A diabetic patient, John, moves to a new city and uses the Internet to select a local primary care physician (PCP), who is a generalist physician and will coordinate his overall care. He is able to select a PCP who appears to have strong outcomes in diabetes and positive patient satisfaction scores. John schedules an appointment via the physician's website and is set up with a user ID and password to link the PCP with John's PHR, which is a record he maintains himself by uploading copies of records from various providers he has seen over the years. This enables the PCP to view and retrieve pertinent information from other providers and information John has recorded about his diet, over-the-counter medications taken, and other information relating to compliance with his diabetic treatment regimen.

John also asks his former hometown physician to send information to this new PCP. This physician does so using standard content and format specifications for exchanging referral information between providers. With the information supplied by the PHR and his former PCP, the new PCP's EHR is prepopulated with a current problem list, recent laboratory results, and other data. Additionally, John's medication history can be directly supplied to his new PCP's EHR by the PCP linking to information available from John's health plan.

When John visits the new PCP, information from these various sources will be validated and updated. The new PCP is able to document all components of John's visit at the time of the visit, including demonstrating medical necessity for lab work by applying ICD diagnosis codes and generating appropriate evaluation and management (E/M) codes for the level of service provided. The PCP decides to put John on a strict smoking-cessation program and exercise routine, with plans to adjust medications according to John's vital signs and blood sugar levels, which will be monitored remotely through a medical device.

All is going well until John has an accident at work that requires a visit to the emergency room, subsequent admission to the hospital, and outpatient physical therapy. All his providers, however, are members of a health information organization (HIO). As a result, each provider has immediate access to the specific information needed to treat John throughout his care and for which John has provided a consent directive enabling him to opt-in to the sharing of such information with all participants in the HIO.

At the hospital, the physician providing care is able to reconcile all of John's medications in accordance with the Joint Commission requirements and to select medications that have been screened against John's known allergies. The hospital is also part of a health reform mechanism that ties reimbursement to quality metrics. This improves the quality of healthcare and reduces costs in an assigned population of patients. As a result, the hospital has access to John's previous lab and x-ray results, so repeating these lab tests is not necessary-saving John time and potential health risks, and reducing overall costs. In selecting the physical therapy referral, the hospitalist has access to John's health plan benefits information, so no time is wasted in arranging for physical therapy to begin.

John's PCP also continuously monitors the impact of the accident on John's diabetes during his hospitalization and makes appropriate adjustments. After John is discharged and in physical therapy, the health plan can monitor whether he is following the prescribed exercise routine and can notify the PCP to follow up if necessary. John can access tailored discharge instructions that superimpose his picture on the exercise instructions so that it is clear how to avoid further injury. In addition, each provider John encountered throughout this episode of care follows up with him on the smoking-cessation program he started with his PCP, motivating him to keep from smoking.

1. What is the standard format in which John's hometown physician can send referral information to his new PCP?
2. Why does John use a standalone personal health record (PHR) instead of one from his provider?

When John is hospitalized, what core EHR component enables medication allergy checking?

Your facility has made the decision to implement a new CPOE system. The Steering Committee has to decide which of the following implementation strategies to utilize

1. Implement the CPOE on all units at the same time
2. Implement the CPOE unit by unit
3. Implement the medication orders unit by unit
4. Implement the medication orders on all units at the same time