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 Name	Required/Optional
11348-0	HISTORY OF PAST ILLNESS	O
46241-6	HOSPITAL ADMISSION DX	O
11535-2	HOSPITAL DISCHARGE DX	R
11450-4	PROBLEM LIST	R
10155-0	HISTORY OF ALLERGIES	R
8658-7	HISTORY OF ALLERGIES
11382-9	MEDICATION ALLERGY	O
10160-0	HISTORY OF MEDICATION USE	O
10183-2	HOSPITAL DISCHARGE MEDICATIONS	R
42346-7	MEDICATIONS ON ADMISSION	O
8648-8	HOSPITAL COURSE	R
10154-3	CHIEF COMPLAINT	O
29299-5	REASON FOR VISIT	O
46239-0	CHIEF COMPLAINT+REASON FOR VISIT	O
42349-1	REASON FOR REFERRAL	O
42348-3	ADVANCE DIRECTIVES	O
10164-2	HISTORY OF PRESENT ILLNESS	O
10158-4	HISTORY OF FUNCTIONAL STATUS	O
10157-6	HISTORY OF FAMILY MEMBER DISEASES	O
29762-2	SOCIAL HISTORY	O
11369-6	HISTORY OF IMMUNIZATIONS	O
10167-5	HISTORY OF SURGICAL PROCEDURES	O
46240-8	HISTORY OF HOSPITALIZATIONS + HISTORY OF OUTPATIENT VISITS	O
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
22029-3	PHYSICAL EXAM.TOTAL	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	O
18776-5	TREATMENT PLAN	O

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.