Wednesday, November 3, 2010

The Circle Never Ends

Between mischeduling meeting, not scheduling meetings, being double-booked, and taking care of my daughter who has strep throat, I've been chasing my own tail quite a bit this morning.  Now that it is the afternoon, I've managed to settle down a bit.
One of the things that I did manage to get done this morning was arrive (late) at a meeting to discuss a Transfer of Care form being proposed for use in the state of Massachusetts convened by the Mass Health Data Consortium.
Now this truly is an interesting circle, or in my case, a vortex that sucked me in.
Massachusetts Transfer Form
ASTM Continuity of Care Record
 ►HL7 Continuity of Care Document
  ►IHE Exchange of Personal Health Record Profile
   ►ANSI/HITSP C32 Summary Documents using CCD
    ►ANSI/HITSP C83 CDA Content Modules
     ►CMS CARE Set Implementation Guide using HITSP C83
      ►Updated Massachusetts Transfer Form

I promised a review of the form based upon:
What is supported by the HITSP C32 Version 2.5
What is required under meaningful use
And I've also indicated what could be added based upon CDA

Page 1 Contact Information and Checklist

Patient Demographics

  • Name
  • Date of Birth
  • Gender
  • Address
  • Phone Number
  • Primary Language
Patient Contacts

  • Name
  • Telephone Number
Healthcare Proxy


Telephone Number

Awareness of Patient Contact/Healthcare Proxy of Transfer

Whether a Healthcare Proxy has been invoked

Current Healthcare Providers
  • Name
  • Facility
  • Telephone Number(s)
Identification of Information Sent at Time of Transfer
  • Med List
  • Progress Notes
  • Pending Encounters and Labs
  • Advance Directives
  • Relevant Lab Results
  • Last History and Physical
  • Whether the Patient was sent with
    • Narcotics
    • Personal Belongings including glasses, hearing aids, dental appliances, et cetera.
  • Signatures of the: 
    • Attending Provider
    • Receiving EMS Personnel or Family Member
Page 2 Physician Orders and Nursing Assessment

Physician Orders

  • Advance Directives
    • DNR
    • DNI
    • DNH
    • Full Code
    • Reason for not completing this section
  • Heads Up -- Clinical Issues requiring special attention, et cetera
  • Reason for Transfer
  • Summary
  • Goals of Care
  • Diagnoses
  • Allergies
  • Vital Signs
Nursing Assessment

  • Mental Status
  • Functional Status
  • Pain Assessment
  • Immunization History
  • Devices/Special Treatments
  • Patient Risks (Falls, Restrained, Elopement, et cetera)
  • Isolation Requirements
Page 3 Patient Assessment

  • Treatment orders
  • Skin/Wound Care orders
  • Diet Orders
  • Insurance Information
  • Activities of Daily Living
  • Vision, hearing and Communication Ability
Page 4 Therapy and Behavioral Information

  • Restricted Activities
  • Weight Bearing Status
  • Physical/Occupational/Speech Therapy
  • Respiratory Care
  • DME / Medical Supplies Needed
  • Behavioral, Social and Family Issues and Interventions
  • Discharge Education Status
  • Signature of the Patient or representative acknowledging discharge planning
Page 5 Medication List

Page 6 Outstanding Tests and Encounters and Additional Notes

Page 7 Anticoagulation Orders and Wafarin Flowsheet

The above is just a preliminary analysis, I have to dig up the HITSP C83-based CARE implemention guide to see what they did because the C83 mapping is already done, and this new form is based on the CMS CARE Data Set.

What is pretty clear is that most of the information can be supported by a HITSP C32 document.  The real question is whether A) It belongs there, and B) how to best address the workflow requirements given what Meaningful Use is already requiring in the US.

This is not a 'Summary of Episode Note', rather it is a 'Transfer of Care Referral' document.  That would actually imply a different document type than is used for CCD.  There's a good reason to mark it as a different kind of document as well.  There will be millions of CCDs created in this state, for every patient visit where a provider can generate one in order to meet the requirements of meaningful use.  Do you really want providers to have to find the ones that are specifically for transfers among all the others?  Probably not.  CCD and C32 is a hammer, but this problem is not quite a nail.

The next issue has to do with alignment with the National program.  If providers are already going to be creating C32 documents electronically, and there are already requirements on their transmission, how should this problem be tackled electronically?

One way would be to divvy up the workflows so that they can work with what will be deployed at the national level.  Creating a new form that requires only that data not already required by our national program will augment that program, introduce a workflow that can, where necessary, be completed separately from functionality supported by systems certified for use under that program.  That form could optionally duplicate information found in the nationally required content.  In that way, the maximum number of healthcare providers can support the regional program without requirement them to further modify workflows that are part of a certified product.

That is in fact another challenge that institutions face.  You can think of this as being 'as simple' as modifying or changing product configurations to support the local requirements.  But if you do that, you've probably introduced enough change to features that have been certified by the supplier that you may need to consider self-certification of your system.

Vocabulary and workflow are other challenges.  I can find vocabulary that represents concepts like DNR, DNI, et cetera, in internationally recongized systems like SNOMED.  But those same terms have LOCAL definitions in law or regulation, and so don't mean the same thing as soon as you start operating across borders.  The Massachussetts form is very heavily influenced by a similar form in Rhode Island, but what happens if you get a Rhode Island form with respect to translation of some of these concepts.  The same is true for other concepts such as 'Healthcare Agent'. 

On the workflow side, when you create lists like this, the question I have to ask is how this impacts workflows of a wide variety of providers.  For example, while Mental Status and Functional Status are data sets that are captured at almost every nursing home and skilled nursing facility, and would be captured at the level of detail in these forms, that same information would never enter a pediatric workflow in the usual case.  It would be captured in the exceptional cases, but for the rest, information about for example, mental status, would have to be reported as 'Unknown', because it isn't part of that providers usual workflow.

The challenge for the Massachusetts Department of Public Health is to figure out how to align this work with the existing National Program, and do so in a way that introduces the least amount of disruption in the workflows of local healthcare providers.  Fortunately, Massachusetts is very well represented on both the HIT Policy and Standards advisory committees, and some discussion will hopefully be occuring with those members and people involved in this project.

When I spoke two weeks ago to a group in Pennsylvania, one of the important points that I made was to be aware of, and contribute to the national discussions.  This is especially true when trying to coordinate activities like this one.

One final note:  Ideally, the 'transfer of care referral note' should also be acceptable as a communication meeting the requirements of meaningful use.  That is not presently allowed at this time under the current regulations, because the document must be a HITSP C32 meeting specific requirements.  But those same content requirements could be met with more encounter focused CDA documents for H&P, Consults, Discharge Summaries, and Transfer of Care referrals.

For phase 2, I hope that the HIT Standards committee thinks about the wider context of clinical documentation, and how it need not all be about the C32.  After all, we are gifted with a whole toolbox when using CDA, not just a hammer.  If we look at the HITSP C83, instead of C32, we can communicate the same data, and support quite a bit more than 'patient summaries'.  That is in fact what we designed it to do.


  1. Don't forget to wrap all that in a Digital Signature and Content Package and Transport...

  2. What about coding the items on this form to SNOMED - such as the mental status choices, devices and special treatments and Vision, Hearing, etc? I could not find clear matches. Did you go that far in your review?