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© 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

109/25/2013


If you cannot hear us!

Please use the HL7 T-Con line: 770-657-9270,310940#

09/25/20132


What would you do with a 69 page C-CDA?

Nothing? Throw it away? Complain?

– OR – Incorporate it into your

EHR?

09/25/20133

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Too much data is almost as bad as none.

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?

09/25/20134

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Relevant and Pertinent Defined

Relevantadjective

1. bearing upon or connected with the matter in hand; pertinent: a relevant remark.

Pertinentadjective

1. pertaining or relating directly and significantly to the matter at hand; relevant: pertinent details.

Source: Dictionary.com. Dictionary.com Unabridged. Random House, Inc. http://dictionary.com (accessed: May 27, 2015).

09/25/20135

http://dictionary.reference.com/browse/pertinent




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

09/25/20136


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.

This 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.

At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.

The Medications section defines a patient's current medications and pertinent medication history.

09/25/20137


ONC provides wiggle room.170.314(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 §170.205(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 §170.207(i) or, at a minimum, the version of the standard specified §170.207(a)(3);(B) Immunizations. The standard specified in §170.207(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.

09/25/20138

When is a Data Element Applicable?


Especially in the Ambulatory Setting

170.314(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 §170.205(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.

09/25/20139


CMS uses Relevant and Pertinent in the 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.

09/25/201310


End of Presentation

Meeting Notes follow

09/25/201311


How do we engage?

Past Engagements as an example. CIC is a co-sponsor of this project Make a list of organizations we would like to target:

Medical Professional Societies Prioritizing those that have a designated informatics/standards/similar function (staff or

committee). Provider Organizations – Referral Coordinators, Care Managers? have Specialist

Requirements Health Story AMIA CMS

09/25/201312


How do we make our list?

09/25/201313


How do we engage?

How could most relevant and pertinent be automated? Current/Historical Status Time Frame Sampling Frequency [don’t need to know 4x a day for 6 weeks in hospital] Scope of Practice [inbound and outbound] RfR/RfV/CC What are the contexts that we should consider? Kind of encounter?

Specific to your specialty or of general use? Patient Age and Gender

09/25/201314


Data Elements

Common MU Data Set

– OR – Common Clinical Data Set

09/25/201315


Qualitative vs. Quantitative Approach? Concrete Use Cases? What are your priorities?

09/25/201316

© 2015 health level seven ® international. all rights reserved. hl7 and health level seven are...

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