Use Case 4 - Exchanging Structured Clinical Data

This use case has been created by the HIMSS Interoperability Maturity Model (IMM) Task Force as a sample of basic technical capabilities necessary for achieving interoperability and improved care processes through health information technology.

If you would like to see other use cases added, please submit a request to interop@himss.org.

This use case describes the capability of a health information system to capture data in a specified structure, with data elements such as clinical vocabularies used in a standardized way.  The following scenario would test if a health information system can capture clinical data consistently across multiple instances or of data entered by multiple clinicians.

Goals:

  • Exchange data in a readable, structured, and standardized format
  • Utilize controlled terminology
  • Definition of data/terms for consistency between end users
  • Ensure mapping of localized data where applicable
  • Leverage core systems of SNOMED CT, ICD-10, LOINC, and RxNorm
  • Ensure privacy and security standards are adhered to
  • Reduce data fragmentation and therefore, improve patient safety, efficiency and interoperability

Primary actors:

  • Patients
  • Providers
  • Vendors
  • Health Care Payers
  • Regulatory Agencies

Preconditions/triggers:

  • Patient visit can trigger data element retrieval for patient care
  • Provider request
  • Request from regulatory agency

List or describe the basic flow of the use case from beginning to end, without error states.

  • Patient arrives at provider organization
  • Patient is identified and registered, and standardized data is documented in appropriate record
  • Encounter is completed
  • Data is transmitted to appropriate third party and/or regulatory agency

Looking for a printer-friendly copy of this basic workflow?  Download the workflow diagram here!

List or describe alternate flows, including those that involve error conditions.

  • Patient arrives at provider organization
  • Provider is unable to find patient in EMR
  • Provider is unable to retrieve and review clinical data and/or document

Are there post conditions that will be true about the system after the use case has been accomplished?

  • Improve patient safety
  • Reduce data fragmentation
  • Improve timeliness and meaningful use of data

Looking for a printer-friendly copy of this use case?  Download the printable PDF here!

 

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Keywords: 
use cases, interoperability, Clinical, Structured, Capture, exchange