ToC+-+Discharge+Instructions+SWG

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**The ToC Use Case and Requirements Workgroup has completed its activities, and is no longer meeting on a regular basis. To view work completed as part of the Discharge Instructions Sub-Workgroup, please reference the material below:**

**Purpose and Goals:**
To evaluate how and if discharge instructions requirements can be incorporated into the current use case without threatening available time and resources and make recommendations to the full WG.

**Meeting Summaries:**

 * **Meeting Date** || **Meeting Summary** || **Date Posted** ||
 * 03/10/11 || [|Meeting Summary] || 03/11/11 ||
 * 03/17/11 || [|Meeting Summary] || 03/18/11 ||

**Participants:**

 * **Name** || **Role** ||
 * Amy Berk || Support Lead ||
 * Ed Larsen || Support Lead ||
 * Greg Smith || Participant ||
 * Teresa Mota || Participant ||
 * Audrey Dickerson || Participant ||
 * Dalana Ostlie || Participant ||
 * Greg Alexander || Participant ||
 * Cyndalynn Tilley || Participant ||
 * Kimberly Tooles || Participant ||
 * Lola McCune || Participant ||
 * Larry Sampson || Participant ||
 * Susan Campbell || Participant ||
 * Jim Hansen || Particpant ||


 * Add attachments related to the Discharge Instructions Sub-Workgroup below!**


 * **Name** || **Size** || **Creator** || **Creation Date** || **Comment** ||
 * [|DischargeInstructions_RIContinuityofCareForm_TMM.pdf] || 318 kB || Teresa M. Mota || Mar 22, 2011 13:55 ||  ||
 * [|ONC_ToC_Discharge Summary Sub-WG Meeting_03-17-11.docx] || 35 kB || Smriti Singal || Mar 18, 2011 15:46 ||  ||
 * [|Onyx_Discharge_Summary-Instructions.jpg] || 78 kB || Gregory L. Smith || Mar 18, 2011 13:01 ||  ||
 * [|Sample Home Care Services Instructions.docx] || 15 kB || Gregory L. Smith || Mar 17, 2011 16:37 ||  ||
 * [|IHE_PCC_Query_for_Existing_Data_QED_Supplement_TI_2008-08-22.pdf] || 1.30 MB || Gregory L. Smith || Mar 17, 2011 09:20 || IHE Plan of Care ||
 * [|HITSP_V0.0.1_2010_C162_-_Plan_of_Care-B1-D.pdf] || 140 kB || Gregory L. Smith || Mar 17, 2011 09:20 || HITSP Plan of Care ||
 * [|HITSP_V1.0_2010_C154_-_Data_Dictionary.pdf] || 1.46 MB || Gregory L. Smith || Mar 17, 2011 08:15 || HITSP v.1 Data Dictionary ||
 * [|Careplan2_IntermountainHealthCare.pdf] || 19 kB || Gregory L. Smith || Mar 16, 2011 15:39 ||  ||
 * [|CarePlan_IntermountainHealthCare.pdf] || 110 kB || Gregory L. Smith || Mar 16, 2011 15:39 ||  ||
 * [|TransferPatient_IntermountainHealthCare.pdf] || 32 kB || Gregory L. Smith || Mar 16, 2011 15:38 ||  ||
 * [|PedDischargeForm_IntermountainHealthCare.pdf] || 50 kB || Gregory L. Smith || Mar 16, 2011 15:37 ||  ||
 * [|OBDI_IntermountainHealthCare.pdf] || 46 kB || Gregory L. Smith || Mar 16, 2011 15:37 ||  ||
 * [|NewbornDI_IntermountainHealthCare.pdf] || 30 kB || Gregory L. Smith || Mar 16, 2011 15:37 ||  ||
 * [|MotherBabyDI_IntermountainHealthCare.pdf] || 133 kB || Gregory L. Smith || Mar 16, 2011 15:37 ||  ||
 * [|DischargeSummarySkeleton_IntermountainHealthCare.doc] || 22 kB || Gregory L. Smith || Mar 16, 2011 15:37 ||  ||
 * [|DI_IntermountainHealthCare.pdf] || 27 kB || Gregory L. Smith || Mar 16, 2011 15:37 ||  ||
 * [|CVDI3_IntermountainHealthCare.pdf] || 183 kB || Gregory L. Smith || Mar 16, 2011 15:36 ||  ||
 * [|CVDI2_IntermountainHealthCare.pdf] || 108 kB || Gregory L. Smith || Mar 16, 2011 15:36 ||  ||
 * [|CVDI_IntermountainHealthCare.pdf] || 32 kB || Gregory L. Smith || Mar 16, 2011 15:36 ||  ||
 * [|BehavioralHealthKardex_IntermountainHealthCare.pdf] || 79 kB || Gregory L. Smith || Mar 16, 2011 15:36 ||  ||
 * [|BehavioralHealthDI_IntermountainHealthCare.pdf] || 351 kB || Gregory L. Smith || Mar 16, 2011 14:58 ||  ||
 * [|DischargeInstructions_Deaconess_Medical_Center.doc] || 32 kB || Gregory L. Smith || Mar 16, 2011 08:01 ||  ||
 * [|DischargeInstructions.docx] || 25 kB || Gregory L. Smith || Mar 11, 2011 10:47 || Draft of Discharge Instruction Sub Workgroup Content ||
 * [|ONC_UCR_Discharge Summary Sub-WG meeting 03-10-11_Final.docx] || 32 kB || Amy Berk || Mar 11, 2011 08:00 ||  ||

1.0 Discharge Instruction in Meaningful Use Source: DEPARTMENT OF HEALTH AND HUMAN SERVICES. Office of the National Coordinator for Health Information Technology. Health Information Technology; HIT Policy Committee: Request for Comment Regarding the Stage 2 Definition of Meaningful Use of Electronic Health Records (EHRs)
 * ===**MU**=== || ===**Engage Patients and Families in Their Care**=== ||  ||   ||
 * ====**Stage 1 Final Rule**==== || ====**Proposed Stage 2**==== || ====**Proposed Stage 3**==== || ====**Comments**==== ||
 * Provide electronic copy of discharge instructions (EH) at discharge (50%) || Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 80% of patients (patients may elect to receive a printed copy of the instructions) || Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 90% of patients in the common primary languages (patients may elect to receive a printed copy of the instructions) || Electronic discharge instructions may include items like a statement of the patient’s condition, discharge medications, activities and diet, follow-up appointments, pending tests that require follow up, referrals, scheduled tests ||
 * (NEW for EH) || 80% of patients offered the ability to view and download via the EHR’s secure portal or the private and secure service of a business associate, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in a uniformly human readable form (HITSC to define; e.g., use of PDF or text). || 80% of patients offered the ability to view and download via the EHR’s secure portal or the private and secure service of a business associate, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in a uniformly human readable form (HITSC to define; e.g., use of CCD or CCR). || "Uniformly" implies HITSC should pick a single standard for human readable and a single standard for structured. Inpatient summaries include: hospitalization admit and discharge date and location; reason for hospitalization; providers; problem list; medication lists; medication allergies; procedures; immunizations; vital signs at discharge; diagnostic test results (when available); discharge instructions; care transitions summary and plan; discharge summary (when available); gender, race, ethnicity, date of birth; preferred language; advance directives; smoking status ||
 * ===**MU**=== || ===**Improve Care Coordination**=== ||  ||   ||
 * ====**Stage 1 Final Rule**==== || ====**Proposed Stage 2**==== || ====**Proposed Stage 3**==== || ====**Comments**==== ||
 * (NEW) || List of care team members (including PCP) available for 10% of patients in EHR || List of care team members (including the PCP) available for 50% of patients via electronic exchange ||  ||
 * (NEW) || Record a longitudinal care plan for 20% of patients with high priority health conditions || Longitudinal care plan available for electronic exchange for 50% of patients with high-priority health conditions || What elements should be included in a longitudinal care plan including: care team members; diagnoses; medications; allergies; goals of care; other elements? ||

**2.0 Comparison of Discharge Instruction to Discharge Summary**
As alluded to in the draft Meaningful Use requirements there is a distinction between discharge instructions and discharge summaries. The following table attempts to highlight the difference.
 * ====**Basis for Comparison**==== || ====**Discharge Instruction**==== || ====**Discharge Summary**==== ||
 * **Care Perspective** || Prospective || Retrospective ||
 * **Prepared By** || Informed by the team in the inpatient setting and may be implemented by nursing. Nurses do the instruction and education. Is multi-disciplinary (physical therapy, social work, etc.) on a campus || Physician ||
 * **General Content** || Evidenced based d/c instructions may be different that what is in the discharge summary || May be ad hoc writing and may not even include discharge instructions ||
 * **Frequency** || Each patient should receive. One time for an acute stay. Typically more patient centric. || Physician comments may not always be provided. Must be provided to the next provider. More provider centric. ||
 * **Sections/Categories of Data**
 * **Data Fields** || CCD/83 Plan of Care (What patient can do): Forward looking sections (Treatment Plan), prescribed medications (what, when, dosage), treatments, diet, activities, alerts for conditions, future visits (may include several depending on condition) including appointment established. Patient education and information on medication (tied to alerts), disease process, wound care, condition based special considerations, etc. Goals are typically disease specific. || Backward looking data such as admitted diagnosis, medications administered, procedures done, problem list, lab test, imaging tests, medications (admit and at discharge), basic in the instruction (practice not ideal) area such as follow up steps (general in nature), etc. ||

**3.0 Comparison of Discharge Instruction to Care Plan**
There appear to be similarities between discharge instructions and care plans. The following table describes the key characteristics of discharge instructions from care plans. Comprehensive document that is ongoing and updated to reflect current progress of patient. || Included will be goals of the care plan. Disease process that recognizes goals along the way in the process. Disease state may relate back to a discharge instruction which indentifies the disease at some point and then the care plan identifies the process towards management/improvement. ||
 * ====**Basis for Comparison**==== || ====**Discharge Instruction**==== || ====**Care Plan**==== ||
 * **Care Perspective** || Prospective || Prospective ||
 * **Prepared By** || Informed by the team in the inpatient setting and may be implemented by nursing. Nurses do the instruction and education. Is multi-disciplinary (physical therapy, social work, etc.) on a campus. || Inter-disciplinary team. ||
 * **General Content** || Evidenced based d/c instructions may be different that what is in the discharge summary || Patient centered medical home driven. Evidence based. Could be focused on preventative in nature. ||
 * **Frequency** || Each patient should receive. One time for an acute stay. Typically more patient centric. || Patient centric. Not necessary for every patient. A care plan is typically used for patients with complex clinical needs; becomes necessary in unique ways for unique patients (most likely to see cost savings; b/c multiple owners of the care being delivered; a multi-disciplinary approach). Sample triggers:
 * Nature of the illness (e.g. disease specific CM programs such as oncology)
 * Severity of illness
 * Frequency of hospitalization
 * Length of hospitalization(s)
 * The patient’s recognized or expressed need for assistance with other services (e.g. housing, transportation)
 * **Measurement of goals** || Adherence. Not as complex as measuring goals in care plan. || Complex measurement of goals. Tied to an intervention. Before and after comparison is targeted. Adjust based on progress between before and after measurement. ||
 * **Sections/Categories of Data**
 * **Data Fields** || CCD/83 Plan of Care (What patient can do): Forward looking sections (Treatment Plan), prescribed medications (what, when, dosage), treatments, diet, activities, alerts for conditions, future visits (may include several depending on condition) including appointment established. Patient education and information on medication (tied to alerts), disease process, wound care, condition based special considerations, etc. Goals are typically disease specific. || CCD/83 Plan of Care (What patient can do): Forward looking sections (Treatment Plan), prescribed medications, treatments, diet.

**4.0 Discharge Instruction Form: Including Sources and Types of Discharge Instruction Examples Leading Design**
Initially the Sub Workgroup relied on the clinical experience of the members to identify the data relevant in discharge instructions. As time permitted the goal was to gather further information relying on other efforts.
 * The HL7 and IHE care planning work is moving forward in the Patient Care TC in HL7 with 2 co-chairs for this topic. Laura H Langfor Laura.Heermann@imail.org and Andre Boudreau a.boudreau@boroan.ca. the group has been meeting for several weeks and is moving forward quickly. I can check with either to see when/if a presentation on the current work can be done.
 * The Object Management Group meeting is the week of 3/20/11 in Crystal City, VA. If you like, I can approach their leadership to see if they could help me reach out to participating vendors for what (like their organization) is, effectively, an “open-source” project.
 * Vendors like McKesson should be participants as they have been in this market for many years. I think virtually all the major HIT vendors participate in OMG, a Standards Development Organization (SDO).
 * OMG takes the BPM/SOA approach to E.H.R and is "open source." I will also ask HL7 experts at Deloitte whether CM, DM modules already exist there. OMB and HL7 have established a collaborative relationship.

Several example discharge instructions were reviewed and considered as the workgroup detailed the impact of discharge instructions. Efforts of other standards defining groups were also considered. The following table lists the examples that were used by the workgroup to inform their efforts.
 * ====**Organization**==== || ====**Diagnostic Relative to Discharge Instruction (See uploaded files)**==== || ====**Notes**==== ||
 * **Deaconess Medical Center** || General physician ordered discharge and nursing discharge instructions. || None. ||
 * **Intermountain HealthCare** || Behavioral Health Discharge Instruction || None ||
 * **Intermountain HealthCare** || Behavioral Health Kardex || None ||
 * **Intermountain HealthCare** || Care plan including discharge instructions || None ||
 * **Intermountain HealthCare** || Care plan (internal) Kardex || None ||
 * **Intermountain HealthCare** || Cardiovascular Discharge Instructions (sample 1) || None ||
 * **Intermountain HealthCare** || Cardiovascular Discharge Instructions (sample 2) || None ||
 * **Intermountain HealthCare** || Cardiovascular Discharge Instructions (sample 3) || None ||
 * **Intermountain HealthCare** || General Discharge Instructions || None ||
 * **Intermountain HealthCare** || Skeleton Discharge Summary and Instructions || None ||
 * **Intermountain HealthCare** || Mother/Baby Discharge Instructions || None ||
 * **Intermountain HealthCare** || Newborn Discharge Information || None ||
 * **Intermountain HealthCare** || Obstetrical Discharge Instructions || None ||
 * **Intermountain HealthCare** || Interdisciplinary Discharge Instructions (PedDischargeForm) || None ||
 * **Intermountain HealthCare** || Transfer of Patient || None ||
 * **Onyx Home Health Care, LLC.** || Home Care Services || None ||

**5.0 User Story for Discharge Instructions**
Discharge instructions are an important communication to other providers and the patient (along with caregivers) regarding the care to be completed following an acute episode of care. The following user story identifies the data sharing to be facilitated by discharge instructions.


 * Terminology**
 * **Term** || **Definition** ||
 * Clinician || Licensed individual, such as MD, RN, etc. ||


 * Triggering Actors and/or Events:**
 * Physician writing a discharge order.


 * Who contributes to Discharge Instructions.**
 * Hospital discharge planning clinician identifies the need: conveys information to receiving facility, patient/caregiver/homecare (VNA), and/or primary care practice. Practices may vary by institution.
 * Specialty Case Managers may be affiliated with disease states such as AIDS.
 * Hospitalist
 * Clinical trials staff


 * Perspective:** 87 year old male with chronic COPD and diabetes admitted for a broken leg suffered in a fall.


 * User Story:** //See User Story developed by User Story Sub Workgroup on discharge.//


 * Actors**
 * **Actor** || **Details** ||
 * Addressees || The patient PHR and PCP and other Team member systems ||
 * Source || Hospital and ED Clinical System ||
 * Destination || The Nurse Case Manager, PCP and Team Clinical System ||
 * Destination || The patient's PHR ||

For details see 6.0 Consolidated CCD sections and data fields. Generally, the transmitted data in this case can and will vary, but some example cases are provided below:
 * Data Exchanged (This section is non-normative)**
 * 1) To providers at PCP, PCMH or ACO instructions that supplement the discharge summary.
 * 2) To patients instructions that identify treatments and patient education.
 * 3) Consist of the text document with an attached summary of care (CCD or CCR).
 * 4) The ideally structured case will consist of an IFR-compliant summary of care document (such as a C32 CCD or a CCR).
 * 5) Optional attachments ....

Message always includes //standard// minimal data set:
 * Message Contents: Both minimal standard data set and Discharge context relevant data set**
 * Demographic information, active //reconciled// medication list (with doses and sig), allergy list, problem list, reason for admission, follow up/discharge instructions (e.g., CCD/83 Plan of Care (What patient can do): Forward looking sections (Treatment Plan), prescribed medications (what, when, dosage), treatments, diet, activities, alerts for conditions, future visits (may include several depending on condition) including appointment established. Patient education and information on medication (tied to alerts), disease process, wound care, condition based special considerations, etc.) etc.

Message contains //variable data set relevant to the hospitalization (selected by the clinician who prepared the discharge message)//:
 * Examples:
 * Procedures during hospitalization
 * Relevant results, reports
 * Wound care (if applicable)
 * Etc.

A patient is being discharged from the hospital or ED). At the time of patient discharge, the discharge message has been prepared within the Hospital EHR by one of the patient’s treating clinicians; who actually does this will depend on the hospital’s workflow. It might be the resident, a hospitalist, an advanced practice nurse or the attending physician of record. Once the discharge message is prepared if it has not been prepared by the attending physician of record, it will be forwarded to the attending physician of record’s (APoR) EHR Task List. The APoR will review the discharge message and address the message to the PCP (some EHRs have automated addressing to the PCP capability, based on the PCP data stored in the EHR) and send the message to the PCP via secure, direct HIE messaging and/or Direct Messaging. The message arrives in the PCP’s EHR (or Direct Messaging account) before the patient has left the hospital. A copy of the message is retained in the hospital EHR per the hospital’s policies and workflow rules.
 * Setting 1: Hospital or ED from where patient is discharged (sends discharge instructions to setting 2 and 3).**

The discharge message can also be addressed and sent to the patient’s PHR via secure, direct HIE messaging and/or Direct Messaging.

Direct HISP or HIE retains message transfer log per the governing Service Level Agreement.

Message received into PCP practices’ EHR (or Direct Messaging account). Patient generally will be known in the EHR system in which case an automated EHR match may occur, patient without an automated match can be reconciled, new patients can be registered in the EHR (in the event that the patient had no PCP at admission but then had one assigned or selected one prior to discharge). If the message is received into the EHR, additional practice variable activities may occur: patient’s message can be directed to a front desk staff EHR Work Queue, as well as to additional staff EHR work queues as appropriate to the practice workflows. How discharge instructions are handled is dependent on the specific PCP workflow already established. For example, the front desk staff may schedule a follow up visit with the patient and add the hospital discharge message to the PCP’s document task list. If the patient has an assigned Care Manager at an advanced practice care facility (such as a Patient-Centered Medical Home), the hospital discharge message may be directed to both the PCP and the Care Manager after the front office staff has scheduled a follow up visit. The care Manager may be aware that the patient becomes confused when medications are altered and call the patient to ensure the patient is taking the correct medications post discharge, and is following the discharge instructions.
 * Setting 2: PCP office, PCMH coordination for patient, or Accountable Care Organization member coordinator.**

Discrete data elements from within the message can be promoted to the PCP’s EHR system date, time and source stamped; eliminating the need for data transcription with its’ inherent error risk. The PCP can review and promote to the EHR the new reconciled active medication and problem lists, any new procedures can be accepted into the EHR, as well as any other new discrete data elements. The hospital (or ED) discharge message can be retained in its entirety as a permanent part of the patient’s EHR record.

The patient comes for the encounter with the PCP and the PCP documents the encounter in the EHR.

Message received into Patient’s PHR via secure, direct HIE messaging and/or Direct Messaging. Depending on the specific PHR, patient may receive a notification to access their PHR as there is new information available. Patient (or patient’s authorized proxy) can access the PHR and review the hospital discharge message. Again, depending on the PHR’s functionality the patient may be able to select sections with of the discharge message (that are discrete data elements) to automatically populate the appropriate fields in the PHR. For example, the new reconciled medication list can be selected to upload to the active medication list section of the PHR and the patient can upload any new problems to the problem list. Some PHR’s may have “all or none” functionality allowing the patient to simply determine if they would like to retain to the PHR or delete from the PHR the discharge message.
 * Setting 3: Patient**

**6.0 Consolidated CCD Sections and Data Fields for Discharge Instructions**
Generally, discharge instructions share data that CCD/83 Plan of Care (What patient can do): Forward looking sections (Treatment Plan), prescribed medications (what, when, dosage), treatments, diet, activities, alerts for conditions, future visits (may include several depending on condition) including appointment established. Patient education and information on medication (tied to alerts), disease process, wound care, condition based special considerations, etc. Goals are typically disease specific.

The first table below indicates whether the data shared is part of the discharge summary or the discharge instruction (the focus of this Sub Workgroup). The second table below provides specific detail about discharge instructions and the data directed towards the two target destinations: providers (PCP, PCMH or ACO) and patients (caregivers). The source for listed sections was "HITSP Plan of Care Component" and "IHE Patient Care Coordination (PCC) Technical Framework Supplement 2008-2009". Data fields were drawn from the sample discharge instructions provided by Sub Workgroup members and "HITSP Data Dictionary Component".

The "HITSP Plan of Care Component" is an individualized, mutually agreed upon plan. The plan includes problem issues (nursing diagnoses), expected healthcare outcomes, implementable interventions, and evaluation of progress toward outcomes based on follow-up assessments. It is a framework to document critical thinking necessary for excellent evidenced-based outcomes.

**6.1 Discharge Summary vs. Discharge Instructions**
The detail makeup of the data within a Discharge Summary is not the focus of the Discharge Instruction Sub Workgroup. Therefore, the following table is intended to define the scope of interest for the transition of care that occurs as a result of discharge. The sections of data included in the Discharge Instruction column marked with a "Y" are described in more detail in the next section.

SHOULD be present when there is relevant family history || Y || N || SHOULD be present when any assessments of functional status are performed on the patient || Y || Y || SHALL be present when there is relevant history of past illness || Y || N || SHALL be present when a physical examination is performed during the assessment of the patient || Y || N || SHALL be present when a review of systems is performed during the assessment of the patient || Y || N || SHOULD be present when there is relevant social history || Y || N || SHALL be present when there is relevant surgical history || Y || N ||
 * Table: Data Included in Discharge Summary vs. Discharge Instructions**
 * **Section (R-required, C-conditional, O-optional / Repeatable Yes - No)** || **Discharge Summary** || **Discharge Instruction** ||
 * Active Problems (R/N)/Chief Complaint (overriding problem at the time of discharge) - chronic illness and congenital problems || Y || Y ||
 * Advance Directives - Coded (R/N) || Y || Y ||
 * Adverse Reactions (R/N) || Y || Y ||
 * Allergies (R/N) || Y || Y ||
 * Assessments (R/N) || Y || N ||
 * Plan of Treatment/Treatment Plan/Care Plan (R/N) - Covers the considerations that encompass a range of scopes and/or timeframe (could be a description of a single encounter or across multiple encounters) || Y || Y ||
 * Diagnosis - Hospital Admission (R/N) || Y || N ||
 * Diagnosis - Discharge (R/N) || Y || N ||
 * Diet Restrictions (R/N) || Y || Y ||
 * Family History (O/N)
 * Fluids Management (C/N) || Y || Y ||
 * Functional Status (O/N)
 * History of Present Illness (C/N)
 * Immunizations (C/N) || Y || Y ||
 * Medical Devices (C/N) || Y || Y ||
 * Medications (C/N) || Y || Y ||
 * Physical Examination (C/N)
 * Procedures and Interventions (C/N) || Y || Y ||
 * Provider Orders (R/N) || N || N ||
 * Results - Coded (R/N) || Y || Y ||
 * Review of Systems (C/N)
 * Social History (O/N)
 * Surgeries - Coded List (C/N)
 * Vital Signs (R/N) including Pain Scale Assessment, Smoking Status || Y || Y ||
 * Person Demographics/Information (R/N) || Y || N ||

**6.2 Discharge Instructions**
Data included in Discharge Instructions and the data fields are shown in the following table.

Updated PHR ||  || Restrictions: Restrictions: SHOULD be present when any assessments of functional status are performed on the patient || Y || Baseline, current and desired: End of discharge instructions.
 * Table: Data fields Included in Discharge Instructions**
 * **Section (R-required, C-conditional, O-optional / Repeatable Yes - No)** || **Discharge Instruction** || **Anticipated Content in Discharge Instructions** || **Significant Difference in Content for NCM, PCP, PCMH, ACO vs. Patient/Caregiver** ||
 * Active Problems (R/N)/Chief Complaint (overriding problem at the time of discharge) - chronic illness and congenital problems || Y || * List of problems/complaints (what was diagnosis, complaint and/or descriptor of problem/complaints, symptoms).
 * How do these problems/complaints impact interventions, orders or instructions.
 * Patient's perception or description of problems/complaints. ||  ||
 * Education ||  || Patient education provided or needed. To included classes, educational sessions, printed materials. ||   ||
 * Electronic Links ||  || How to get to future results, summaries, etc.
 * Facility Checklist ||  || List of facility dependent items (e.g., pain scale at discharge, last ECG, etc.) ||   ||
 * Advance Directives - Coded (R/N) || Y || * Yes/No
 * Yes/No if POLST form returned
 * Where is last known version/original is located
 * Going forward how the "state" and how it affects care ||  ||
 * Adverse Reactions (R/N) || Y || * Yes/No/Unknown, and if Yes or Unknown how does it affect care.
 * Other history that guide care.
 * Patient supplied information about reaction. ||  ||
 * Allergies (R/N) || Y || List of allegries which might include allergy to what (e.g., medication. food, environment) ||  ||
 * Plan of Treatment/Treatment Plan/Care Plan (R/N) - Covers the considerations that encompass a range of scopes and/or timeframe (could be a description of a single encounter or across multiple encounters) || Y || * Goals.
 * Active interventions and orders (short term direct instructions - in the long run as validated by the patient and those contributed by the patient/caregiver).
 * Yes/No - has the discharge instruction been reviewed with the patient.
 * Yes/No - has the discharge instruction been accepted by the patient, if no then how addressed. ||  ||
 * Diet/Diet Restrictions (R/N) || Y || Diet:
 * All instructions that describe the expected diet.
 * List of limitations being placed on the diet. ||  ||
 * Fluids Management (C/N) || Y || Fluids:
 * All instructions that describe the expected fluids and method of administration.
 * List of limitations being placed on fluids ||  ||
 * Functional Status (O/N) - Might be Smoking
 * Functional status
 * End state/goal expressed/Projected change in functional status (will relate to the goals identified) ||  ||
 * Immunizations (C/N) || Y || Comprehensive list of immunizations (have - patient reported, got, need):
 * list of immunizations necessary to get after discharge.
 * list of education or information about immunizations they received while hospitalization. ||  ||
 * Medical Devices (C/N) - includes assistive devices and is related to functional status. || Y || * List of devices and where the device is to be secured/prescribed/embedded.
 * Duration of medical devices.
 * History of devices for this patient. ||  ||
 * Medications (C/N) || Y || * list of prescribed medications or other medications.
 * If to be reconciled then list needs to be inclusive of self administered medications (herbals, over the counter)
 * See notes on medication reconciliation regarding expectations such as discontinued medications from inpatient if not included in discharge summary ||  ||
 * Procedures and Interventions (C/N) || Y || Scheduled procedures and interventions, such as labs, etc. (procedure/intervention, schedule, etc.) ||  ||
 * Results - Coded (R/N) || Y || Corresponding results to the scheduled procedures and interventions. ||  ||
 * Vital Signs (R/N) including Pain Scale Assessment, Smoking Status || Y || Instructions regarding the capture of vital signs at points along the care plan and any special instructions regarding how to capture ||  ||

**6.3 Recommendations for Coordination with Other Groups**
Must be determined at the next step
 * Whether an item is mandatory, conditional or optional will be determined during the harmonization process by the Harmonization Workgroup.
 * The Discharge Instruction Sub Workgroup defined data fields that met the need to facilitate and effect a successful transition of care following a hospitalization. While the Sub Workgroup is unaware of any sections of of data or data fields that have been added or changed from existing standards, the Sub Workgroup encourages the Harmonization Workgroup to modify standards if necessary and to consult with other groups listed below who have also considered this question.

The following efforts/groups are also considering the activity described in this Sub Workgroup. The Sub Workgroup recommends that a more detailed inspection occur by the Harmonization workgroup.
 * The HL7 and IHE care planning work is moving forward in the Patient Care TC in HL7 with 2 co-chairs for this topic. Laura H Langford Laura.Heermann@imail.org and Andre Boudreau a.boudreau@boroan.ca. the group has been meeting for several weeks and is moving forward quickly. I can check with either to see when/if a presentation on the current work can be done.
 * Case Management Society of America that has a meeting in early June.
 * Static views envisioned by those defining the role/requirements of Health Trusts
 * Patient centered medical home groups that maybe defining standards and any expectations ACO regulations,
 * Others

Finished.

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