This morning's frustration is because ONC and CMS didn't get that message. Current Meaningful Use regulations selecting standards (CCD and CCR), and proposed regulations on Incentives that ONC and CMS have provided have described communicating discharge summaries in a way that doesn't work, because, ...well..., everything isn't a nail.
First, let's help ONC explore what a discharge summary is:
A few of the links below come up from that query provide some ideas about what should appear:
There are a few things you can determine from this research:
- A discharge summary is required to have 6 things according to Joint Commission
- Reason for hospitalization
- Significant findings
- Procedures and treatment provided
- Patient’s discharge condition
- Patient and family instructions
- Attending physician’s signature
- A discharge summary is required to have 3 things according to CMS
- Outcome of Hospitalization
- Patient Disposition
- Provisions for Follup Care
- Common practice shows that discharge summaries typically include:
- Chief Complaint/Reason for Admission
- History of Present Illness
- Admission Diagnosis
- Discharge Diagnosis
- Medications on Discharge
- Discharge Instructions
- Followup Care
|11490-0||PHYSICIAN HOSPITAL DISCHARGE SUMMARY|
|8656-1||HOSPITAL ADMISSION DATE|
|8646-2||HOSPITAL ADMISSION DX|
|8649-6||HOSPITAL DISCHARGE DATE|
|8650-4||HOSPITAL DISCHARGE DISPOSITION|
|11535-2||HOSPITAL DISCHARGE DX (NARRATIVE)|
|8651-2||HOSPITAL DISCHARGE DX|
|11544-4||HOSPITAL DISCHARGE FOLLOWUP|
|18842-5||HOSPITAL DISCHARGE HISTORY|
|8653-8||HOSPITAL DISCHARGE INSTRUCTIONS|
|10183-2||HOSPITAL DISCHARGE MEDICATIONS|
|10184-0||HOSPITAL DISCHARGE PHYSICAL|
|10185-7||HOSPITAL DISCHARGE PROCEDURES|
|8655-3||HOSPITAL DISCHARGE PROCEDURES|
|11493-4||HOSPITAL DISCHARGE STUDIES SUMMARY|
|18776-5||TREATMENT PLAN, PLAN OF TREATMENT|
|11513-9||PROVIDER SIGNING - IDENTIFIER|
|18771-6||PROVIDER SIGNING - NAME|
|18775-7||PROVIDER, STAFF PRACTITIONER IDENTIFIER|
|18774-0||PROVIDER, STAFF PRACTITIONER NAME|
The HL7 Care Record Summary (release 1.0) further refined these requirements, and these were subsequently adopted by the IHE XDS-MS profile, which has also been selected by HITSP (see C48) and recognized be the former secretary of HHS:
|11348-0||HISTORY OF PAST ILLNESS||O|
|46241-6||HOSPITAL ADMISSION DX||O|
|11535-2||HOSPITAL DISCHARGE DX||R|
|10155-0||HISTORY OF ALLERGIES||R|
|8658-7||HISTORY OF ALLERGIES|
|10160-0||HISTORY OF MEDICATION USE||O|
|10183-2||HOSPITAL DISCHARGE MEDICATIONS||R|
|42346-7||MEDICATIONS ON ADMISSION||O|
|29299-5||REASON FOR VISIT||O|
|46239-0||CHIEF COMPLAINT+REASON FOR VISIT||O|
|42349-1||REASON FOR REFERRAL||O|
|10164-2||HISTORY OF PRESENT ILLNESS||O|
|10158-4||HISTORY OF FUNCTIONAL STATUS||O|
|10157-6||HISTORY OF FAMILY MEMBER DISEASES||O|
|11369-6||HISTORY OF IMMUNIZATIONS||O|
|10167-5||HISTORY OF SURGICAL PROCEDURES||O|
|46240-8||HISTORY OF HOSPITALIZATIONS|
+ HISTORY OF OUTPATIENT VISITS
|11336-5||HISTORY OF HOSPITALIZATIONS||O|
|11346-4||HISTORY OF OUTPATIENT VISITS||O|
|10187-3||REVIEW OF SYSTEMS||O|
|10184-0||HOSPITAL DISCHARGE PHYSICAL||O|
|8716-3||VITAL SIGNS, PHYSICAL FINDINGS||O|
|46242-2||VITAL SIGNS MEASUREMENTS, FETUS||O|
|11493-4||HOSPITAL DISCHARGE STUDIES SUMMARY||O|
|30954-2||RELEVANT DIAGNOSTIC TESTS |
AND/OR LABORATORY DATA
So, ignoring all the standardization that's already gone on before, let's look at the ramifications of stuffing a discharge summary into a CCD and/or CCR.
- What section will Admission and Discharge Diagonosis go in the CCD?
These could be listed as problems, but how will you distinguish between what was thought to be a heart attack on admission and was later found out to be an ulcer (or visa versa) prior to discharge. We could of course add a CDA section using the above LOINC codes, and that's allowed for by CDA, but CCD doesn't say how to record these items, and CCR doesn't have the capability to add sections at all.
- Where will the patient's discharge condition go? There's not a place for that either defined by CCD or CCR.
- How about the reason for hospitalization? There's not a place for that either defined by CCD or CCR
- History of Present Illness? There's not a place for that either defined by CCD or CCR
- Physical Examination? Guess what I'm going to say here...
- Hospital Course? Guess again...
- Patient Disposition? ...
- Outcome of Hospitalization? ...
A discharge summary is a document that is mandated to be produced by a hospital on discharge or transfer of a patient from an inpatient stay. It has required content for accreditation and existing regulation or requirements for payment. Standards have already been developed that are consistent with some of the selected standards by the Meaningful Use IFR. Let's stick with the standards, shall we, and not try to invent something new that doesn't work the way existing standards and implementation guides had intended.