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Step 5: Achieve Meaningful Use Stage 1

Transition of Care Summary

Objective:

The eligible professional who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral.

Measure:

The eligible professional who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 percent of transitions of care and referrals.

Clinical Importance

A transition of care summary, also known as a discharge summary in some circumstances, provides essential clinical information for the receiving care team and helps organize final clinical and administrative activities for the transferring care team. This summary helps ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. This document improves transitions and discharges, communication among providers, and cross-setting relationships which can improve care quality and safety.

CMS Resources

The following resource is available to help you meet the Transition of Care Summary meaningful use menu measure:

Related CMS EHR Incentive Program Frequently Asked Questions

National Learning Consortium Resources

The NLC resources are examples of tools that are used in the field today, and that are recommended by “boots-on-the-ground” professionals. The NLC, in partnership with HealthIT.gov, shares this collective EHR implementation knowledge and resources throughout this site.

National Learning Consortium Resources
Resource NameDescriptionSource

Care Delivery Management

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Resources and tools to enhance the management of care delivery, including implementation guides, assessment forms, surveys, and links to other resources.

American Academy of Pediatrics (AAP)

Health Information Technology Toolkit for Physician Offices

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Toolkit that helps healthcare organizations assess their readiness, plan, select, implement, make effective use of, and exchange important information about clients.

Stratis Health

Medical Home - Practice-Based Care Coordination Workbook

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[PDF - 294k] 

Workbook that provides tools needed for a primary care practice to develop their capacity to offer a pediatric care coordination service, particularly for children with special health care needs.

Center for Medical Home Improvement (CMHI)

Transitioning to a New Provider of Care (HIE scenario, workflow, and specifications)

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[DOCX - 1.2 MB]

A series of health information exchange (HIE) scenarios intended to provide a straightforward view into the standards, services and policies behind HIE solutions related to this Meaningful Use Measure.

ONC Office of Science and Technology

Transferring Records Between Providers (HIE scenario, workflow, and specifications)

Download

[DOCX - 1.2 MB]

A series of health information exchange (HIE) scenarios intended to provide a straightforward view into the standards, services and policies behind HIE solutions related to this Meaningful Use Measure.

ONC Office of Science and Technology

Care Transition Summary Toolkit

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[DOCX - 1.6 MB]

Toolkit includes factsheet and checklist to understand how to improve care coordination by using electronic health record (EHR) system for generating summary records at transitions of care and meet the attestation requirements for Meaningful Use (MU)

Health Information Technology Resource Center (HITRC)

The material in these guides and tools represents the collective EHR implementation experiences and knowledge gained directly from the field of ONC’s outreach programs (REC, Beacon, State HIE) and through the Health Information Technology Research Center (HITRC) Communities of Practice (CoPs) in their performance of technical support and EHR implementation assistance to primary care providers. The information contained in these resources is not intended to serve as legal advice nor should it substitute for legal counsel. The resource list is not exhaustive, and readers are encouraged to seek additional detailed technical guidance to supplement the information contained herein.

Reference in this web site to any specific resources, tools, products, process, service, manufacturer, or company does not constitute its endorsement or recommendation by the U.S. Government or the U.S. Department of Health and Human Services.

 

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