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ATTENTION:  The final Gravity Use Case Package is now available.  Thank you to everyone who voted and provided comments during the Consensus Voting period. 


Click here to download the Use Case Package.

The Gravity Project use cases focus on three priority social domains, food security, housing stability and quality, and transportation access, captured across three core health care activities:

  • Screening: This refers to activities where SDH data from individual patients are initially captured, whether through a self-administered, provider-administered, or health plan-administered questionnaire. These activities may also be repeated at certain intervals to monitor changes in social risks.
  • Assessment/Diagnosis: These include activities where providers (clinical and community-based) and health plans analyze the data obtained through screening to determine a patient’s social risks and needs.
  • Treatment/Interventions: These refer to actions undertaken by providers (clinical and community-based) and health plans to help address identified social needs. These include referrals, case management, care planning, counseling and education, and provision of services and orders.

The Gravity Project Use Case Package includes the three following components, which are described below on this page:

  1. Use Cases
  2. Patient Story
  3. Personas

Gravity Use Cases


Use Cases are technical narratives of the interactions between the Personas and the systems they use. They are described using the following elements:

  • Actors and Roles. Actors may be a person, entity, or system. An Actor describes the role within a specific transaction in a series of steps in a use case. Roles indicate the relationship between the sender and receiver of the data exchange through a specific transaction.
  • Items expected to be true or to be in place such as a policy, process, or procedure for the execution of a specific transaction.
  • Pre-conditions. Refer to the initial state of the system before an action or transaction occurs. These describe what must be in place from a systems perspective to support interoperable data sharing for a specific transaction.
  • Post-conditions. Describe the state of the system that will result after the execution of the transaction.
  • The data exchange between two systems.
  • Message Content or Payload. The content or substance of what is exchanged within a specific transaction.

Use case elements are typically illustrated using an actor-transaction diagram. The Gravity Project use cases and respective actor-transaction diagrams are presented in Section 6.0 of the Use Case Package.  The three use cases for Gravity are as follows:

  1. Document SDH Data in Conjunction with the Patient Encounter
  2. Document and Track SDH Related Interventions to Completion
  3. Gather and Aggregate SDH Data for Uses Beyond the Point of Care

Gravity Patient Story


The Patient Story describes Personas engaging with a service, technology, or setting over a period of time to accomplish a specific goal. They summarize the interactions among Personas, and specify what information is captured, shared, and exchanged from a contextual perspective. Patient Stories serve to illustrate an example of a real-world application of the technical solution.

The Patient Story is used to identify a series of value-add transactions among the Personas in the story and the technical systems they use to access and share electronic information. The Gravity Project Patient Story for Rebecca Smith is described in Section 4.0 of the Use Case Package.

Gravity Personas


The Gravity Project encourages participants to submit personas that will supplement the Use Case Package being developed as part of this project.  The Use Case(s) will be relevant to three social determinants of health domains: food insecurity, housing instability and quality, and transportation access. All other domains are out of scope for Phase 1 of this project.

What is a Persona?

A persona is the "who" in a Use Case.  Personas are fictional characters who are expected to use a service or product.  Personas are also referred to as "human actors" within a Use Case. (Note:  a Use Case is a narrative of the interactions between personas and the systems they use.)

Personas serve the following purposes:

  • Commonly used in user-centered design where developers create a fictional character to represent a user type that might use a site, brand, or product in a similar way
  • Typically presented in a one- or two-page document describing the user's behavior patterns, skills, preferences, and needs
  • Enables a deeper understanding of a target audience in order to develop an exceptional service or product
  • In standards development, allows stakeholders to prioritize key data capture and exchange features based on how well they address the needs of a primary persona(s)

How to Submit a Persona

  1. Click here to download Gravity Personas Worksheet

  2. Rename the Gravity Personas Worksheet file using the following format:  orgname_domain_actortype_submittername_date.xlsx
    1. Example:  BestCare_food_practitioner_lynetteelliott_20190525.xlsx
  3. Populate worksheet with persona(s) you wish to submit for inclusion in the Use Case package
    1. Please use a separate worksheet for each actor type (see file format example above):  individuals not acting as practitioners in the patient story versus practitioners acting as care and service providers in the patient story
  4. Email completed worksheet(s) to gravityproject@emiadvisors.net

Gravity Persona Components

The Gravity Personas worksheet includes fields for each of the following components.  Please include as much detail as possible in your submitted persona(s). Click here for example personas.

  • Name
  • Role
  • Age
  • Qualifications/Specialties (if a practitioner)
  • What organization working for (if a practioner)
  • About the Persona
    • Brief description of persona. What is their profession? What is their history with health and social conditions identified? Are they married, divorced? How many children? Do they live with them? What are activities they are currently engaged in? What worries them about their existing conditions or situation? What are their preferences and needs?
  • Clinical Health Concern
  • Social Risk Factors
  • Typical routine and interactions
    • What does a regular day look like and include?
  • Challenges and Goals
    • What are the primary challenges faced at the most recent point in time?
  • What the persona wants from the health system


Consolidated Personas Submissions To-Date

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