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

2. 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

3. 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

4. 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

5. 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)

6. 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

7. 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.

8. 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

9. 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

10. Value – Hospitalizations (Alternative graphical view)
Please indicate for each category of information the value to your practice from Hospital Discharge ToC documentation

11. 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

12. 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)

13. 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

14. 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

15. 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

16. 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

17. 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%)

18. 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

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

20. BACKUP SLIDES

21. 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

22. 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

23. 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

24. Value – Hospitalization and Ambulatory Experience with ToC Only

25. 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

26. 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)

27. 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)

28. 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