patient safety, outcomes and overall experience

Transitions of Care: Summaries of Care

Summaries of Care

Supported Objectives

Resources

Summaries of Care from Community Health Center to Partner Hospitals
  • Share CCDs between partnering organizations
  • Improve patient care, lower costs, reduce redundancy
  • Streamline transition of care for patients transferring from a community health center to a hospital
Summaries of Care from Hospital to Specialized Medical Center
  • Share medical documents between two healthcare organizations with different EHR systems
  • Improve transition of care for patients who need to receive prenatal care at a specialized medical center
Summaries of Care from Children's Hospital to Community Health Center
  • Share medical records
  • Improve care coordination and patient care while reducing the likelihood of lost reports and recording errors
Summaries of Care from Hospital to Home Health Care Agency
  • Share medical care documents
  • Enhance the process of sending necessary documents from hospitals to home health care agencies to improve the coordination of care for shared patients
Summaries of Care from PCP to Behavorial Health Specialist
  • Improve specialty referrals to Behavioral Health (BH) providers
  • Send the information needed by a BH provider to safely treat a referred patient
Summaries of Care from Behavioral Health Specialist to PCP
  • Send behavioral health information to a primary care physician, so they can integrate this information into a client's diagnosis and updated treatment plan
  • Enhance coordination of care between behavioral health and primary care providers

Transitions of Care: Discharge Summaries

Discharge Summaries

Supported Objectives

Resources

Discharge Summaries from Hospital to Healthcare Practice
  • Receive Discharge Summaries and CCDs from a hospital
  • Improve patient care and reduce delays in care by replacing faxing with electronic document exchange
Discharge Summaries from Hospital to Post-Acute Care
  • Send Discharge Summaries to a post-acute care organization
  • Improve care coordination and reduce delays in care for hospital patients who receive post-acute care at another organization with a different EHR system
Discharge Summaries from Rehab Center to Home Health Agency
  • Receive Discharge Summaries from a rehab center
  • Provide uninterrupted care when patients transfer from rehab center to home care to improve patient safety and outcomes
Discharge Summaries from Hospital to Post-Acute Care or Home Care
  • Send discharge summaries to post-acute and home care​​
  • Improve care coordination
  • Reduce hospital readmissions
  • Meet Meaningful Use HIE objective

Care Coordination

Care Coordination

Supported Objectives

Resources

Care Plan Document Exchange between a MassHealth ACO and its Community Partners

  • Electronic exchange of care plans between ACOs and their Community Partners
  • Provide long term support or behavioral health services
  • Reduce time delays and attain better patient outcomes
Care Coordination for Substance Use Disorder
  • Share eReferrals, treatment and medication status, discharge summaries and care plans to attain better patient outcomes and reduce costly readmissions
  • Improve coordination of care for patients with substance use disorder
Care Coordination for Co-Occurring Acute Medical and Behavioral Health Conditions
  • Share treatment, medication status, discharge summaries and care plans to attain better patient outcomes and reduce costly readmissions
  • Prompt, accurate assessment and coordination of care for patient with co-occurring medical and behavioral health condition
    Care Coordination for Surgery between Orthopedic Specialty Provider, Hospital, and Home Care
  • Send notifications of planned surgery, schedule patient education, and coordinate pre-admission testing
  • Coordinate care to reduce hospital readmissions
  • Reduce healthcare costs
  • Meet Meaningful Use HIE objective
    Care Coordination between PCP and Behavioral Health Provider
  • Exchange Summaries of Care
  • Improve care coordination
  • Support Patient Centered Medical Home standards
  • Meet Meaningful Use HIE and Medication Reconciliation objectives

Lab Exchange

Lab Exchange

Supported Objectives

Resources

Exchange of Lab Order and Lab Results between Hospital Lab and Home Health Agency  
  • Exchange lab orders and results
  • Develop efficient way to communicate lab results to visiting nurses in the community
  • Improve patient safety and reduce costs associated with lab results management

Query HIE

Query HIE

Supported Objectives

Resources

Customized Query HIE between Medical Group and Partnering Hospitals 
  • Utilize a customized Query HIE approach to improve care coordination between shared patients

Public Health Reporting

Public Health Reporting

Supported Objectives

Resources

Child and Adolescent Needs and Strengths (CANS) Assessments from Community-based Organization to MassHealth
  • Submit CANS assessments directly from the provider’s EHR to MassHealth
  • Simplify and semi-automate the process to reduce data submission errors
Send and Retrieve Immunization Data to and from MIIS (Massachusetts Immunization Information System)
  • Send and retrieve immunization records to and from MIIS
  • Improve patient care and reduce over- and under-vaccination by having a record of a patient’s prior immunizations
Send Immunization Data to MIIS with Acknowledgement of Receipt
  • Send immunization data to MIIS
  • Meet M.G.L. c. 111, s.24M requirement that all licensed healthcare providers who administer immunizations need to report all immunization data to MIIS
  • Meet Meaningful Use objective to electronically submit vaccination data to an immunization registry