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Wednesday, March 14, 2012

Defining a Summary Care Record for MeaningfulUse Stage2

In Yesterday's post, I talked about how confusing the descriptions of Summary Care Record were in the Meaningful Use Stage 2 rules.  Today I'm going to work at simplifying those for you.  There are two tables below.  The first table just shows the summarized the results.  The second table provides the detail for the first.

The Name, Gender, Race, Ethnicity, Preferred Language, and Date of Birth are common to all summaries and appear in the <patient> element of the CDA Document in any CDA header.

Provider information also appears in the header and is common across all summaries.

Smoking Status, Vital Signs, Medications, Allergies, Problems, Procedures, Lab Tests and Results, and Care Plan are also common across all summaries, and can be found in appropriate sections of the CDA Document in the consolidated guide.  In some cases, you might want to add sections (e.g., Lab Tests and Results) to a document that doesn't contain it in order to meet the MU Criteria.

Patient Instructions could arguably show up in the Care Plan section, or elsewhere as written text in the summary, but in CDA Consolidation, there is an Instructions section that can be used, and probably should be used in whatever summary is produced, possibly as a subsection under the Care Plan.

The date and location of the visit or stay would show up in any summary in the <encompassingEncounter> element.  Those are not required under the incentives rule, but are under the standards rule for all summaries.  It should be added in incentives.

The reason for visit can show up in several different ways: admission diagnosis, chief complaint, or reason for visit, and there are appropriate sections for those.  It too appears to be missing from the incentives rule.

Section 170.314(e)(2) stands out as the biggest odd-ball in the lot.  It includes medications and immunizations administered, patient decision aids, scheduled tests and visits and referrals.  The medications and immunizations administered should probably be recorded in the respective sections.  Patient Decision aids should be included in patient instructions.  The last three (future plans) should be included in the care plan.   That would normalize it nicely into the other groups.

Growth charts also stand out.  These are not summaries, rather, they are assessments over time that can be crafted from data in multiple summaries.

Care Team members don't show up in Clinical Summaries provided to patients.  Why wouldn't they be present when available?

It isn't clear why diagnoses wouldn't be incorporated when available, or be viewable by the patient.

It isn't clear why immunizations are reported in an ambulatory setting, but not in the inpatient setting (it's fairly common for some kinds of immunizations to be given during inpatient stays).

Rationalizing these data elements across the summaries could easily get us to one or two definitions for summaries.

A spreadsheet containing this content is available.


NameGenderRaceEthn.Lang.DOBSmokingVitalsMedsAllergyProbsProc.LabsPrvdrDate/LocInst.ReasonPlanTeamDiag.
Med/Imm.AidsSch. TestSch. VisitRefrls.Gth Chrt
170.314(b)(1) Transitions of care -- incorporate summary care record. Upon receipt of a summary care record formatted according to the standard adopted at § 170.205(a)(3), electronically incorporate, at a minimum, the following data elements: XXXXXXXXXXXXXXXXXXX
170.314(b)(2) Transitions of care--create and transmit summary care record. (i) Enable a user to electronically create a summary care record formatted according to the standard adopted at § 170.205(a)(3) and that includes, at a minimum, the following data elements expressed, where applicable, according to the specified standard(s):XXXXXXXXXXXXXXXXXXXX
170.314 (e)(1) View, download, and transmit to 3rd party. (i) Enable a user to provide patients (and their authorized representatives) with online access to do all of the following: (A) View. Electronically view in accordance with the standard adopted at § 170.204(a), at a minimum, the following data elements:XXXXXXXXXXXXXXXXXXX
170.314(e)(1)(B)(2) A summary care record formatted according to the standards adopted at § 170.205(a)(3) and that includes, at a minimum, the following data elements expressed, where applicable, according to the specified standard(s):XXXXXXXXXXXXXXXXXXXX
170.314(e)(2) Ambulatory setting only -- clinical summaries. Enable a user to provide clinical summaries to patients for each office visit that include, at a minimum, the following data elements: XXXXXXXXXXXXXXXXXXXXXXXX
All summary of care documents used to meet (this) objective must include the following: ... In circumstances where there is no information available to populate one or more of the fields listed previously, either because the EP, eligible hospital or CAH can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the EP, eligible hospital or CAH may leave the field(s) blank and still meet the objective and its associated measure. In addition, all summary of care documents used to meet (this) objective must include the following:XXXXXXXXXXXXXXXXXX

Table 2: Detail
NameGenderRaceEthn.Lang.DOBSmokingVitalsMedsAllergyProbsProc.LabsPrvdrDate/LocInst.ReasonPlanTeamDiag.
Med/Imm.AidsSch. TestSch. VisitRefrls.Gth Chrt
170.314(b)(1) Transitions of care -- incorporate summary care record. Upon receipt of a summary care record formatted according to the standard adopted at § 170.205(a)(3), electronically incorporate, at a minimum, the following data elements: XXXXXXXXXXXXXXXXXXX
Patient nameX
genderX
raceX
ethnicityX
preferred languageX
date of birthX
smoking statusX
vital signsX
medicationsX
medication allergiesX
problemsX
proceduresX
laboratory tests and values/resultsX
the referring or transitioning provider's name and contact informationX
hospital admission and discharge dates and locationsX
discharge instructionsX
reason(s) for hospitalizationX
care plan, including goals and instructionsX
names of providers of care during hospitalizationsX
and names and contact information of any additional known care team members beyond the referring or transitioning provider and the receiving provider.
170.314(b)(2) Transitions of care--create and transmit summary care record. (i) Enable a user to electronically create a summary care record formatted according to the standard adopted at § 170.205(a)(3) and that includes, at a minimum, the following data elements expressed, where applicable, according to the specified standard(s):XXXXXXXXXXXXXXXXXXXX
(A) Patient nameX
genderX
date of birthX
medication allergiesX
vital signsX
laboratory tests and values/resultsX
the referring or transitioning provider's name and contact informationX
names and contact information of any additional care team members beyond the referring or transitioning provider and the receiving providerX
care plan, including goals and instructionsX
(B) Race and ethnicity. The standard specified in § 170.207(f)XX
(C) Preferred language. The standard specified in § 170.207(j)X
(D) Smoking status. The standard specified in § 170.207(1)X
(E) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3)X
(F) Encounter diagnoses. The standard specified in § 170.207(m)X
(G) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3)X
(H) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g)X
(I) Laboratory value(s)/result(s). The value(s)/results of the laboratory test(s) performedX
(J) Medications. At a minimum, the version of the standard specified in § 170.207(h); andX
(K) Inpatient setting only. Hospital admission and discharge dates and locationX
names of providers of care during hospitalizationsX
discharge instructionsX
and reason(s) for hospitalization.X
170.314 (e)(1) View, download, and transmit to 3rd party. (i) Enable a user to provide patients (and their authorized representatives) with online access to do all of the following: (A) View. Electronically view in accordance with the standard adopted at § 170.204(a), at a minimum, the following data elements:XXXXXXXXXXXXXXXXXXX
(1) Patient nameX
 genderX
 date of birthX
 raceX
 ethnicityX
 preferred languageX
 smoking statusX
 problem listX
 medication listX
 medication allergy listX
 proceduresX
 vital signsX
 laboratory tests and values/resultsX
 provider's name and contact informationX
 names and contact information of any additional care team members beyond the referring or transitioning provider and the receiving providerX
 and care plan, including goals and instructions.X
(2) Inpatient setting only. Admission and discharge dates and locationsX
reason(s) for hospitalizationX
names of providers of care during hospitalizationX
laboratory tests and values/results (available at time of discharge)X
and discharge instructions for patient.X
170.314(e)(1)(B)(2) A summary care record formatted according to the standards adopted at § 170.205(a)(3) and that includes, at a minimum, the following data elements expressed, where applicable, according to the specified standard(s):XXXXXXXXXXXXXXXXXXXX
(i) Patient nameX
genderX
date of birthX
medication allergiesX
vital signsX
the provider's name and contact informationX
names and contact information of any additional care team members beyond the referring or transitioning provider and the receiving providerX
care plan, including goals and instructionsX
(ii) Race and ethnicity. The standard specified in § 170.207(f)XX
(iii) Preferred language. The standard specified in § 170.207(j)X
(iv) Smoking status. The standard specified in § 170.207(l)X
(v) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3)X
(vi) Encounter diagnoses. The standard specified in § 170.207(m)X
(vii) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3)X
(viii) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g)X
(ix) Laboratory value(s)/result(s). The value(s)/results of the laboratory test(s) performedX
(x) Medications. At a minimum, the version of the standard specified in § 170.207(h); andX
(xi) Inpatient setting only. The data elements specified in paragraph (e)(1)(i)(A)(2) of (this) section.
(2) Inpatient setting only. Admission and discharge dates and locationsX
reason(s) for hospitalizationX
names of providers of care during hospitalizationX
laboratory tests and values/results (available at time of discharge)X
and discharge instructions for patient.X


170.314(e)(2) Ambulatory setting only—clinical summaries. Enable a user to provide clinical summaries to patients for each office visit that include, at a minimum, the following data elements: XXXXXXXXXXXXXXXXXXXXXXXX
Provider's name and office contact informationX
date and location of visitX
reason for visitX
patient's nameX
genderX
raceX
ethnicityX
date of birthX
preferred languageX
smoking statusX
vital signs and any updatesX
problem list and any updatesX
medication list and any updatesX
medication allergy list and any updatesX
immunizations and/or medications administered during the visitX
procedures performed during the visitX
laboratory tests and values/results, including any tests and value/results pendingX
clinical instructionsX
care plan, including goals and instructionsX
recommended patient decision aids (if applicable to the visit)X
future scheduled testsX
future appointmentsX
and referrals to other providers. If the clinical summary is provided electronically, it must be:X
(i) Provided in human readable format; and
(ii) Provided in a summary care record formatted according to the standard adopted at § 170.205(a)(3) with the following data elements expressed, where applicable, according to the specified standard(s):
(A) Race and ethnicity. The standard specified in § 170.207(f)XX
(B) Preferred language. The standard specified in § 170.207(j)X
(C) Smoking status. The standard specified in § 170.207(l)X
(D) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3)X
(E) Encounter diagnoses. The standard specified in § 170.207(m)X
(F) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3)X
(G) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g)X
(H) Laboratory value(s)/result(s). The value(s)/results of the laboratory test(s) performed; andX
(I) Medications. At a minimum, the version of the standard specified in § 170.207(h).X
All summary of care documents used to meet (this) objective must include the following: ... In circumstances where there is no information available to populate one or more of the fields listed previously, either because the EP, eligible hospital or CAH can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the EP, eligible hospital or CAH may leave the field(s) blank and still meet the objective and its associated measure. In addition, all summary of care documents used to meet (this) objective must include the following:XXXXXXXXXXXXXXXXXX
Patient name.X
Referring or transitioning provider's name and office contact information (EP only).X
Procedures.X
Relevant past diagnoses.X
Laboratory test results.X
Vital signs (height, weight, blood pressure, BMI, growth charts).XX
Smoking status.
Demographic information (
preferred languageX
genderX
raceX
ethnicityX
date of birth)X
Care plan field, including goals and instructions, andX
Any additional known care team members beyond the referring or transitioning provider and the receiving provider.X
In addition, eligible hospitals and CAHs would be required to include discharge instructions.X
An up-to-date problem list of current and active diagnoses.X
An active medication list, andX
An active medication allergy list.X

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