Priority 1
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Required/Urgent/Now/Current-next version
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Priority 2
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Highly desired/Future priority/1–2 y/Subsequent version
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Priority 3
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Advanced/Future development
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Transitions of care
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Feature/Function
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Recommendation
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Rationale
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Priority
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Outbound message functions
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TO1:
Real-time message delivery
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Direct interoperability messages are sent in “real time” and are never “batched” for timed sends
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The sending of messages in real time, following a patient's transition of care, supports end users' ability to utilize information for patient care immediately. Clinicians, who have successfully used Direct, report that receiving the Direct message in “real-time” as opposed to batch processes allows the receiver to initiate appropriate patient outreach and follow up immediately preventing patient adverse events. It also allows patient care and transitional care management to be provided more efficiently
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1
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TO2:
Direct messages automatically triggered by specific events
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HIT systems can automatically send Direct messages based on specific triggers (e.g., discharge or referral orders)
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Automated real-time sending of Direct messages ensures that the patient's treating clinicians are aware of care transitions and are provided with the most current and up to date information. Timely receipt of messages facilitates information reconciliation in the recipient systems, helps to prevent unnecessary duplicate testing, and reduces adverse events. For example, an acute care system can be configured so that when a patient discharge order is entered this triggers the automated sending of a Consolidated Clinical Document Architecture (C-CDA) document, or a template of combined C-CDA document sections to the patient's Primary Care Provider (PCP) and/or ambulatory provider of record in the system, if a Direct address is available for that clinician. The ambulatory systems can be configured to send a Direct Message to a specialist triggered by a PCP's referral order. Similarly, consultants' EHR systems can be configured to send a Direct Message to the referring provider prompted by a referred patient being seen and/or the completion of the consultation note
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1
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TO3:
Automatically send Direct message(s) to provider(s) of record with Direct addresses in the sending system
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Once a triggering event occurs, the sending system is able to automatically send a message to:
– the PCP of record
– the referring physician
– all providers identified as members of the patient's care
team, and/or
– another identified provider, given that the(se) provider(s) have Direct Addresses
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This recommendation ensures continuity of care with the identified members of the patient's care team and prevents the blocking of information flow to the patient's providers across organizational boundaries
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1
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TO4:
Include patient-specific
attachments
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The sending facility is able to configure a Direct “template” (see also TO7) that includes automatically attached document types and/or sections from the sending HIT system based on the specific clinical scenario. Attachments can include structured data (e.g., C-CDA, or a template with a combination of C-CDA document types or sections, spreadsheets); unstructured data (e.g., Word, PDF, or plain text files) and image files (e.g., JPG and GIF). In addition, providers can attach documents “on the fly” as needed
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Direct has been demonstrated to provide a critical capability for information sharing in support of patient care, which essentially virtualizes the EHR across disparate HIT systems and health care organizations to support care team access to critical patient information. Direct messages should support the inclusion of all clinically relevant document types in support of best practice and efficient care as patients transition across their medical neighborhoods. The inclusion of a variety of document types also prevents duplicate testing or gaps in clinical information required for patient care
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1
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TO5:
Use HIT industry-wide standardized discrete data terminology for problem, medication, allergy, immunization data in Direct documents
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Vendors use all existing recognized standard vocabularies to promote information sharing across all HIT systems and the ability of the recipient system to readily consume and reconcile discrete information
Data reconciliation by the sending provider preceding and by the recipient provider following all care transitions should include all data for which there are discrete vocabularies including active problems, allergies, medications, and historical immunizations (PAMI data)
Specific vocabularies (e.g., SNOMED, ICD10, RxNorm, and CVX) should be used to encode discrete PAMI data as applicable in all C-CDA and other documents sent via Direct
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Direct interoperability supports the sharing of patient data using standardized data vocabularies across all EHR vendors. Standardized use and transmission of discrete data would allow for exceptional end user functionality creating care and documentation efficiencies and preventing life-threatening transcription errors. These efficiencies would further promote the desirability and use of Direct messaging and facilitate medical information reconciliation across the patient's care team. Exchange of discrete data via Direct, with appropriate pre- and posttransition of care clinician data reconciliation, can save clinicians documentation time and prevent potentially life-threatening transcription errors and patient adverse events
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1
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TO6:
Automated outgoing messages include the “trigger” for sending the message in the message metadata
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Automatic outgoing messages' metadata include the “trigger” for sending the automated message (e.g., hospital discharge or specialty referral)
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Including information regarding the message trigger in the metadata sent with a Direct message allows the recipient systems to automatically or manually route and/or prioritize messages for specific organizational role-based workflows
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2
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TO7:
Ability to customize C-CDA templates
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Sending organization are able to configure templates for specific clinical circumstances such as discharge, referral, specific conditions/diagnoses, or encounter types. Templates are configurable at the provider or organization level
Templates can be a single or a combination of C-CDA document types or C-CDA document type sections Examples include:
• A “Discharge Template” could be configured to include a brief clinical summary, a reconciled discharge problem list, medications, allergies, immunizations, procedures, first and last instance of any laboratory or test results, imaging studies, operative notes, vital signs, discharge instructions, etc.
• A “Cardiology Referral Template” could be configured to include the patient's last clinic note, specific laboratories and studies relevant to cardiology, the patient's active problems, medications, allergies, immunizations, family, medical, surgical, and social histories, urgency of request, and request for a specific cardiologist
Templates could be configured either at the provider or organization level. With the organization having the ability to determine the level (e.g., only allowing templates to be configured at the organizational level to support organizational standardization). Appropriate templates could be generated automatically based the message trigger event (e.g., Cardiology referral or discharge order) the system will automatically assemble the appropriate template.
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Template customization allows the organization to preconfigure Direct messages to include the appropriate information for the next provider caring for the patient. As a result, messages will include the right information and the right amount of information and will save the sending clinician time by avoiding the need to collate information manually for every outgoing Direct message. Having the right amount and most current patient information may also cause the recipient to attribute greater value to incoming messages preventing information overload and inaccuracies resulting from outdated information
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2
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TO8:
System alert if automated message cannot be sent when the send trigger is invoked
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The system can issue an alert if the sending of an automated message fails. For example, a discharge order may trigger an automated discharge message, but the sending of the message fails because the system lacks a PCP of record or the PCP of record does not have a Direct address. In this case, the system will alert the provider, or his or her delegate, whose action (e.g., discharge order) precipitated the trigger event
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This system alert will ensure that the failure of a Direct message to leave the initiating system will result in an alert to the clinician, or his or her designee, who can then initiate an alternative information sharing process (e.g., fax, postal mail, telephone call, etc.) As health care providers and organizations implement new automated electronic messaging systems, older communications processes may be left in place leading to redundant communication via multiple channels with resultant information overload and decreased attention to information received. The ability to know when an automated Direct message cannot be sent supports the decommissioning of alternate automated messaging, such as faxing/mailing result reports or discharge summaries, allowing these methodologies to be used only in circumstances where a Direct message cannot be sent
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2
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TO9:
Use HIT industry-wide standardized discrete data terminology for additional data types including procedures and laboratory results
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Vendors will use recognized standardized vocabularies to exchange discrete data beyond PAMI data types (e.g., LOINC codes for laboratory results and CPT codes for procedures) to allow information sharing, consumption, and reconciliation across HIT systems
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This recommendation promotes the exchange and recipient system consumption of discrete patient data in support of data reconciliation, care efficiency, population health management, and reduces medical errors and duplicate testing
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2
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TO10:
Automatically send Direct message to the patient
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According to the health care organization's protocols and policies and the patient's wishes, the system may automatically send relevant Direct messages to the patient if the patient has a Direct address
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This recommendation allows patients to receive their health information without the need to visit multiple health care organization linked portals
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3
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TO11:
Medical societies shall create condition-specific templates for referrals
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We recommend that specialty-specific medical societies create and share with the health care community diagnosis and condition-specific templates that include the clinical information and data elements such as tests and study results to be sent when a patient is being referred to a specialist, or health care facility with that specific diagnosis or condition
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Diagnosis/condition-specific templates specified and supported by medical societies will assure that specialists receive the appropriate information from referring providers in a standardized fashion and will prevent information overload by recipient clinicians, improving the efficiency of care transitions and coordination
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3
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Inbound message functions
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TI1:
Receive, store and display message attachments in the recipient HIT system
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In addition to the C-CDA, or a template of combined C-CDA documents and/or document sections, HIT systems support receipt, storage, and display of a wide variety of attachment types including:
• structured data (e.g., C-CDA, spreadsheets)
• unstructured data (e.g., Word, PDF)
• plain text files
• image files (e.g., JPG and GIF)
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Medical information exists in a variety of formats (e.g., structured data, unstructured data, images, and PDF files). To support efficient care, avoid duplication of tests and procedures, and reduce information gaps, Direct messages should allow the inclusion of all clinically relevant document types to support the transition of patients across their medical neighborhoods. This recommendation discourages vendors from removing valuable information by stripping attachments from messages
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1
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TI2:
Automated patient identification
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All HIT systems automatically match incoming Direct messages with existing patients in the recipient system. Without a unique patient identifier, systems use their existing patient matching algorithms. For new patients or patients, who cannot be automatically matched (e.g., new referral to a specialist, or patient demographic information that could match to more than one existing patient record); the receiving system will route the message to a work queue for patient registration and/or manual matching. Incoming data for matched patients will be stored and available to the designated recipient and his or her delegate(s)
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Lack of an automated patient identification/matching service degrades Direct interoperability to the level of an EHR integrated fax server. Manual patient matching delays Direct messages from reaching the appropriate user, putting patients at increased risk for adverse events in the context of care transitions
Depending on HIT functionality, staffing models and volume of Direct messages, delays from manual matching may exceed 24 hours, putting patients at risk for adverse events. Patient matching must be automated to prevent impeding data flowing to the intended recipients, to support information sharing for patient care, and to reduce the risk of life-threatening complications including adverse drug events
As Direct is adopted for all transitions of care (TOC) and clinical messaging, the anticipated volume of incoming messages would require additional staff resources if incoming message patient matching were conducted manually
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1
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TI3:
Reconciliation of active medications
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The system supports the reconciliation of active medications Following any patient care transition, the C-CDA or a template with a combination of C-CDA document types or sections includes a list of active medications:
• For new patients, the recipient, or his or her delegate(s), can use the medication list to integrate all medications and associated administration instructions (Sigs) into the receiving system as discrete, actionable data
• For established patients, the recipient, or his or her delegate(s), can directly review and compare the received medication list and sig with the medication list and sig in his/her native HIT system. The provider can then use his/her judgment to perform medication reconciliation by: discontinuing medications, adding medications, or changing the dose of medications in his/her system based on medication changes made by the sending provider. As the receiving user accepts new medications information from a received C-CDA document into the receiving system, the medication information is transferred as discrete data with the sig
• Medications that the provider sees on the C-CDA, but does not want the patient to continue would not be integrated into his or her updated medication list and could trigger a discontinuation discussion with the patient
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Pre- and post-transition of care medication reconciliation using discrete data received via Direct can ensure that recipient clinicians have the most accurate and current information available for information reconciliation and system data consumption thereby enhancing care efficiency, saving clinicians' time, resulting in reduced errors, saved patient lives, and decreased costs
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1
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TI4:
Reconciliation of active problems
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The system supports the reconciliation of active problems
Following any patient care transition, the provided C-CDA or a template with a combination of C-CDA document types, or sections includes an encoded list (e.g., utilizing ICD10 and/or SNOMED codes) of active medical problems/conditions:
• For new patients, the recipient user, or his or her delegate(s) should be able to integrate this list directly into his/her HIT system as discrete, actionable data
• For established patients, the recipient provider should be able to compare onscreen the problem list in his/her native system and with the problem list received in the C-CDA, allowing the provider to perform problem list reconciliation by discontinuing problems that have been superseded or are inactive or adding new problems to his/her EHR that are warranted
• Problems in the C-CDA that the providers does not considers active would not be transferred to the new list and may generate follow-up discussion with the patient
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Reconciliation of patient problem lists pre- and post-transitions of care using discrete data exchanged via Direct can improve care efficiency and save clinicians time resulting in reduced errors and decreased costs
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1
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TI5:
Reconciliation of allergies
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The system supports the reconciliation of patient allergies
Following any patient care transition, the received C-CDA or a template with a combination of C-CDA document types or sections includes an encoded list of the patient's current/active allergies:
• For new patients, the recipient provider, or his or her delegate(s) should be able to integrate this list directly into his/her HIT system as discrete, actionable data
• For established patients, the recipient provider should be able to compare onscreen the allergies list in his/her local system and the allergies list received in the C-CDA document. The provider can them perform allergy reconciliation
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Reconciliation of patient allergies pre- and post-transition of care using discrete data exchanged via Direct can improve care efficiency and save clinicians time resulting in reduced errors and decreased costs
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1
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TI6:
Reconciliation of immunizations
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The system supports the reconciliation of patient immunization histories
Following any patient care transition, the provided C-CDA or a template with a combination of C-CDA document types or sections includes an encoded list (e.g., utilizing CXV codes) of the patient's current/active immunizations:
• For new patients, the recipient provider, or his or her delegate(s) should be able to integrate this list directly into his/her EHR system as discrete, actionable data
• For established patients, the recipient provider should be able to compare onscreen the immunization list in his/her local EHR and the immunization list received in the C-CDA. The provider can them perform immunization reconciliation
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Reconciliation of patient immunization histories pre- and post-transition of care using discrete data exchanged via Direct can improve care efficiency and save clinicians time resulting in reduced errors and decreased costs
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1
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TI7:
Reconciliation of procedures
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The system supports the reconciliation of patient procedure histories
Following any patient care transition, the provided C-CDA or a template with a combination of C-CDA document types or sections includes an encoded list (e.g., utilizing CPT or SNOMED codes) of the patient's past procedures and operations:
• For new patients, the recipient provider (or his or her delegate) should be able to integrate this list directly into his/her EHR system as discrete, actionable data
• For established patients, the recipient provider should be able to compare onscreen the procedures and operations (CPT Codes) list in his/her local EHR and the procedures and operations (CPT Codes) list received in the C-CDA. The provider can them perform procedure reconciliation
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Reconciliation of patient procedure and surgical histories pre- and post-transition of care using discrete data exchanged via Direct can improve care efficiency and save clinicians time resulting in reduced errors and decreased costs
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2
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TI8:
Reconciliation of test results
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Following any patient care transition, the provided C-CDA, or a template with a combination of C-CDA document types and sections, includes an encoded list of tests or studies performed and their results (e.g., utilizing LOINC codes for laboratory test result components and SNOMED codes for other result values):
• For new and established patients, the recipient user, or his or her delegate(s) should be able to integrate, at their discretion, all or some of these tests and studies directly into his/her HIT system as discrete, actionable data including but not limited to laboratory, radiology, gastroenterology, neurology, cardiovascular, and pulmonary testing. All of the native system functionalities (e.g., being able to compare results, create flow sheets, and utilize graphing functions) shall be applicable to the data received
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Receipt and incorporation of historical laboratory and other test results using discrete data exchanged via Direct can reduce duplicative testing, improve patient safety and care efficiency and save clinicians' time resulting in reduced errors, decreased costs, and improved clinical outcomes.
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2
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TI9:
Other discrete data exchange and reconciliation
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As standardized vocabulary use increases in HIT systems, additional standardized data elements will be included in Direct messages and enabled for reconciliation across systems. Data may include social, family, and medical histories, genomic data, patient-generated health data, patient satisfaction, social determinates of health, medical device data, patient care team members, etc.
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Direct exchange and reconciliation of additional data types using discrete data can reduce duplicative testing, improve patient safety and care efficiency, and save clinicians' time resulting in reduced errors, decreased costs, and improved clinical outcomes
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3
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TI10:
Recipient configuration of the information viewed from the incoming message (C-CDA)
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Recipient systems are able to configure the display of information received with an incoming message Configuration may be specified at the organization or user level
For example, the view of a discharge summary that includes all of the information from a hospitalization (every vital sign, laboratory test and study, input and output, etc.) deemed unnecessary by the recipient provider can be configured so that, for example, only the first and last vital sign and first and last instance of any laboratory test or study are visible. Configurability assures that the information that is displayed is limited to the information that the recipient wants to see and is presented to the user in a consistent manner. The system will also allow the recipient to view the information that was received but not displayed by default (i.e., drill down)
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Allowing users to determine which information is most relevant information and to configure his/her view of the received information facilitates efficient review of critical information for patient care and enhances the adoption of this technology. The ability for the recipient user to drill down to other information, if needed, allows the recipient user to access all information if the preconfigured view does not include information the user requires in a specific instance of care
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3
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TI11:
Recipient system identifies new or revised data
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For existing patients, the recipient system will identify all discrete information in the received document that is new or changed compared with the existing discrete information in the receiving system
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Identifying new or modified data automatically, enables clinicians to focus their attention on relevant new and revised data resulting in more efficient patient care following a patient's care transition. This also facilitates ease of data reconciliation and prevention of duplicate testing and adverse patient events, thereby reducing health care costs
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3
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