Relevant and Pertinent Short Survey Results Summary May 5, 2016 Robert Dieterle Holly Miller, MD Russel Leftwich, MD

Summary of Participation Organization Total ToC1 American Academy of Family Physicians 103 62 American Hospital Association 34 28 American Medical Association 433 163 Other 43 23 613 275 Note 1: ToC – declared they have received ToC Documents Note: there are no significant differences in in answers between the full set of respondents and the 275 that have experience receiving ToC documents

Demographics Practice location distribution matches US population distribution General Practice and all relevant specialties represented All practice types (IDN/Hospital/Unaffiliated) represented Response by practice size represents solo to >20 provider practices All payer types well represented

EHR and ToC Experience 84% have used EHRs for more than 3 years 64% have or plan to send ToC documents 47% have received ToC documents hospital discharge and consults are the most common documents (80% receive at least one of each per month) 44% review the ToC as a document 33% incorporate discrete clinical data personally C i

General ToC Issues 56% declare too much information 46% declare needed information is missing 73% declare ToC organization and 57% declare lack of a clear summary are a problem >31% did not receive ToC in a timely fashion

Hospital Discharge 81% want same information as traditional discharge summary 68% want limited information rather than all hospitalization data 43% declare that important information is missing over 50% of the time

Ambulatory 81% want all information from the current ambulatory visit 87% want new or changed information from all ambulatory visits 49% declare they receive all information from the current ambulatory visit in the ToC at least 50% of the time 29% declare that important information is missing over 50% of the time

Value of Specific Information Hospital Discharge and CCD 18 of the 26 sections (includes optional sections) are considered valuable or necessary by over 50 % of those receiving ToCs Of the 26 sections listed only 4 are consider valuable or necessary by less than 30% of the respondents Ambulatory (consult/progress note/CCD) 20 of the 28 sections (includes optional sections) are considered valuable or necessary by over 50 % of those receiving ToCs Of the 28 sections listed only 1 is consider valuable or necessary by less than 30% of the respondents

Value – Hospitalizations (Discharge Summary/Continuity of Care) ToC Please indicate for each category of information the value to your practice from Hospital Discharge ToC documentation Section All Exp Discharge Medications 92% 94% Allergies / Intolerances 80% 81% Immunizations 48% 57% Discharge Diagnoses 90% Hospital Course 79% Encounters 47% 42% Results 89% Problems 83% Discharge Diet 37% 41% Procedures 86% Discharge Instruction 64% 68% Medical Equipment 36% Chief Complaint / RoV 85% Functional Status 59% 58% Social History 34% Plan of Treatment Mental Status 60% Family History 29% 27% Hospital Consultation 84% Advance Directives 56% Payer Information 24% History of Present Illness 82% Vital Signs 52% 53% Review of Systems 28% Admission Diagnosis History of Past Illness 49% Notes: 1) Percentage include responses of Necessary and Valuable 2) All is an average of 583 respondents, Exp is based on the 263 with ToC experience 3) Stop light coding is based on responses – green: highly relevant, yellow: relevant, red: less relevant

Value – Hospitalizations (Discharge Summary/Continuity of Care) ToC Please indicate for each category of information the value to your practice from Hospital Discharge ToC documentation

Value – Ambulatory Encounters (Consult/Progress Note/Continuity of Care) ToC Please indicate for each category of information the value to your practice from ambulatory visit ToC documentation Section All Exp Diagnosis 94% 96% Interventions 74% 79% History of Past Illness 47% 46% Medications 93% Physical Exam 64% 66% Immunizations 55% Plan of Treatment 88% 91% Instructions 60% Medical Equipment 38% 44% Chief Complaint / RoV 86% Vital Signs 56% 59% Nutrition/Diet 36% 39% Results Mental Status 52% 53% Social History Assessment 85% Objective 54% Family History 33% 31% Procedures 83% Encounters 50% 45% Payer Information 28% History of Present Illness 81% 82% Functional Status 51% Review of Systems 30% Problems Subjective Allergies / Intolerances 78% Advance Directives Notes: 1) Percentage include responses of Necessary and Valuable 2) All is an average of 583 respondents, Exp is based on the 255 with ToC experience 3) Stop light coding is based on responses – green: highly relevant, yellow: relevant, red: less relevant

Value – Ambulatory Encounters (Consult/Progress Note/Continuity of Care) ToC Please indicate for each category of information the value to your practice from ambulatory visit ToC documentation

Value – Hospitalization and Ambulatory Experience with ToC Only Section Hosp Amb Medications 94% 96% Problems 83% History of Past Illness 49% 46% Diagnosis 92% Allergies / Intolerances 81% 78% Encounters 42% 45% Results 90% 88% Instructions 68% 66% Medical Equipment 41% 44% Plan of Treatment 89% 91% Mental Status 60% 53% Nutrition/Diet 39% Procedures 86% Advance Directives Social History 34% 36% Interventions 79% Functional Status 58% 51% Family History 27% 31% Chief Complaint / RoV 85% Immunizations 57% 55% Review of Systems 24% 30% History of Present Illness 84% 82% Vital Signs 59% Payer Information 28% Notes: 1) Percentage include responses of Necessary and Valuable 2) Hospital is average of 263 respondents and Ambulatory is aver of 255 respondents 3) Excludes for Hospitalization: Admission Diagnosis, Hospital Course 4) Excludes for Ambulatory: Assessment, Physical Exam, Objective Subjective 5) Stop light coding is based on responses – green: highly relevant, yellow: relevant, red: less relevant

Value – Hospitalization and Ambulatory Experience with ToC Only

Scope Preferred for Specific Information Hospital Discharge and CCD 65% want all procedures (from all hospitalizations) Roughly 50% want last available functional status (51%), plan of treatment (51%), review of systems (66%) and vital signs (48%) Hospital studies and results are equally distributed between last, first and last and all Ambulatory (consult/progress note/CCD) Majority want functional status (77%), plan of treatment (74%), problems (64%), procedures (52%) , results (65%) review of systems (87%) and vital signs (79%) from the current visit only (not from prior or all visits)

Medications Hospitalization Ambulatory Visit 89% declare active and prescribed meds at discharge necessary (60% declare they are always received) admission (88%) and administered (82%) medications necessary or useful (<25% declare they are always received) Ambulatory Visit new (89%) and discontinued (83%) medications are necessary (52% declare they always receive new meds and only 31% declare they receive discontinued meds) 68% declare current meds at time of visit are necessary (43% declare they are always received)

Alternative Approaches 39% want to receive less information 61% want to receive more information if they have better display and incorporation capability A significant number of respondents want (4 or 5 out of 5) User defined summaries (48%) Table of contents with links (44%) Drag and drop for incorporation of discrete data (47%) Automated incorporation (44%) Detection of duplicate data (53%)

Comments and Follow-up Count Percentage Contact information 142 23 % Willing to participate 278 46 % Providing contact information 129 Provided exit comments 86 14 % Note: this from all respondents

Summary 47% of responding providers currently receive ToC documents Hospital visit – want same information as paper discharge document Ambulatory – want all information from current visit Ambulatory – want changed information from prior visits Over 50% want 18 of 26 and 20 of 28 sections Only 4 sections of discharge summary / CCD and 1 section of consult/progress note/CCD are wanted by <30% 56% want less information -- appears to be related to repeated sections (e.g. results / vitals from hospitalizations) and prior visits 61% want better tools to review and incorporate 46% declare important information is missing in ToCs