Use Case Description:
A clinician is seeing a patient and considering which health maintenance screenings are appropriate. The clinician, possibly seeing this patient for the first time, wishes to consider appropriateness by reviewing an up-to-date summary of relevant issues including
1) what sexual organs the patient has (e.g. testicals, ovaries, uterus, cervix, breasts/mammography, osteopenia screening/estrogen status, prostate/PSA/DRE),
2) previously determined screening needs (e.g. determined at the time of gender affirming surgery(s),
3) previously recorded goals and preferences relative to health maintenance screening,
4) appropriateness of using USPHTF screening based on guidelines based on recorded sex or gender at birth,
5) need to update SFCU-specific screening status (e.g. diagnoses and/or surgeries since screening plan.)
Note: Roles and local workflows will vary. This is intended to be a basic use case (specific instance; does not cover everything)
EHR record may have current status for eligible screening
Referral for task of classifying the patient as concurrent or scheduled classification, based on local or plan policy.
Policy question: who (which roles) are qualified to classify the patient's needs?
Use case covers ambulatory annual visit when health maintenance is considered.
Sex and Gender appropriate history and physical is either:
previously done relative to this use case
if not done, another use case covers collecting the necessary screening information.
In other words, this use case does not exhaustively address health maintenance assessment, the underlying knowledge bases required, or a requisite workflow. Instead, we are focusing on the HL7 standards and their use to insure the relevant content models (e.g. FHIR Resources, cCDA and v2 messaging) have specific defined means of capturing sex for clinical use (SFCU). In this case, that 'Clinical Use' is determining the appropriate screening health maintenance tasks (history taking including patient-specific physiologic, anatomic, pharmacologic, and other factors including preferences). Once those tasks are performed, clinical decision support (CDS) not elaborated in this use case will take those input factors and considerations to inform the provider's and patient's shared decision making on the appropriate health maintenance screening plan. This use case focuses on the standardization and interoperability (information exchange) practices available and recommended with the three HL7 product lines (FHIR, cCDA, v2 messages).
Screening considerations beyond United States Public Health Task Force (USPHTF) screening recommendations (broader minimal survey, according to 2022 literature review)
The clinician and patient involved have determined which health maintenance screening tests are appropriate based on previously captured information which relates the patient to the USPHTF guidelines.
No new Resources and Elements or In-line extensions are populated. There is no write-back as a result of completing this workflow.
== Before Gender Harmony Project:
Provider made health maintenance screening decisions based on age, gender (=male or female), and major risk factors including prior medical history and family history.
== After Gender Harmony Project:
Workflow/thoughtflow is the same AND gender consideration reflects the patient's current and past gender history to ensure appropriate care. For example, people who required Estrogen for bone health (most commonly women) without replacement of Estrogen after age-related cessation of endogenous Estrogen may require bone density determination, independent of current gender.
The workflow demands to capture the health maintenance needs of a patient that are variably unmet in contemporary 2022 clinical practice parallel and in some cases overlap with uncaptured patients needs from a SDOH perspective. They therefore share the following swimlane-based workflow example: (see FIgure 1 here:
Evaluation of a social determinants [paralleling uncapture gender and sex related needs] of health screening questionnaire and workflow pilot within an adult ambulatory clinic
This use case and example will focus on the representation of HL7 content model and exchange for the GHP elements in this implementation guide, specific to this Health Maintenance use case. For example, in the FHIR context,
- GHP Information swim lane position 1 may be a health maintenance-specific questionnaire (or questionnaire section which produces new resources, with elements of ressources expressed as SFCU content expressed as extensions.)
- GHP conversation - swim lane position 6 - would be be expected to be communicated through a native EHR application, with the HL7 expression of the collected or reviewed information cast into SFCU unambiguous structures in each of the HL7 family constructs (FHIR, cCDA, v2.)
see USPHTF for inventory of health maintenance screening: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations?SORT=T
Note: As of the 2021 update, there are 52 potential recommendations. 23 have no gender associated terms. 17 contain "Women". 2 contain "men" (AAA and IPV). 17 contain "Gestation" or "Pregnant".
Note: There is also group-specific categorical "Top Issues" here: https://store.samhsa.gov/sites/default/files/d7/priv/sma12-4684.pdf
Expected Workflow Variations:
Alternative and/or related Workflow(s):
Alignment and/or Misalignment with Gender Harmony Model:
|Care must be taken to not exacerbate stigmatizing concerns for providers at various degrees of Gender Harmony awareness. For example, providers must be trained in applying health maintenance screening based on Genderbread person characteristics.|
Current Standard Support:
- HL7 V2.x
- HL7 V3
- HL7 FHIR
|FHIR Resource: All computable data elements such as anatomic, hormonal, physiologic, and other information necessary to reason over screening needs are in appropriate structures reflecting IG bindings.|
Other (please specify standard and resource below)