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Relevant and Pertinent Findings and Recommendations

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

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Relevant and Pertinent Findings and Recommendations

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  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

  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 ToCorganization 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 ToCelectronic 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 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 distinctsections (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 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. Reasonsfor 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 lessinformation • 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 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 AmbulatoryExperience with ToC Only 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 AmbulatoryExperience 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 FINDINGSNEEDED? 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

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