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Friday, March 16, 2012

There can be only one: What should the Summary Care Record look like in MeaningfulUse Stage2

Having done all of this work over the past week on what a Summary Care Record is, and how it maps to the standards, I'm now prepared to suggest how we should take a sharp sword the Meaningful Use regulations to address the confusion and reduce us to only one definition.  Please note that this post only addresses the issue around multiple definitions of Summary Care Record in the Meaningful Use rule.  There may be other changes I'll suggest, for example, with regard to patients being able to get their record in an inpatient setting in 170.314(e)(2). Also, please remember, this is my blog, these are just my own opinions.

In the Standards and Certification Rule, I'd suggest adding a Section defining the Summary Care Record.  The point of this definition is that it is written once, and is referenced as necessary from other locations.  You'll note that I consolidated the various requirements across ambulatory and inpatient so that there was really only one definition.  For examples, see subsection (a), items (4), (5), (7), and (14).

§170.208 Summary Care Record
The secretary adopts the following as the definition of a Summary Care Record
(a) Content A summary care record contains the following information:
(1) Patient Name
(2) Patient Demographics, including
(i) Gender,
(ii) Date of Birth,
(iii) Race and Ethnicity
(3) The patient's preferred language
(4) The date and location of care, including:
(i) Ambulatory Only -- The date of the visit
(ii) Inpatient Only -- The admit and discharge date of the hospital stay
(5) Contact information for the provider(s) responsible for the patient's care during the visit or inpatient stay.
(6) Contact information for other providers on the patient's care team when known
(7) The reason for receiving care (e.g., Chief complaint, reason for visit, or admission diagnosis)
(8) The Patient's smoking status
(9) Most recent vital signs, including Blood Pressure, Height and Weight where applicable (note that I dropped BMI and Growth Charts, more on that later).
(10) A list of current and relevant past problems.
(11) A list of currently active medications.
(12) A list of currently active medication allergies.
(13) A list of procedures performed during the visit or inpatient stay.
(14) A list of immunizations given during the visit or inpatient stay.
(15) A list of medications given during the visit or inpatient stay.
(16) A list of lab tests and results provided during the visit, or tests and results on discharge for an inpatient stay, including any results still pending.
(17) Any diagnoses produced as a result of the visit or inpatient stay.
(18) Care Plan, including Patient Instructions, Decision Aids; Goals; and any future scheduled tests, visits or referrals
(b) Standards When supplied in an electronic form, the summary care record shall be formatted according to the standards specified in §170.205(a)(3).
(1) Race and ethnicity. The standard specified in § 170.207(f)
(2) Preferred language. The standard specified in § 170.207(j)
(3) Smoking status. The standard specified in § 170.207(l)
(4) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3)
(5) Encounter diagnoses. The standard specified in § 170.207(m)
(6) Medications. At a minimum, the version of the standard specified in § 170.207(h); and
(7) Reserved (For Allergies)
(8) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3)
(9) Immunizations. The standard specified in § 170.207(i)
(9) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g)

Elsewhere in the Standards rule, reference the appropriate parts of this section:

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 § 170.208(b), electronically incorporate the data elements found in § 170.208(a).

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 standards as described in § 170.208(b) and that includes the data elements expressed in § 170.208(a) according to the specified standard(s)

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 data elements expressed in § 170.208(a)

170.314(e)(1)(B)(2) A summary care record formatted according to the standards adopted at § 170.208(b) and that includes, at a minimum, the data elements expressed in 170.208(a).

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 data elements expressed in 170.208(a).
(On another note, strike the Ambulatory Setting Only part, but that's another set of edits to apply). 

(ii) Provided in a summary care record formatted according to the standard adopted at § 170.208(b) with the data elements in § 170.208(b) expressed, where applicable, according to the specified standard(s).

To the Incentive Rule, replace the text describing a Summary Care Record in the preface with:
All summary of care documents used to meet this objective must meet the definition in §170.208(a).
And add the following definition at 495.4:
Summary Care Record
A document containing the data elements found in §170.208(a) and formatted according to the standards at § 170.208(b) when exchanged electronically.



2 comments:

  1. In your (a)(10), how are relevant past problems defined?

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    Replies
    1. That's a clinical judgement, as I discuss here. How would you define them?

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