Use Cases Demonstrating the Utilization of Direct in Four ... · Use Cases Demonstrating the...

December 2013

Use Cases Demonstrating the Utilization of Direct in Four States:

Alabama, Florida, Illinois, Rhode Island

Appendices

Prepared for

Office of the National Coordinator for Health Information Technology U.S. Department of Health and Human Services

300 C Street, SW Washington, DC 20201

Prepared by

Gloria J. Deckard, Ph.D. Monica Chiarini Tremblay Ph.D.

Debra VanderMeer Florida International University

Michael Shapiro RTI International

230 W. Monroe St, Suite 2100 Chicago, IL 60606

RTI Project Number 0212050.007.000.006

_________________________________ RTI International is a trade name of Research Triangle Institute.

RTI Project Number 0212050.007.000.006

Use Cases Demonstrating the Utilization of Direct in Four States:

Alabama, Florida, Illinois, Rhode Island

Appendices

December 2013

Prepared for

Office of the National Coordinator for Health Information Technology U.S. Department of Health and Human Services

300 C Street, SW Washington, DC 20201

Prepared by

Gloria J. Deckard, Ph.D. Monica Chiarini Tremblay Ph.D.

Debra VanderMeer Florida International University

Michael Shapiro RTI International

230 W. Monroe St, Suite 2100 Chicago, IL 60606

iii

Contents

Appendix Page

Appendix A: Guideline for Use Case Development A-1

Appendix B: Activity Models B-1

B.1 Overview of Activity Modeling .................................................................. B-1

B.2 Alabama Activity Models .......................................................................... B-2 B.2.1 Dyad 1: Eastern Alabama .............................................................. B-2 B.2.2 Dyad 2: Southern Alabama .......................................................... B-12

B.3 Florida Activity Models .......................................................................... B-14 B.3.1 Dyad 1: Central Florida ............................................................... B-14 B.3.2 Dyad 2: Southwest Florida ........................................................... B-21

B.4 Illinois Activity Models ........................................................................... B-26 B.4.1 Dyad 1: Illinois Behavioral Assessment .......................................... B-26 B.4.2 Dyad 2: Illinois Methadone Services .............................................. B-31

B.5 Rhode Island Activity Models .................................................................. B-38 B.5.1 Dyad 1: Rhode Island Integrated Care ........................................... B-38 B.5.2 Dyad 2: Rhode Island Community Behavioral Services ..................... B-46

iv

Exhibits

Number Page

B-1. Example Activity Model ................................................................................ B-1 B-2. Review of Eastern Alabama, Scenario 1 .......................................................... B-2 B-3. Eastern Alabama Scenario 1 Pre-Direct Initiate Referral .................................... B-3 B-4. Eastern Alabama Scenario 1 with-Direct Initiate Referral ................................... B-4 B-5. Eastern Alabama Scenario 1 Pre-Direct Receive Referral ................................... B-5 B-6. Eastern Alabama Scenario 1 With-Direct Receive Referral ................................. B-6 B-7. Eastern Alabama Scenario 1 Pre-Direct Monitor Followup .................................. B-7 B-8. Eastern Alabama Scenario 1 With-Direct Monitor Followup ................................ B-8 B-9. Review of Eastern Alabama Interaction, Scenario 2 .......................................... B-9 B-10. Eastern Alabama Scenario 2, Pre-Direct ....................................................... B-10 B-11. Eastern Alabama Scenario 2, With Direct ...................................................... B-11 B-12. Review of Southern Alabama Interaction ...................................................... B-12 B-13. Southern Alabama Interaction, Pre-Direct ..................................................... B-13 B-14. Review of Central Florida Interaction ............................................................ B-14 B-15. Central Florida Pre-Direct Initiate Referral ..................................................... B-15 B-16. Central Florida Direct-Enabled Initiate Referral .............................................. B-16 B-17. Central Florida Pre-Direct Receive Referral, Treat Patient, and Provide

Treatment Record ..................................................................................... B-17 B-18. Central Florida Direct-Enabled Receive Referral, Treat Patient, and Provide

Treatment Record ..................................................................................... B-18 B-19. Central Florida Pre-Direct Receive Treatment Record ...................................... B-19 B-20. Central Florida Direct-Enabled Receive Treatment Record ............................... B-20 B-21. Review of Southwest Florida Interaction ....................................................... B-21 B-22. Southwest Florida Pre-Direct Initiate Referral ................................................ B-22 B-23. Southwest Florida Direct-Enabled Initiate Referral .......................................... B-23 B-24. Southwest Florida Pre-Direct Receive Referral ............................................... B-24 B-25. Southwest Florida Direct-Enabled Receive Referral ......................................... B-25 B-26. Review of Illinois behavioral Assessment ...................................................... B-26 B-27. Illinois Behavioral Assessment Pre-Direct Initiate Referral ............................... B-27 B-28. Illinois Behavioral Assessment with-Direct Initiate referral .............................. B-28 B-29. Illinois Behavioral Assessment Pre-Direct Receive Referral .............................. B-29 B-30. Illinois Behavioral Assessment with-Direct Receive Referral ............................. B-30 B-31. Illinois Behavioral Assessment, Receive Discharge Notice for Pre-Direct and

With-Direct .............................................................................................. B-31 B-32. Review of Illinois Methadone Services interaction ........................................... B-31

v

B-33. Illinois Methadone Services Pre-Direct Initiate Referral ................................... B-32B-34. Illinois Methadone Services with Direct Initiate Referral .................................. B-33B-35. Illinois Methadone Services Pre-Direct Receive Referral .................................. B-34 B-36. Illinois Methadone Services with-Direct Receive Referral ................................. B-35 B-37. Illinois Methadone Services Pre-Direct Receive Treatment Record ..................... B-36 B-38. Illinois Methadone Services With-Direct Receive Treatment Record ................... B-37 B-39. Review of Rhode Island Integrated Care, Scenario 1 ...................................... B-38 B-40. Rhode Island Integrated care, Scenario 1, Pre-Direct Initiate Referral ............... B-39 B-41. Rhode Island Integrated Care, Scenario 1, Post-Direct Initiate Referral ............. B-40 B-42. Rhode Island Integrated Care, Scenario 1, Pre-Direct Receive Referral .............. B-41 B-43. Rhode Island Integrated Care, Scenario 1, With-Direct Receive Referral ............ B-42 B-44. Review of Rhode Island Integrated Care, Scenario 2 ...................................... B-43 B-45. Rhode Island Integrated Care Scenario 2, Pre-Direct ...................................... B-44 B-46. Rhode Island Integrated Care Scenario 2, With-Direct .................................... B-45 B-47. Review of Rhode Island Community Behavioral Services, Scenario 1 ................. B-46 B-48. Rhode Island Community Behavioral Services, Scenario 1, Pre-Direct ............... B-47 B-49. Rhode Island Community Behavioral services Scenario 2, With-Direct ............... B-48 B-50. Review of Rhode Island Community Behavioral Services, scenario 2 ................. B-49 B-51. Rhode Island Community Behavioral Services Scenario 2, Pre-Direct ................ B-50 B-52. Rhode Island Community Behavioral Services Scenario 2, With-Direct .............. B-51

vi

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A-1

APPENDIX A: GUIDELINE FOR USE CASE DEVELOPMENT

Pre-Observation Discussion: To diagram the workflow and illustrate the impact of Direct adoption, we spoke with contacts at each location before our observations were conducted. We elicited the following information to prepare our initial workflow diagrams:

1. Length of time using Direct

2. Reasons for adoption

3. Number of individuals using Direct in location

4. Primary user of Direct in location to identify individuals to observe

5. Integration of Direct with EHR

6. Integration of Direct with any other IT systems within location

7. Adoption process

a. Internal

b. External

8. Current uses of Direct (what would be observed)

9. Workflow for exchange of protected health information prior to adoption of Direct

Observation: Prior to the observation, we detailed the individual steps (workflow) for the exchange of protected health information as discussed in the pre-observation phone conference. At the observation we would:

1. Share the UML diagram representing of pre-Direct workflow to assure accuracy.

2. Discuss changes in the workflow diagram following the adoption of Direct.

3. Discuss any other impacts created by the adoption of Direct.

4. Observe use of Direct.

Post-Observation Discussion: To verify that the UML diagram accurately reflected the use of Direct as observed, we emailed a copy of the diagrams to each location and conducted a post-observation phone conference with our contact at each location.

State Health Policy Consortium: FIU Direct Use Case

A-2

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B-1

APPENDIX B: ACTIVITY MODELS

B.1 Overview of Activity Modeling

We describe the details of interaction among the people and systems in each Use Case scenario in the form of UML Activity Models. UML is a graphical modeling language in which each graphical element has a specific meaning. Exhibit B-1 provides an overview of the elements of UML Activity Models here. Subsequent exhibits present detailed Activity Models for the observation Use Cases.

Exhibit B-1. Example Activity Model


B-2

Exhibit B-1 depicts a simple scenario in which patient calls a medical practice for an appointment. Here, each separate vertical column or “swimlane” represents a participant in the process. Each swimlane is labeled with the role and the words denoting whether a person or the system executes the role. Swimlanes that are contiguous reside with a single organization. Rounded-corner boxes represent activities in the workflow process. Each activity resides within a swimlane, which indicates that the swimlane’s owner is responsible for performing the activity. The solid black dot indicates the start of the workflow process, and the black dot with the circle around it indicates the end. Arrows between activities indicate the precedence ordering of activities. These arrows do not carry data for communication purposes; rather, communication between participants is explicitly represented in the activities. The diamond indicates conditional logic, where multiple options are available, and each outgoing arrow indicates which option is selected by following it. A rectangular box with arrows leading away from it or into it (not pictured in this example) indicates the beginning or end of parallel processing, respectively.

B.2 Alabama Activity Models

B.2.1 Dyad 1: Eastern Alabama

In this section, we provide detailed Activity Models for the Eastern Alabama Dyad. This dyad has two scenarios; we present each in turn. Scenario 1 describes the interaction between a Case Management Agency that helps Medicare clients navigate the health care system and the State Department of Public Health, where some of the Case Managers are employed. Exhibit B-2 provides a review of the interaction steps in the Use Case scenario.

Exhibit B-2. Review of Eastern Alabama, Scenario 1

We present our Activity Models for this Use Case scenario for these steps. Specifically, Exhibit B-3 and Exhibit B-4 depict the details for Step A for the pre-Direct and Direct-enabled cases, respectively; Exhibit B-5 and Exhibit B-6 show the details for Step B for the pre-Direct and Direct-enabled cases, respectively; and Exhibit B-7 and Exhibit B-8 show the details for Step C for the pre-Direct and Direct-enabled cases, respectively.

Step A: Location 1 sends

follow-up case referrals to Location 2

Step B: Location 2 receives follow-up referral,

follows up with client, and records

activity in statewide system

Step C: Location 1 audits follow-up cases in

the statewide system, and sends

out audit reports for incomplete follow-

up cases

B-3

Appendix B

— A

ctivity Models

Exhibit B-3. Eastern Alabama Scenario 1 Pre-Direct Initiate Referral

State Medicaid Staff

Case Management System Staff (Person)

Case Management Staff (System)

Case Management Agency Email (System) Case Management Agency Quality Manager (Person) State Dept. of Public Health Case

Manager (Person)

Compile monthly report

of Medicaid activity

Provide data to Case

Management system staf for

Upload data to Case Management

system

Run report

Store data

Log in Case Management system

Run report for list of clients with chronic conditions

Note unusual/missing activity for

followup

Determine which case management is responsible for

client’s case

Send internal email with instructions for followup on

client

Call clinician

Wait a few hours

Tell clinician about client followup needs

Receive client followup

information

Transmit email

YesNo

Clinician is within agency?

No YesReach clinician?

State H

ealth Policy Consortium

: FIU D

irect Use C

ase

B-4

Exhibit B-4. Eastern Alabama Scenario 1 with-Direct Initiate Referral

State Medicaid Staff Case Management System Staff (Person) Case Management Staff (System)

Compile monthly report of

Medicaid activity

Provide data to Case

Management system staf for

Upload data to Remedy system

Run report

Store data

Case Management Agency Quality Manager (Person)

Log in Case Management system

Run report for list of clients with chronic conditions

Note unusual/missing activity for followup

Determine which case management is responsible for client’s case

Log in to DirectSend internal email with instructions for followup on

client

Yes

No


Case Management Agency Email (System)

Transmit email

Create email with instructions for followup on client; include copy to

supervisor

Send email

Send non-Direct email to notify of new Direct

message; include copy to supervisor

Transmit email

Direct (System)

Transmit email

Appendix B — Activity Models

B-5

Exhibit B-5. Eastern Alabama Scenario 1 Pre-Direct Receive Referral

B-6

State H


: FIU D

irect Use C

ase

Exhibit B-6. Eastern Alabama Scenario 1 With-Direct Receive Referral

B-7

Appendix B

— A

ctivity Models

Exhibit B-7. Eastern Alabama Scenario 1 Pre-Direct Monitor Followup


Log in to Case Management system

Load client record in Case Management System

Look for follow-up records in client case

record

Determine which case manager is responsible for client’s case

Call case manager

Send internal email asking

about any problems in

following up with client

YesNo



Transmit email

Drop off audit paper copy to case management

supervisor

Ask clinician about any problems in following

up with client

Case Management System (System)

Return client record

State Dept. of Public Health Case Manager (Person)

State Dept. of Public Health Case Mgt. Supervisor (Person)

Discuss any problems in following up with

client

Receive audit report

For each client needing follow-up

Yes

No

Followup complete?

Wait a few hours

Reach a case manager?

Yes

No

B-8

State H


: FIU D

irect Use C

ase

Exhibit B-8. Eastern Alabama Scenario 1 With-Direct Monitor Followup


Determine which case manager is responsible for client’s case

Log in to Direct

Send internal email asking

about any problems in

following up with client

YesNo



Transmit email

Send Direct email with followup questions for

case manager

Send Direct email with audit results

to supervisor

Transmit email

Direct (System)

Transmit email

Case Management System (System)

Return client record

Log in to Case Management System

Load client record in Case Management System

Look for follow-up records in client case

record

for each client needing follow-up

Yes

No

Followup complete?

Send non-Direct email to notify of

Direct email

Send non-Direct email with audit

results to supervisor

Transmit email

Transmit email


B-9

Scenario 2 considers the interaction between the Transportation Coordinator at the Case Management Agency and the Case Manager at the State Department of Public Health as they coordinate the transportation of a client to/from medical facilities or the delivery of needed medical equipment. Exhibit B-9 provides a review of the interaction steps in the Use Case scenario.

Exhibit B-9. Review of Eastern Alabama Interaction, Scenario 2

We present our Activity Models for this Use Case scenario for these steps summarized in two activity models. Specifically, Exhibit B-10 and Exhibit B-11 depict the details for the pre-Direct and Direct-enabled cases, respectively.

Step A: Location 2

sends a request for

transportation to Location 1

Step B: Location 1

receives requests and

requests coordination details from Location 2

Step C: Location 1

receives coordination

detail requests and responds to Location 2

Step D: Location 2 provides

transportation as agreed

B-1

0

State H


: FIU D

irect Use C

ase

Exhibit B-10. Eastern Alabama Scenario 2, Pre-Direct

Appendix B

— A

ctivity Models

B-1

1

Exhibit B-11. Eastern Alabama Scenario 2, With Direct

Dept. of Public Health Staff (Person) Direct (System)Dept. of Public Health

Fax (System)Dept. of Public Email Fax

(System)Case Management Agency

Fax (System)Case Management Agency

Email (System)Case Management Agency Transport

Coordinator (Person)

Transport person/item

Log in to Direct

Send Direct email to coordinate pickup/dropoff locations, etc.


Direct mail

Read email

Receive request

Transmit email

Receive email

Log in to Direct

Transmit email

Receive email

Transmit request

Transmit email

Log in to Direct

Fax request for transport to Case

Management Agency

Send Direct coordination

response


Direct mail

Transmit email

Client needs transportation or medical item

Sufficient information?

Yes

No


B-12

B.2.2 Dyad 2: Southern Alabama

In this section, we provide detailed Activity Models for the Southern Alabama Dyad, where a Mental Health Provider manages the treatment and transfer of clients under the care of the State Department of Mental Health. In this specific interaction the Mental Health Provider notifies the State Department of Mental Health about the transfer of a client between facilities or about the client’s discharge. Exhibit B-12 provides a review of the interaction steps in the Use Case scenario.

Exhibit B-12. Review of Southern Alabama Interaction

In this Use Case, only the pre-Direct case is modeled (the participants had not yet fully integrated Direct at the time of observation).

Exhibit B-13 presents the Activity Models for the pre-Direct interaction in this Use Case.

Step A: Location 1 transfers or discharges a

client and notifies Location 2

Step B: Location 2 receives the notification

from Location 1

Appendix B

— A

ctivity Models

B-1

3

Exhibit B-13. Southern Alabama Interaction, Pre-Direct


B-14

B.3 Florida Activity Models

B.3.1 Dyad 1: Central Florida

In this section, we provide detailed Activity Models for the Central Florida Dyad, in which a Specialist Practice refers a patient to another Specialist Practice for a particular type of specialized surgery. Exhibit B-14 provides a review of the interaction steps in the Use Case scenario.

Exhibit B-14. Review of Central Florida Interaction

Our Activity Models for this Use Case map closely to these steps. Specifically, Exhibit B-15 and Exhibit B-16 depict the details for Step A for the pre-Direct and Direct-enabled cases, respectively; Exhibit B-17 and Exhibit B-18 show the details for Step B for the pre-Direct and Direct-enabled cases, respectively; and Exhibit B-19 and Exhibit B-20 show the details for Step C for the pre-Direct and Direct-enabled cases, respectively.

Step A: Location 1 initiates

referral to Location 2

Step B: Location 2 receives

referral, treats patient, and sends a record of treatment

to Location 1

Step C: Location 1 receives

treatment record

Appendix B

— A

ctivity Models

B-1

5

Exhibit B-15. Central Florida Pre-Direct Initiate Referral

State H


: FIU D

irect Use C

ase

B-1

6

Exhibit B-16. Central Florida Direct-Enabled Initiate Referral

Appendix B

— A

ctivity Models

B-1

7

Exhibit B-17. Central Florida Pre-Direct Receive Referral, Treat Patient, and Provide Treatment Record

Referring Practice Staff (Person) Administrative Staff (Person)

Walk to referring practice

Create new patient in EMR

Administrative Staff PC (System) EMR (System) Clinical Staff (Person) Reviewing Physician (Person) Treating Physician (Person)

Hold referral documents for

pickup

Pick up referral documents from referring practice

Scan referral documents into EMR (referral, demographics,

pathology, picture)

Give paper referral

documents to reviewing

physician for review

Store new patient record

new patient?

Yes

No

Store new patient record

Schedule patient

treatment, obtain history,

and medications

Assign patient to physician

Treat patient

Enter treatment details in patient records in EMR

Store treatment details

Export treatment record

Store treatment record as PDF

Print record for review and signature

Print digitally signed record

Walk to referring practice

Deliver treatment record to referring office

Receive treatment record

Physician preference

Review and digitally sign treatment record

Scan signed paper record Store scanned

record

Store digitally signed record

sign paper record

Review and sign paper copy


B-18

Exhibit B-18. Central Florida Direct-Enabled Receive Referral, Treat Patient, and Provide Treatment Record

B-1

9

Appendix B

— A

ctivity Models

Exhibit B-19. Central Florida Pre-Direct Receive Treatment Record

B-2

0

State H


: FIU D

irect Use C

ase

Exhibit B-20. Central Florida Direct-Enabled Receive Treatment Record


B-21

B.3.2 Dyad 2: Southwest Florida

In this section, we provide detailed Activity Models for the Southwest Florida Dyad, which considers the interactions between a Children’s Social Services Agency and a School System as children age out of the Agency’s early intervention program and potentially become eligible for an individual education plan in the School System. Exhibit B-21 provides a review of the interaction steps in the Use Case scenario.

Exhibit B-21. Review of Southwest Florida Interaction

The workflow in this scenario requires significant interaction between the communicating parties; thus, rather than separating the steps shown above into separate Activity Models, we have developed Activity Models that represent the points of view of Location 1 and Location 2 for all steps in the interaction. Exhibit B-22 and Exhibit B-23 depict the interaction from Location 1’s point of view for the pre-Direct and Direct-enabled cases, respectively. Exhibit B-24 and Exhibit B-25 show the interaction from Location 2’s point of view for the pre-Direct and Direct-enabled cases, respectively.

Step A: On a monthly basis,

Location 1 provides a list of upcoming transfer cases to

Location 2

Step B: For each transfer

case, Locations 1 and 2 interact until

Location 2 has all needed records to

determine eligibility

Step C: On a quarterly basis,

Locations 1 and 2 interact to audit

complete and pending cases to

ensure full coverage


B-22

Exhibit B-22. Southwest Florida Pre-Direct Initiate Referral


B-23

Exhibit B-23. Southwest Florida Direct-Enabled Initiate Referral

Children’s Social Services Agency Staff (Person)

Review caseload to identify children eligible for referral to

school system

Children’s Social Services Agency PC (System) Direct (System)

Transmit email

Every month

Compile list of children turning 3 in the next 9

months

Log in to Direct

Create email; attach list

Send email

Prepare exit assessment and referral packet (including relevant test

results); this packet contains PHI and FERPA-protected information

Log in to Direct

Send email

Create list of completed and transfer cases

Log in to Direct

Create email; attach audit list

Send email for audit reconciliation to

ensure all referral cases are complete

Store list to local drive

Store referral documents to local

hard drive

Create email; attach list

Transmit email

Transmit email


B-24

Exhibit B-24. Southwest Florida Pre-Direct Receive Referral

School Staff (Person)

Receive list of expected children

Early Intervention Staff (Person)

Scan documents in referral packet to local

drive

Upload referral packet documents to IEP software

Hold IEP decision meeting

Meet with social services agency staff to ensure all

referral cases are complete

School Fax (System)

Drop off referral packet

Receive further records

Every monthAs each child approaches 3rd birthday

Check received documents against

checklist for IEP program acceptance

Drop off further records

Wait a few days

Call to remind social services agency staff of needed

documents/reports

Quarterly audit of children transitioning

File complete?

Yes

No


B-25

Exhibit B-25. Southwest Florida Direct-Enabled Receive Referral

School Staff (Person)

Receive list of expected children

Create record IEP in software for each child

Log in to Direct

Direct (System) School PC (System) IEP Tracking (System)

Receive email with expected

children

Receive email with child’s records

Open email; download

attachments

Upload referral documents in IEP

Check received referral documents against

checklist for IEP program acceptance

Store attachments to local drive

Store list of expected children

Create new record

Store referral documents to child’s record

Create email to request missing

documents

Meet with social services agency staff to ensure all

referral cases are complete

Wait a few days

Log in to Direct

Quarterly audit of children transitioning

File complete?Yes

No

Send emailTransmit email

Receive response?

YesNo

Receive email documents

Hold IEP decision meeting


B-26

B.4 Illinois Activity Models

B.4.1 Dyad 1: Illinois Behavioral Assessment

In this section, we provide detailed Activity Models for the Illinois Behavioral Assessment Dyad, where a Social Service Agency performs assessments of adolescents in crisis, and refers those needing acute care to a Hospital. Here, the interaction involves transmitting the details of the assessment from Clinician in the field to the Hospital. Exhibit B-26 provides a review of the interaction steps in the Use Case scenario.

Exhibit B-26. Review of Illinois behavioral Assessment

Our Activity Models for this Use Case map these steps as follows. Exhibit B-27 depict the details for Steps A, B, and C for the pre-Direct case, while Exhibit B-28 illustrates the corresponding Direct-enabled cases. Exhibit B-29 and Exhibit B-30 show the details for Step D for the pre-Direct and Direct-enabled cases, respectively. Step E is the same for both the pre-Direct and Direct-enabled cases, and is shown in Exhibit B-31.

Step A: Location 1

verifies bed

availability with

Location 2 to verify

availability of a bed

Step B: Location 2

verifies availability

Step C: Location 1

sends assessment

to Location 2

Step D: Location 2

treats adolescent

Step E: Location 1 provides follow-up

care

Appendix B

— A

ctivity Models

B-2

7

Exhibit B-27. Illinois Behavioral Assessment Pre-Direct Initiate Referral

Reporting Person

Request for adolescent psychiatric assessment

Assessing Clinician (Person)

Go to site to assess

Assess adolescent

Call hospital to verify bed availability

Suggest other help

requires hospitalization

Yes

No

Keep calling other hospitals

Provide case basics verbally

available?No

Yes

Fax available nearby?

Rewrite assessment for transport with

adolescent

Fax assessment to hospital

No Yes

Fax assessment to hospital

Social Services Agency Fax (System)

Transmit assessment

Local Fax (System)

Transmit assessment to hospital

Transporting Person (Person)

Transport handwritten assessment

with adolescent

Hospital Fax (System)

Receive assessment

Hospital Staff (Person)

Receive adolescent

and handwritten assessment

Receive assessment

Wait for official

assessment

Begin treating adolescent


B-28

Exhibit B-28. Illinois Behavioral Assessment with-Direct Initiate referral

Reporting Person

Request for adolescent psychiatric assessment

Social Service Agency Clinician (Person)

Go to site to assess

Assess adolescent

Call hospital to verify bed availability

Suggest other help

requires hospitalization

Yes

No

Keep calling other

hospitals

Provide case basics verbally

available?No

Yes

Social Services Agency EHR (System)

Social Service Agency Shared Storage (System) Direct (System)

Log in to VPN

Enter assessment

into EHR

Export assessment as PDF to shared

storage

Log in to Direct

Create email; attach assessment

Send emailTransmit

email

Store assessment

Export assessment

Store assessment


B-29

Exhibit B-29. Illinois Behavioral Assessment Pre-Direct Receive Referral


B-30

Exhibit B-30. Illinois Behavioral Assessment with-Direct Receive Referral


B-31

Exhibit B-31. Illinois Behavioral Assessment, Receive Discharge Notice for Pre-Direct and With-Direct

B.4.2 Dyad 2: Illinois Methadone Services

In this section, we provide detailed Activity Models for the Illinois Behavioral Assessment Dyad, in which a Methadone Clinic refers new clients (at start of treatment) and ongoing clients (on an annual basis) to a Community Health Center for a physical checkup. Exhibit B-32 provides a review of the interaction steps in the Use Case scenario.

Exhibit B-32. Review of Illinois Methadone Services interaction

Our Activity Models for this Use Case map closely to these steps. Specifically, Exhibit B-33 and Exhibit B-34 depict the details for Step A for the pre-Direct and Direct-enabled cases, respectively; Exhibit B-35 and Exhibit B-36 show the details for Step B for the pre-Direct and Direct-enabled cases, respectively; and Exhibit B-37 and Exhibit B-38 show the details for Step C for the pre-Direct and Direct-enabled cases, respectively.

Step A: Location 1 refers client for physical

checkup

Step B: Location 2 performs

physical checkup

Step C: Location 1 receives results of physical

checkup from Location 2


B-32

Exhibit B-33. Illinois Methadone Services Pre-Direct Initiate Referral


B-33

Exhibit B-34. Illinois Methadone Services with Direct Initiate Referral

Clinician (Person)

Process new patient

Perform quarterly

case review

Make appointment for physical

Yes No

Needs annual physical?

Create referral sheet

Admin staff (Person) Scanner (System) Shared Storage (System) Direct (System)

Transmit email

Give referral sheet to

admin staff

Scan referral to PDF on shared

storageScan document Scan document

Log in to Direct

Create email

Attach documents to email

Send email


B-34

Exhibit B-35. Illinois Methadone Services Pre-Direct Receive Referral

Patient (Person)

Give referral paperwork to

admin staff

Admin Staff (Person) Practice Fax (System) Clinician (Person)

Create new patient file (episodic charts)

Give referral to Clinician

Perform physical

Create clearance document (confirmation

of physical, clearance for treatment, initial

dose amount)

Write up initial record of physical

Wait for lab results

Finalize report of physical

Hold final report for clinic staff pickup

Fax for clearance

Transmit clearance to clinic

For new clients


B-35

Exhibit B-36. Illinois Methadone Services with-Direct Receive Referral

State H


: FIU D

irect Use C

ase

B-3

6

Exhibit B-37. Illinois Methadone Services Pre-Direct Receive Treatment Record

Practice Admin Staff (Person)

Fax initial clearance to

clinic

Hold full record for clinic pickup

Practice Fax (System)

Transmit initial clearance

Clinic Fax (System)

Receive initial clearance

Admin Staff (Person)

Give clearance document to

clinician

Each Thursday, drive to practice

with another admin staff member

Another Admin Staff (Person)

Go into practice to pick up

records

Clinicial (Person)

Review clearance document

Begin dosage regimen for

patient

Wait in car

Drive back to clinic Return to car

Give records to clinician

Wait for full record

Review record and modify

dosage regimen as needed


B-37

Exhibit B-38. Illinois Methadone Services With-Direct Receive Treatment Record

Direct (System)

Transmit main med record

Admin Staff (Person) Clinician (Person)

Log in to Direct

Open mail, print attachments

Review lab results, change treatments

if needed

day of appointment

Transmit lab records

day after appointment

Place paper med record in patient file

Give record to clinician

Log in to Direct

Open mail, print attachments

Place paper med record in patient file

Give record to clinician

Review med record, change treatment if

needed


B-38

B.5 Rhode Island Activity Models

B.5.1 Dyad 1: Rhode Island Integrated Care

In this section, we provide detailed Activity Models for the Rhode Island Integrated Care Dyad. There are two scenarios for this dyad. We present each in turn.

Scenario 1 considers the case of a Primary Care Practice referring a patient to a Behavioral Health Provider. Exhibit B-39 provides a review of the interaction steps in the Use Case scenario.

Exhibit B-39. Review of Rhode Island Integrated Care, Scenario 1

We present our Activity Models for this Use Case scenario for these steps. Specifically, Exhibit B-40 and Exhibit B-41 depict the details for Step A for the pre-Direct and Direct-enabled cases, respectively, while Exhibit B-42 and Exhibit B-43 show the details for Step B for the pre-Direct and Direct-enabled cases, respectively.

Step A: Location 1 makes referral appointment for patient

at Location 2

Step B: Location 2 receives referral, and

treats client


B-39

Exhibit B-40. Rhode Island Integrated care, Scenario 1, Pre-Direct Initiate Referral

Physician (Person) EMR (System)

Create referral in EHR

Store referral and print to

central printer


Match printout to patient at counter

Fax (System)

Transmit referral

Patient needs referral to behavioral provider

Make appointment

Fax referral

Create EMR reminder to

follow up every two days until patient keeps appointment

Store reminder

Call referral practice to

check

After two days, remind

physician

Cancel reminder

Remove reminder from EMR

Patient kept appointment

No

Yes

for critical referrrals

At the end of patient visit

State H


: FIU D

irect Use C

ase

B-4

0 Exhibit B-41. Rhode Island Integrated Care, Scenario 1, Post-Direct Initiate Referral

Physician (Person) EMR (System)

Create referral in EHR

Store referral and print to

central printer


Match printout to patient at counter

DIRECT (System)

Transmit referral

Patient needs referral to behavioral provider

Make appointmentCreate EMR reminder to

follow up every two days until patient keeps appointment

Store reminder

Call referral practice to

check

After two days, remind

physician

Cancel reminder

Remove reminder from EMR

Patient kept appointment

No

Yes

for critical referrrals

At the end of patient visit

Admin PC (System)

Scan referral, demographics, insurance info

Move from shared folder to

local folder

Log in to Direct

Attach documents to Direct email

and send


B-41

Exhibit B-42. Rhode Island Integrated Care, Scenario 1, Pre-Direct Receive Referral

Fax (System)

Receive referral

Admin Staff (Person) Intake Staff (Person) Clinician (Person)

Check for client in Master Client Index

Place paper referral fax in clinician’s box

Interview client

Treat client

Add clinical notes to client treatment

record

existing client record?

Place paper referral fax in clinician’s box

No

Yes


B-42

Exhibit B-43. Rhode Island Integrated Care, Scenario 1, With-Direct Receive Referral

Scenario 2 considers the interaction for a Primary Care Practice receiving automated admission, transfer, and discharge notifications from a Hospital. Exhibit B-44 provides a review of the interaction steps in the Use Case scenario.

Direct (System)

Transmit referral email

Admin Staff (Person) Intake Staff (Person) Clinician (Person)

Log in to Direct

Check for client in Master Client

IndexInterview client

Treat client

Add clinical notes to client treatment

record

existing client record?

Pass record to appropriate

clinicianNo

Yes

Open mail and send acknowledgement

Print email and attachments


B-43

Exhibit B-44. Review of Rhode Island Integrated Care, Scenario 2

We present our Activity Models for this Use Case scenario for these steps; Exhibit B-45 depicts the details for the pre-Direct case, while Exhibit B-46 shows the details for the Direct-enabled case.

Step A: Admit, transfer, or discharge event occurs for a patient in the Hospital

Step B: Practice follows up on patient

status

State H


: FIU D

irect Use C

ase

B-4

4

Exhibit B-45. Rhode Island Integrated Care Scenario 2, Pre-Direct


Admit Patient

Hospital Fax (System) Provider Fax (System) Provider Admin Staff (Person)

Deliver notice of admission

Fax treatment records

Deliver treatment record

Add treatment to patient record

Remove from follow list


Fax notice of admission to primary care provider

Maintain treatment

records

Receive notice of admission

Add patient to “follow list”

Every day, call hospital for

status

Every day, call hospital for

treatment record

Discharged

No

Yes

Received

No

Yes

Follow up with patient regularly until followup is complete

Appendix B

— A

ctivity Models

B-4

5

Exhibit B-46. Rhode Island Integrated Care Scenario 2, With-Direct

Hospital EHR (System)

Generate admission alert


Admit patient

Hospital Fax System

Transfer patient

Direct (System)

Transmit referral email

Provider Admin Staff (Person)

Log in to Direct

Provider Fax (System)

Deliver alert

Provider EHR (System)

Open and print email

Provider Clinical Staff (Person) Clinical Staff PC (System)

Discharge patient

Fax treatment record



Deliver treatment record

Note activity in patient chart

Shred printout

Move email to “Current Care”

folder

Store record

Log in to Direct

Open email from “Current Care”

folder

Review treatment activity record

Store attachments to local storage

Add PDF attachments to patient medical

record

Store attachments

Store attachments

Add treatment record to patient record

Follow up with patient regularly until followup is complete

Remove from follow list



B-46

B.5.2 Dyad 2: Rhode Island Community Behavioral Services

In this section, we provide detailed Activity Models for the Rhode Island Community Behavioral Services Dyad. There are two scenarios for this dyad. We present each in turn.

Scenario 1 considers the intake process for incoming referrals. Exhibit B-47 provides a review of the interaction steps in the Use Case scenario.

Exhibit B-47. Review of Rhode Island Community Behavioral Services, Scenario 1

We present our Activity Models for this Use Case scenario for these steps. Specifically, Exhibit B-48 and Exhibit B-49 depict the details for the pre-Direct and Direct-enabled cases, respectively.

Step A: Staff collect information for

referral, and assigns to clinician

Step B: Clinician receives referral

documents

Appendix B

— A

ctivity Models

B-4

7

Exhibit B-48. Rhode Island Community Behavioral Services, Scenario 1, Pre-Direct

Client (Person)

Request appointment

Referring Physician (Person)

Refer patient

Intaker (Person)

Type administrative (insurance, etc.) info

into document

Type referral clinical info into

document

Select clinician based on client

need, geography, workloads

Print documentNo

send digitally?

Direct referral to clinician

Not direct referral

Yes

Fax document to clinician

Place in clinician inbox

Forgot to password protect

Forget to password

protectPassword protect

document

Remember to password protect

Create new email, attach

referral document

Upload document to shared cloud

storage

Share document with clinician

Transmit document Receive document

Clinician (Person)

Pick up document

Corporate Email Corporate Cloud Storage

Transmit emailOpen email and download documents

Enter passwordStore referral document in

original format

Notify of new shared document

Receive referral documents

Download document

Enter password

Read document

Yes

No

Hold for clinician

Via fax

via email

via shared storage

Password?

No

Yes

Fax (System)

Request appointment

State H


: FIU D

irect Use C

ase

B-4

8

Exhibit B-49. Rhode Island Community Behavioral services Scenario 2, With-Direct

Client (Person)

Request appointment

Referring Physician (Person)

Refer patient

Coordinator (Person)

Type referral clinical info

into document

Clinician (Person)

Received direct external referral

Direct (System)

Type administrative (insurance, etc.)

info into documents

Select clinician based on client

need, geography, workloads

Log in to Direct

Create email, attach document

Transmit email

Notify of new emailLog in to Direct

Open email and attachment

Read document

Direct referral to clinician

Not direct referral

Send email


B-49

Scenario 2 considers the communication of counseling notes between a Clinician and Supervisor. Exhibit B-50 provides a review of the interaction steps in the Use Case scenario.

Exhibit B-50. Review of Rhode Island Community Behavioral Services, scenario 2

We present our Activity Models for this Use Case scenario for these steps. Specifically, Exhibit B-51 and Exhibit B-52 depict the details for the pre-Direct and Direct-enabled cases, respectively.

Step A: Clinician counsels client, documents

notes, and sends to Supervisor

Step B: Supervisor receives notes for

feedback and supervision

B-5

0

State H


: FIU D

irect Use C

ase

Exhibit B-51. Rhode Island Community Behavioral Services Scenario 2, Pre-Direct

Appendix B

— A

ctivity Models

B-5

1

Exhibit B-52. Rhode Island Community Behavioral Services Scenario 2, With-Direct

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