ehr onc final certification - Department of Health Care Services

a minimum, the version of the standard specified in
§170.207(a)(2);
(B) Procedures. The standard specified in §170.207(b)(1) or
§170.207(b)(2);
(C) Laboratory test results. At a minimum, the version of the
standard specified in §170.207(c); and
(D) Medications. The standard specified in §170.207(d).
Overall this certification criterion is very similar to the certification criterion
applicable to Complete EHRs and EHR Modules designed for an ambulatory setting. As
a result, our responses and subsequent changes to the certification criterion above are also
applicable to this certification criterion. Below are the comments that are unique to this
certification criterion.
Comment. A few commenters requested clarification on what is meant by the
term “discharge summary.” The commenter stated that neither the CCD nor the CCR has
a document section or module for a “discharge summary.” One commenter suggested
that we either define the term or remove it. At least one commenter suggested that
discharge summary be initially permitted to be an unstructured CDA instead of requiring
the use of a CCD. As an alternative, it was suggested that the CCD combined with the
"Hospital Course" CDA section be allowed to qualify as the discharge summary.
Response. As noted in one of our responses above, we recognize that neither
CCD nor CCR specifically supports the inclusion of discharge summary. In the Medicare
and Medicaid EHR Incentive Program final rule, CMS references discharge summary in
the meaningful use objective as an example of “key clinical information” but further
clarifies within the preamble of that rule that it is up to an eligible professional or eligible
hospital to determine what constitutes key clinical information. In that regard, CMS
notes that we specify the minimum set of information that Certified EHR Technology
must be capable of electronically transmitting. Given our prior statements regarding the
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