Relevant and Pertinent Findings and Recommendations September 17, 2016 David Tao Robert Dieterle Keith Boone

Background and Purpose Anecdotal evidence and testimony about dissatisfaction with clinical summaries received in Meaningful Use (MU) program Complaints (“too long,” “difficult to use”) lacked specificity, and therefore could not be acted upon Approach: reach out to providers to gather detailed and specific preferences and experiences Survey designed by Robert Dieterle, Dr. Holly Miller, and Dr. Russell Leftwich Surveys sent in November, 2015, to many professional societies to distribute to thousands of members Deliverable: guidance to developers on what automatically generated clinical summaries should contain

Demographics 613 responses: 433 American Medical Assn, 103 American Academy of Family Practitioners, 34 American Hospital Assn, 43 other 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 Transitions of Care (ToC) Experience 84% have used EHRs for more than 3 years 64% have or plan to send ToC (electronic) documents 47% have received ToC documents ¹ 44% review the ToC as a document 33% incorporate discrete clinical data personally Documents fairly evenly divided among hospital discharges, ambulatory consults, ambulatory referrals ¹ Statistics in this presentation reflect ALL responses (with or without ToC experience) except where noted C i

Meaningful Use Context The vast majority of documents received were CCD, mostly constrained by HITSP C32 for MU Stage 1, and some C-CDA 1.1 (for MU2), none using C-CDA 2.1 Only 16% of providers had attested to MU2 as of the RnP survey CCD/C32 was the only CDA document permitted in MU1 Most documents contained sections required for certification, but probably few optional sections (e.g., narrative)

General ToC Issues 56% say there is too much information 46% say needed information is missing 73% say ToC organization causes difficulties in usage 57% say a clear summary is lacking 31% did not receive ToC in a timely fashion The results above were from the subset with ToC electronic document experience

Premise for Recommendations Many survey questions asked about “preference” followed by corresponding questions about “experience.” Working premise: that satisfaction will increase to the extent that preferences are met in actual experience, and will decrease to the extent that preferences are not met in actual experience.

Hospital Discharge Findings 80% want same information as traditional discharge summary 63% want limited information rather than all hospitalization data 46% declare that important information is missing over 50% of the time

Value – Hospitalizations (Discharge Summary, CCD) 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% 17 of the 26 sections are considered valuable or necessary by over 50% 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 (Alternative graphical view) Please indicate for each category of information the value to your practice from Hospital Discharge ToC documentation

Hospital Discharge Recommendations Include “patient story” narrative: Hospital Course plus the following sections if info is available: Chief Complaint, CC and Reason for Visit, History of Present Illness, Hospital Consultations, Plan of Treatment Consider generating C-CDA Discharge Summary as alternative to CCD Avoid including detail from prior hospitalizations, and include only relevant data from the current hospitalization Strongly consider including all invasive procedures from current hospitalization, and historical procedures pertinent to the current treatment Keep in mind the intended purpose and recipients (e.g., specialty) and their specific information preferences

Hospital Discharge Recommendations: Medications Necessary: Include Discharge Medications (or current medications in Medications Section) High value: Include Admission Medications where available Useful: Include Medications Administered Sections where available Display the above medications in three distinct sections (lists)

Ambulatory Findings 80% want all information from the current ambulatory visit 86% want new or changed information from all ambulatory visits 44% say they receive all information from the current ambulatory visit in the ToC at least 50% of the time 33% say that important information is missing over 50% of the time

Value – Ambulatory Encounters (Consult Note, Progress Note, CCD) 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 19 of the 28 sections are considered valuable or necessary by at least 50% 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

Ambulatory Recommendations Include patient story narrative, using the following sections for which info is available: Chief Complaint, CC and Reason for Visit, Assessment, History of Present Illness, Plan of Treatment Keep in mind the intended purpose and recipients (e.g., specialty) and what is especially important to them (For ONC) – consider allowing more C-CDA document types beyond CCD and Referral Note, e.g., Consultation Note, Progress Note, History and Physical

Ambulatory Recommendations: Medications Ensure that medications lists include all medications that are active, that are newly prescribed, and that were discontinue during visit. Each of these should be distinctly labeled and identified. If any past medications (discontinued prior to the current visit) are included, separate them from those that were active, new, or discontinued as of the current visit. Reasons for discontinuation (e.g., ineffective, condition resolved, superseded by different medication, adverse reaction, etc.) would be valuable information, if available

Alternative Approaches 43% want to receive less information 57% want to receive more information if they have better display and incorporation capability A significant number of experienced 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%)

Summary of RECOMMENDATIONS Content: Include the patient story narrative, as this is highly valued by providers, yet often missing Hospital discharges: summarize current hospitalization, and avoid information from prior hospitalizations. Consider sending Discharge Summary rather than CCD Ambulatory: include all information from current visit Keep in mind the intended purpose and the unique information preferences of specialists Provide better receiving system tools to render, filter, incorporate (ONC): consider allowing more than two C-CDA document types for ambulatory ToC

Conclusion and Next Steps To be added Timeline and window of opportunity? Publication format: white paper, IG, published in journal? Off-cycle ballot?

BACKUP SLIDES

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

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 – 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

Value of Specific Information COMBINE INTO HOSPITAL AND AMBULATORY 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

Scope Preferred for Specific Information TO BE DONE: SPLIT AND MOVE TO HOSPITAL AND AMBULATORY SECTIONS 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 SPLIT AND MOVE TO HOSPITAL AND AMBULATORY SECTIONS Hospitalization 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)

Summary of FINDINGS NEEDED? 47% of responding providers currently receive ToC documents Hospital visit – want same information as paper discharge document Ambulatory – want all information from current visit and changed information from prior visits Over 50% want 17 of 26 and 19 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