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David's RnP Questions

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(From David Tao) I've included both QUESTIONS (for the outreach to Professional Societies) and NOTES (suggestions to our project group). I've also included some citations from CMS that we must consider.


  1. In general, for documents that contain too much information that is NOT relevant or pertinent, what are the main places (e.g., categories of data) that cause the problem?
  2. Is there any minimum core of data that should ALWAYS be sent in every instance of a summary document, regardless of the patient or recipient? The CMS NPRM suggests that it always be current problems, current meds, and current med allergies (see citation from p. 124 in CMS NPRM below) -- is there agreement on that?
  3. Is there any other important data (e.g., physician notes, reason, etc.) that you need to receive in a ToC, that is NOT in the Common MU DS or CCDS?
  4. Are there any requirements or strong preferences regarding formatting and sequencing of the document? For example, should the sequence always be the same (standardized), or should it be decided by the sender?
  5. What would you like to see at the top of a document? (This is mainly about the CCDA HEADER, though we should leave the question open-ended to not bias the answers. Since there is no standard for how much of the header to display, this could be an area of wide variability.)
  6. Do you tend to read documents from start to finish, or do you prefer to navigate them using a clickable table of contents to get to the sections you're most interested in? Is "too much information" the root problem in CCDA usability, or are there other factors such as how the information is displayed and accessed?
  7. [Alternative to previous question] - We could start by listing sections within CCDS or Common MU2 Data Set, and ask for which types of entries SHOULD and SHOULD NOT be included. I suggest that we prioritize by starting with the sections that have most potential for being lengthy and containing some irrelevant data, e.g., Lab Tests, Problems, Meds, Vital Signs, Procedures. I doubt that allergies would be a problemmatic section because of probable lower volume and less likelihood of obsolete information.
  8. As a rule of thumb, realizing that it will vary based on the patient, is there a size (number of printed pages) that you would consider a reasonable target for the "average" summary record?
  9. In actual Meaningful Use experience, which document(s) have you been receiving? (Ideally, get their names and frequency). Prioritize optimization for the most prevalent ones. Anecdotal evidence says CCD is the most common, but is it 50%, 75%, 90%...?
  10. Do you have any rules of thumb (heuristics) for "how old is too old" or "what is not relevant" for data in a summary record? If it should vary depending on the type of data, please describe. E.g., older Surgical Procedures should be listed, but not older Medications, Lab Results, or Vital Signs.


  1. Should the target (for R&P) be the “minimum floor” (the smallest document meeting requirements, above which more can be added)?, the “mid point” (a best guess as to the sweet spot, to which providers using EHRs can add or subtract), or the “maximum” (the most that should ever be sent)?
  2. Are we presuming that the burden is only on the SENDER to send the documents that are R&P? Should we assume no capabilities on the receiving end to filter?
  3. We should consider what parameters are available in most EHRs to filter the information being sent, e.g., date range, status, abnormal, other flags?. EHRs will have their own unique capabilities, but I suggest that we limit our parameters to data elements available and commonly used (SHALL and maybe SHOULD) in CCDA, specific to each category of data.

    CITATIONS FROM CMS Meaningful Use Stage 3 (EHR Incentive Program) NPRM

    Pages are from the Display Edition (Word format), not the 3-column Federal Register version. Direct quotes are in italics. My comments are non-italics. While the Public comment deadline has passed (May 29) the following citations give an idea of the current thinking of CMS (and possibly ONC)

  4. p 123 “In circumstances where there is no information available to populate one or more of the fields included in the CCDS, either because the EP, eligible hospital, or CAH can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the EP, eligible hospital, or CAH may leave the field blank and still meet the requirements for the measure.”
  5. P 124 “However, all summary of care documents used to meet this objective must be populated with the following information using the CCDS certification standards for those fields: Current problem list (Providers may also include historical problems at their discretion). current medication list. current medication allergy list.” Note the word “Current”) Also “We propose to maintain that all summary of care documents contain the most recent and up-to-date information on all elements. In the event that there are no current diagnoses for a patient, the patient is not currently taking any medications, or the patient has no known medication allergies; the EP, eligible hospital, or CAH must record or document within the required fields that there are no problems, no medications, or no medication allergies recorded for the patient to satisfy the measure of this objective. The EP or hospital must verify that the fields for problem list, medication list, and medication allergy list are not blank and include the most recent information known by the EP or hospital as of the time of generating the summary of care document.”
  6. P 125 “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 active or resolved, that have ever populated the problem list. While a current problem list must always be included, the provider can use his or her judgment in deciding which items historically present on the problem list, medical history list (if it exists in CEHRT), or surgical history list are relevant given the clinical circumstances.”
  7. P 125-126 “Therefore, we defer to provider discretion on the circumstances and cases wherein a limitation around clinical relevance may be beneficial and note that such a limitation would be incumbent on the provider to define and develop in partnership with their health IT developer as best fits their organizational needs and patient population. We specify that while the provider has the discretion to define the relevant clinical notes or relevant laboratory results to send as part of the summary of care record, providers must be able to provide all clinical notes or laboratory results through an electronic transmission of a summary of care document if that level of detail is subsequently requested by a provider receiving a transition of care or referral or the patient is transitioning to another setting of care. We note that this proposal would apply for lab results, clinical notes, problem lists, and the care plan within the summary of care document” I commented that it shouldn’t be limited thusly. What about Vitals, Old Meds? Old Procedures? The word “Current” is not included when those were listed in CCDS or in CMS NPRM. Clearly, there is the potential for high volumes of irrelevant information included in these categories.