In 2005 and 2006, I spent a significant amount of time explaining the "Document Rewrite" problem to the HL7 Claims Attachments (now renamed Payer/Provider Information Exchange) workgroup.
In short, if you have an existing CDA (or C-CDA) document, and now, for regulatory reasons (for example, to attach a digital signature to it), you must open and rewrite the document, for a subsequent purpose (e.g., to attach an electronic [digital] signature for Claims Attachments), you've introduced a second artifact that must be separately identified, linked to the original, and stored; increasing costs of storage and implementation, and subsequent delays in deployments. I suspect these additional costs are NOT accounted for in the current proposed rule.
This problem was original introduced in the Attachments AIS back in 2005 in an attempt to insert the attachment linking information into the original artifact, and is now a potential consequence associated with the electronic signature requirements of the currently proposed rule. At least our institutional memory has had at least one opportunity to notify HHS of this problem again.
Honestly, I'm a supporter of EHRs adding a digital signature to the CDA artifact when the document is SIGNED by the provider creating it, but such technology is NOT readily available in certified EHR technology today. I don't believe that such an imposition should be made for attachments until after such technology is broadly available through certified EHR systems, and then only for documents created after such technology is required for use by healthcare providers under CMS programs.
