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Wednesday, February 10, 2010

If I had a Hammer Redux

My second post is also the second most popular post of all time on this blog:  If I had a Hammer

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:
http://lmgtfy.com/?q=Discharge+Summary

A few of the links below come up from that query provide some ideas about what should appear:

http://medical-dictionary.thefreedictionary.com/discharge+summary
http://www.partnerstransitions.org/Home/Home/discharge-summary-tutorial/essential-elements
http://www.acphospitalist.org/archives/2009/03/discharge.htm
http://www.todayshospitalist.com/index.php?b=articles_read&cnt=193
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_034459.hcsp

There are a few things you can determine from this research:
  1. A discharge summary is required to have 6 things according to Joint Commission
    1. Reason for hospitalization
    2. Significant findings
    3. Procedures and treatment provided
    4. Patient’s discharge condition
    5. Patient and family instructions
    6. Attending physician’s signature
  2. A discharge summary is required to have 3 things according to CMS
    1. Outcome of Hospitalization
    2. Patient Disposition
    3. Provisions for Follup Care
  3. Common practice shows that discharge summaries typically include:
    1. Chief Complaint/Reason for Admission
    2. History of Present Illness
    3. Admission Diagnosis
    4. Discharge Diagnosis
    5. Medications on Discharge
    6. Discharge Instructions
    7. Followup Care
By the way, this is really old news.  The December 2001 publication of the HL7 Claims Attachments specification for Clinical Reports describes a discharge summary using the following LOINC codes.  The table below is drawn from the HL7 Claims Attachement guides which were produced by HL7 in its role as a designated standards maintenance organization under HIPAA.  Later releases of these guides were referenced in the Claims Attachments regulation proposed by CMS some three or more years ago, and HL7 developed Release 3.0 of these guides were developed throughout 2006 and 2007.  More than 8 years of standardization effort went into that work.

11490-0 PHYSICIAN HOSPITAL DISCHARGE SUMMARY
8656-1 HOSPITAL ADMISSION DATE
8646-2 HOSPITAL ADMISSION DX
18841-7 HOSPITAL CONSULTATIONS
8648-8 HOSPITAL COURSE
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:
Code        Component NameRequired/Optional
11348-0HISTORY OF PAST ILLNESSO
46241-6HOSPITAL ADMISSION DXO
11535-2HOSPITAL DISCHARGE DXR
11450-4PROBLEM LISTR
10155-0HISTORY OF ALLERGIESR
8658-7HISTORY OF ALLERGIES
11382-9MEDICATION ALLERGYO
10160-0HISTORY OF MEDICATION USEO
10183-2HOSPITAL DISCHARGE MEDICATIONSR
42346-7MEDICATIONS ON ADMISSIONO
8648-8HOSPITAL COURSER
10154-3CHIEF COMPLAINTO
29299-5REASON FOR VISITO
46239-0CHIEF COMPLAINT+REASON FOR VISITO
42349-1REASON FOR REFERRALO
42348-3ADVANCE DIRECTIVESO
10164-2HISTORY OF PRESENT ILLNESSO
10158-4HISTORY OF FUNCTIONAL STATUSO
10157-6HISTORY OF FAMILY MEMBER DISEASESO
29762-2SOCIAL HISTORYO
11369-6HISTORY OF IMMUNIZATIONSO
10167-5HISTORY OF SURGICAL PROCEDURESO
46240-8HISTORY OF HOSPITALIZATIONS
+ HISTORY OF OUTPATIENT VISITS
O
11336-5HISTORY OF HOSPITALIZATIONSO
11346-4HISTORY OF OUTPATIENT VISITSO
10187-3REVIEW OF SYSTEMSO
10184-0HOSPITAL DISCHARGE PHYSICALO
22029-3PHYSICAL EXAM.TOTALO
8716-3VITAL SIGNS, PHYSICAL FINDINGSO
46242-2VITAL SIGNS MEASUREMENTS, FETUSO
11493-4HOSPITAL DISCHARGE STUDIES SUMMARYO
30954-2RELEVANT DIAGNOSTIC TESTS
AND/OR LABORATORY DATA
O
18776-5TREATMENT PLANO

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.
  1. 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.
  2. Where will the patient's discharge condition go?  There's not a place for that either defined by CCD or CCR.
  3. How about the reason for hospitalization?  There's not a place for that either defined by CCD or CCR
  4. History of Present Illness? There's not a place for that either defined by CCD or CCR
  5. Physical Examination? Guess what I'm going to say here...
  6. Hospital Course?  Guess again...
  7. Patient Disposition? ...
  8. Outcome of Hospitalization?  ...
The most significant issue here is that in order to put a discharge summary inside a CCD or CCR, we have to stretch both of those publications past what they are intended to do.  A secondary issue is that by so doing, we will not get discharge summaries in any standard format because those publications do NOT say how to do it.

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.

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