© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. Keith Boone, GE Healthcare Relevant and Pertinent Project 1 09/25/2013

© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. What would you do with a 69 page C-CDA? Nothing? Throw it away? Refuse to accept? – OR – Incorporate it into your EHR? 09/25/ Image By Niklas Bildhauer [CC BY-SA 2.0], via Wikimedia CommonsCC BY-SA 2.0

© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. Too much data is almost as bad as none (or possibly worse, from the medicolegal perspective). Cognitive Overload  How could I possibly tell what is the most important?  How can I find what I care about?  What is my liability if I miss something? 09/25/ © Copyright Maigheach-gheal and licensed for reuse under this Creative Commons Licence.Maigheach-ghealreuseCreative Commons Licence

© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. Relevant and Pertinent Defined Relevant adjective 1. bearing upon or connected with the matter in hand; pertinent: a relevant remark. Pertinent adjective 1. pertaining or relating directly and significantly to the matter at hand; relevant: pertinent details. Source: Dictionary.com. Dictionary.com Unabridged. Random House, Inc. (accessed: May 27, 2015). 09/25/2013 4

© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. These words define the CCD use case. The CCD is a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. Page 84, HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 09/25/2013 5

© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. They also appear in other document types and sections The Discharge Summary is a document that is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The Problems section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed. The Medications section defines a patient's current medications and pertinent medication history. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. 09/25/2013 6

© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. ONC rule does allow flexibility (b)(2) Transitions of care—create and transmit transition of care/referral summaries. (i) Create. Enable a user to electronically create a transition of care/referral summary formatted according to the standard adopted at § (a)(3) that includes, at a minimum, the Common MU Data Set and the following data expressed, where applicable, according to the specified standard(s): (A) Encounter diagnoses. The standard specified in § (i) or, at a minimum, the version of the standard specified § (a)(3); (B) Immunizations. The standard specified in § (e)(2); (C) Cognitive status; (D) Functional status; and (E) Ambulatory setting only. The reason for referral; and referring or transitioning provider's name and office contact information. (F) Inpatient setting only. Discharge instructions. 09/25/ When is a Data Element Applicable?

© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. Especially in the Ambulatory Setting (e)(2) Ambulatory setting only—clinical summary. (i) Create. Enable a user to create a clinical summary for a patient in human readable format and formatted according to the standards adopted at § (a)(3). (ii) Customization. Enable a user to customize the data included in the clinical summary. (iii) Minimum data from which to select. EHR technology must permit a user to select, at a minimum, the following data when creating a clinical summary: (A) Common MU Data Set (which, for the human readable version, should be in their English representation if they associate with a vocabulary/code set) (B) The provider's name and office contact information; date and location of visit; reason for visit; immunizations and/or medications administered during the visit; diagnostic tests pending; clinical instructions; future appointments; referrals to other providers; future scheduled tests; and recommended patient decision aids. 09/25/2013 8

© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. CMS uses Relevant and Pertinent in the EHR Incentive Rule For summary of care documents at transitions of care, we encourage providers to send a list of items that he or she believes to be pertinent and relevant to the patient's care, rather than a list of all problems, whether they are active or resolved, that have ever populated the problem list. While a current problem list should always be included, the provider can use his or her judgment in deciding which items historically present on the problem list, PMHx list (if it exists in CEHRT), or surgical history list are included given the clinical circumstances. This same principle presumably applies to other data. 09/25/2013 9

© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. Real-world Experience with C-CDA Despite the flexibility referenced in the rules, sites and providers report high variability in the method of selecting content to transmit Many files contain literally every piece of data recorded that pertains to the patient (hundreds of pages) Some sites filter and others don’t Some sites reject files due to size or medicolegal concerns Some sites print out C-CDA files and deliver on paper 09/25/

© 2015 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office. What’s “relevant and pertinent”? Providers should provide the guidance to improve and streamline the specification, its guidance, and use HL7 and HHS agencies want to reduce complexity and improve successful exchange We need your help to determine what the requirements are for ideal summaries of care 09/25/