Use Case Submission Form

Use Case Submission Form

The DC HIE Use Case form collects essential information on proposed use cases to assess feasibility, conceptualization, design, and adoption. This form is also utilized to collect secondary use case requests as part of the DC HIE Interagency Data Use Work Group.

If you have questions on any aspects of this form, please contact healthIT@dc.gov.

Use Case Information

In this section, provide background information on the use case including name, description, goal, related document transactions, and data sources.

Use Case Name*

Briefly describe this use case (no more than 15 words)

Example: Discharge instructions sent from hospital inpatient unit to skilled-nursing facility prior to patient being admitted to SNF

Use Case Category*

Identify which of the following areas this use case best fits under – Please select ONE

Select or enter value

Other - Please Specify*

Use Case Description*

Provide additional details regarding this use case, including the purpose of the data request and how the data will be used. You may also provide a description of any intended workflows or processes. Be specific – clearly outline definitions and how the data will be used. You can also add OneDrive links to additional information as applicable in the box below.

Example: When a patient is discharged from the Hospital (sending Organization), clinical data is sent from the Hospital EHR system in an agreed upon format, received by the SNF, combined with existing patient data and made available to staff immediately. If this is a new patient, a new patient record is created.

Use Case Goal

Identify the strategic (clinical, organizational, business) results the agency/organization wants to achieve through this use case.

Details Regarding Data Requested

In this section, provide information regarding the data elements requested.

Identified or De-identified Data*

Indicate if the data requested consists of individually identifiable information. This may include fields such as name, date of birth, or address.

Yes

Data Dissemination and Use*

Specify if this data will be used internally, externally, or a combination of both.

Internal use is defined as use of the data by agency staff only. External use encompasses use of the data or information derived from the data by any other individuals apart from the requesting party.

Data Source*

Does your agency/organization plan to use data sources from other organizations (e.g. other DC agencies)? If so, please provide the following 1) name of the agency, 2) if the use of the data has been approved, 3) name and e-mail of the point of contact at the agency who approved the use of the date.

Data Elements*

List all applicable data elements for this use case. Be specific – list out specific data elements that you require such as circumstantial information, medical encounter information, identifiable information.

Example: Name, DOB, Insurance status, Ward, chief compliant, facility type, length of stay, etc.

Time Period*

Identify the time period of the data request (e.g., one-time request, ongoing request, retrospective request). Please specify the starting year/date. If this is an ongoing request, please specify frequency of the report.

Example: 2019 – present, ongoing request, weekly report

Reasoning for Data Elements and Time Period *

Provide an explanation of why each of the requested data elements and time period are the minimum necessary required for the implementation of this use case.

Implementation Deadline*

Use this space to provide any additional details about how soon this data is required, deadlines, etc.

Funding*

Is funding available to support the implementation of this use case?

Yes

Please provide additional details *

Please specify the funding source.

Regulation

In this section, provide information on whether the use case is being developed in response to relevant regulations

Response to Regulations*

Is this use case in response to a federal regulation, District legislation, or District level administrative rule or directive?

Yes

Name or Number of Legislation, Rule, Directive, or Public Act*

Provide the reference to the precise regulation, legislation, or administrative act such as Public Law 111-152 (Affordable Care Act), Public Law 111-5; Section 4104 (Meaningful Use), 42 CFR 2 (substance information), etc.

Other Regulatory Impacts*

Please use this space to specify if your use case may be impacted by other regulatory requirements (e.g., if your data request includes identifiable information that may include information that is protected under 42 CFR Part 2). If not, you may respond with "N/A"

Agency/Organization Contact Information

In this section, provide information on the point of contact for the use case (if you or someone else), e-mail address, DC government agency, agency administration or team name.

Point of Contact [Name and Last Name]*

E-mail Address*

DC Government Agency (if applicable)*

Select or enter value

Other*

If agency was not listed in the drop-down above, please provide below.

Agency Administration, or Team*

Supporting Documents

In this section, attach any supporting documents for the use case. Examples are provided below.

File Upload

Diagram: A visual providing background on the information flow for this use case. The diagram should include the major senders and receivers involved and types of information being shared.

Persona/ Use Case Scenario: Develop and assign a persona to this use case and provide an example of the persona following use case flow from start to finish.

Metrics: Defined metrics for the Use Case to be successful.

Drag and drop files here or

Send me a copy of my responses

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