Relevant and Pertinent Findings and Recommendations Short Summary

1. Relevant and Pertinent Findings and RecommendationsShort Summary September 22, 2016 David Tao

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 • Approach: reach out to gather detailed and specific provider preferences and experiences • Survey designed by Robert Dieterle, Dr. Holly Miller, and Dr. Russell Leftwich • Surveys sent in November, 2015, to 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 Association • 103 American Academy of Family Practitioners • 34 American Hospital Association • 43 other • Practice location, specialty, and practice types, practice type, and payment sources were all well represented

4. EHR and Transitions of Care(ToC) Experience • 84% have used EHRs for more than 3 years • 47% have received ToC (electronic) documents ¹ • 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

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) • Only 16% of providers had attested to MU2 as of the survey (November 2015) • 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. Premise for Recommendations Many survey questions asked about “preference” followed by corresponding questions about “experience.” Our working premise: that satisfaction increases to the extent that preferences are met in actual experience, and decreases as preferences are not met in experience. We avoided injecting personal recommendations not based on the survey questions.

7. General ToC Issues (quantitative) 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 The results above were from the subset with ToCelectronic document experience

8. General ToC Issues (qualitative) These results were from interviews with representatives of 13 organizations (“Long Survey”). They complement and reinforce the short survey findings.

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

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

11. Hospital Discharge Recommendations Include “patient story” narrative: Hospital Course plus the following sections if 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 Include 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. “What Happened?” -- the patient story Example #1, Hospital Course: “The patient underwent L5-S1 Gill decompressive laminectomy and posterior lumbar interbody fusion with pedicle screws with general anesthesia. She tolerated the procedure well. She did complain of some persisting numbness in the S1 dermatome of the right foot postoperatively. She was ambulatory, and her pain was under control with oral analgesics at the time of her discharge.” Example #2, History of Present Illness: “MsJ. K. is an 83 year old retired nurse with a long history of hypertension that was previously well controlled on diuretic therapy. She was first admitted to XYZ in 2014 when she presented with a complaint of intermittent midsternal chest pain. Her electrocardiogram at that time showed first degree atrioventricular block, and a chest X-ray showed mild pulmonary congestion, with cardiomegaly. Myocardial infarction was ruled out by the lack of electrocardiographic and cardiac enzyme abnormalities. Patient was discharged after a brief stay on a regimen of enalapril, and lasix, and digoxin, for presumed congestive heart failure. Since then...”

13. 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)

14. 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

15. 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 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

16. Ambulatory Recommendations Include “patient story”narrative, using the following sections if 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

17. Ambulatory Recommendations: Medications Ensure that medications lists include all medications that are active, that are newly prescribed, and that were discontinue during visit. Each should be distinctly labeled and identified. Reasonsfor discontinuation (e.g., ineffective, condition resolved, superseded by different medication, adverse reaction, etc.) would be valuable information, if available

18. 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 incorporation of discrete data (47%) • Automated incorporation (44%) • Detection of duplicate data (53%) • In hindsight, it would have been good to ask more about receiving/display/incorporation

19. Highlights 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 • Avoid repetitive information • 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

20. Conclusion and Next Steps • Intent to Ballot • Timeline and window of opportunity? • Publication format: white paper? IG? Submit to journal? • RnP Wiki: http://wiki.hl7.org/index.php?title=Relevant_and_Pertinent#Final_Report_Drafts_and_Deliverables • Contacts: • Keith Boone keith.boone@ge.com • Robert Dieterlerdieterle@enablecare.us • David Tao dtao12@gmail.com