Consider expanding the explanation associated with the example use case. Figure 1 clearly shows the complexity of patient transitions and the opportunity for interoperability between care settings. Expanding the paragraph above the figure to include that cognitive status assessment is conducted by professional staff at each of the care settings. Also consider adding that effective care coordination can occur when the care coordination team has assessments from all the setting providing care [a longitudinal picture of the patient's cognitive status] versus the most recent assessment from a single setting representing a single time point. Especially important if cognitive status has declined between assessments.