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Tuesday, March 13, 2012

A MeaningfulUse Summary by any other name ... is as clear as mud

One of the benefits of the CDA Consolidation guide is that we have different options for enabling providers to use medical summaries appropriate to their practice.  Hospital based providers can use the discharge summary, general practice physicians can use the history and physical or consult note, and specialists can use the consult note or imaging report as a medical summary.  The nice thing about this is that we can apply the appropriate summary report format to the appropriate provider's workflow.

The challenge in Meaningful Use though is that there are several different requirements around summaries in the proposed rules.  The problem isn't in the CDA Consolidation guide, but rather in the rules. The phrase summary care record appears 42 times in the Standards and Certification Rule and 5 times in the Incentives rule, and little clarity about what systems and providers must do is added by either rule.

Here are the relevant text citations on the content needed in a summary care record.  What I need to do next is put these into a spreadsheet and rationalize it across CDA Consolidation Guide document types, sections and entries.

Meaningful Use Standards and Certification
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: Patient name; gender; race; ethnicity; preferred language; date of birth; smoking status; vital signs; medications; medication allergies; problems; procedures; laboratory tests and values/results; the referring or transitioning provider's name and contact information; hospital admission and discharge dates and locations; discharge instructions; reason(s) for hospitalization; care plan, including goals and instructions; names of providers of care during hospitalizations; 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):
(A) Patient name; gender; date of birth; medication allergies; vital signs; laboratory tests and values/results; the referring or transitioning provider's name and contact information; names and contact information of any additional care team members beyond the referring or transitioning provider and the receiving provider; care plan, including goals and instructions;
(B) Race and ethnicity. The standard specified in § 170.207(f);
(C) Preferred language. The standard specified in § 170.207(j);
(D) Smoking status. The standard specified in § 170.207(1);
(E) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3);
(F) Encounter diagnoses. The standard specified in § 170.207(m);
(G) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3);
(H) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g);
(I) Laboratory value(s)/result(s). The value(s)/results of the laboratory test(s) performed;
(J) Medications. At a minimum, the version of the standard specified in § 170.207(h); and
(K) Inpatient setting only. Hospital admission and discharge dates and location; names of providers of care during hospitalizations; discharge instructions; and reason(s) for hospitalization.




(e) Patient engagement.
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:
(1) Patient name; gender; date of birth; race; ethnicity; preferred language; smoking status; problem list; medication list; medication allergy list; procedures; vital signs; laboratory tests and values/results; provider's name and contact information; names and contact information of any additional care team members beyond the referring or transitioning provider and the receiving provider; and care plan, including goals and instructions.
(2) Inpatient setting only. Admission and discharge dates and locations; reason(s) for hospitalization; names of providers of care during hospitalization; laboratory tests and values/results (available at time of discharge); and discharge instructions for patient.

(B) Download. Electronically download:
(1) A file in human readable format that includes, at a minimum:
(i) Ambulatory setting only. All of the data elements specified in paragraph (e)(1)(i)(A)(1) of this section.
(ii) Inpatient setting only. All of the data elements specified in paragraphs (e)(1)(i)(A)(1) and (2) of this section.

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):
(i) Patient name; gender; date of birth; medication allergies; vital signs; the provider's name and contact information; names and contact information of any additional care team members beyond the referring or transitioning provider and the receiving provider; care plan, including goals and instructions;
(ii) Race and ethnicity. The standard specified in § 170.207(f);
(iii) Preferred language. The standard specified in § 170.207(j);
(iv) Smoking status. The standard specified in § 170.207(l);
(v) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3);
(vi) Encounter diagnoses. The standard specified in § 170.207(m);
(vii) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3);
(viii) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g);
(ix) Laboratory value(s)/result(s). The value(s)/results of the laboratory test(s) performed;
(x) Medications. At a minimum, the version of the standard specified in § 170.207(h); and
(xi) Inpatient setting only. The data elements specified in paragraph (e)(1)(i)(A)(2) of this section.
(3) Images formatted according to the standard adopted at § 170.205(j).

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: Provider's name and office contact information; date and location of visit; reason for visit; patient's name; gender; race; ethnicity; date of birth; preferred language; smoking status; vital signs and any updates; problem list and any updates; medication list and any updates; medication allergy list and any updates; immunizations and/or medications administered during the visit; procedures performed during the visit; laboratory tests and values/results, including any tests and value/results pending; clinical instructions; care plan, including goals and instructions; recommended patient decision aids (if applicable to the visit); future scheduled tests; future appointments; and referrals to other providers. If the clinical summary is provided electronically, it must be:
(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);
(B) Preferred language. The standard specified in § 170.207(j);
(C) Smoking status. The standard specified in § 170.207(l);
(D) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3);
(E) Encounter diagnoses. The standard specified in § 170.207(m);
(F) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3);
(G) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g);
(H) Laboratory value(s)/result(s). The value(s)/results of the laboratory test(s) performed; and
(I) Medications. At a minimum, the version of the standard specified in § 170.207(h).

Meaningful Use Incentives

Proposed Objective: The EP, eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral.
 ...  Therefore, we are proposing to eliminate the objective for the exchange of key clinical information for Stage 2 and instead include such information as part of the summary of care when it is a part of the patient's electronic record.
In addition the HIT Policy Committee made two separate Stage 2 recommendations for EPs, eligible hospitals, and CAHs to record additional information—
Record care plan fields, including goals and instructions, for at least 10 percent of transitions of care; and
Record team member, including primary care practitioner, for at least 10 percent of patients.

We believe that this information is best incorporated as required data within the summary of care record itself.  Rather than implement two separate objectives and measures for these recommendations, we are establishing these as required fields along with the summary of care information listed later. The ONC proposed rule on standards and certification includes these as standard fields required to populate the summary of care document so Certified EHR Technology would be able to include this information. We also recognize that a “care plan” may require further definition. The content of the care plan is dependent on the clinical context. We propose to describe a care plan as the structure used to define the management actions for the various conditions, problems, or issues. For purposes of meaningful use measurement we propose that a care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).
...
All summary of care documents used to meet this objective must include the following:

  • Patient name.
  • Referring or transitioning provider's name and office contact information (EP only).
  • Procedures.
  • Relevant past diagnoses.
  • Laboratory test results.
  • Vital signs (height, weight, blood pressure, BMI, growth charts).
  • Smoking status.
  • Demographic information (preferred language, gender, race, ethnicity, date of birth).
  • Care plan field, including goals and instructions, and
  • Any additional known care team members beyond the referring or transitioning provider and the receiving provider.
  • In addition, eligible hospitals and CAHs would be required to include discharge instructions.

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:

  • An up-to-date problem list of current and active diagnoses.
  • An active medication list, and
  • An active medication allergy list.
496.6(j)(14)(i) Objective. The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral.

496.6(l)(11)(i) Objective. The eligible hospital or CAH that transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral.






3 comments:

  1. Keith,
    I agree that a lot more clarity is needed, so that we don't have "mud" final regulations. ONC's S&I implementation guidance subworkgroup http://wiki.siframework.org/TOC+Implementation+Guidance+SWG is trying to deal with many of the same issues you raised above, and more. They're starting with a spreadsheet that I put together (and which is available on this page http://wiki.siframework.org/ToC+MU+Analysis). It needs review, so I welcome yours as well as other vendors, providers, HIEs, and anyone else. It doesn't deal with "document types" but rather sections. However, my initial impression is that CCD is the closest match, though not exact, of a document type that can contain the MU2 data and doesn't require data beyond the MU2 data. Discharge Summary, Consultation Note, H&P, and the other doc types in C-CDA don't seem to fit as well. What do you think?

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    Replies
    1. I'm working on this today. I'll take a look at what you've put together and see what I come up with. I see no reason why H&P, Consult or Discharge Summary wouldn't be applicable for some use cases also.

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    2. Sure, all the document types are valid for some use cases. But the spreadsheet I put together addresses only the "use case" (if we can call it that) of the MU2 objectives that call for CDA: 1. clinical summaries after each visit; 2. patient view/download and transmit; and 3. transition of care. You could break down 3 into many different types of TOC, but currently it is really a single requirement (with slight variations for EP vs EH)

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