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Step 5: Achieve Meaningful Use Stage 2

Summary Of Care

Objective:

The EP 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:

EPs must satisfy both of the following measures in order to meet the objective:

Measure 1:

The EP 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.

Measure 2:

The EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either (a) electronically transmitted using certified EHR technology (CEHRT) to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the NwHIN.

Measure 3:

An EP must satisfy one of the following criteria:

  • Conducts one or more successful electronic exchanges of a summary of care document, as part of which is counted in "measure 2" (for EPs the measure at §495.6(j)(14)(ii)(B) with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology certified to 45 CFR 170.314(b)(2).
  • Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period.

Changes from Meaningful Use Stage 1:

The Summary of Care Objective changed from being a Menu Objective in Stage 1 to a Core Objective in Stage 2.

 Stage 1Stage 2
Objective The EP 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 of care record for each transition of care or referral The EP 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 of care record for each transition of care or referral
Measure The EP 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% of transitions of care and referrals
  1. The EP 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% of transitions of care and referrals
  2. The EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record either a) electronically transmitted to a recipient using CEHRT or b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or is validated through an ONC‑established governance mechanism to facilitate exchange for 10% of transitions and referrals
  3. The EP who transitions or refers their patient to another setting of care or provider of care must either a) conduct one or more successful electronic exchanges of a summary of care record with a recipient using technology that was designed by a different EHR developer than the sender's, or b) conduct one or more successful tests with the CMS-designated test EHR during the EHR reporting period

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 resources are available to help you meet the Summary of Care meaningful use core measure:

CMS EHR Incentive Program Frequently Asked Questions (FAQs)

Lessons from the Field:

We worked collectively with staff and providers to develop internal workflow policies and procedures to ensure smooth transition of care when patients move between our practice and other providers/facilities.” David Gorelick, MD, EHRs Improving Care Coordination with Local Referral Network

Taking a proactive approach to develop internal workflow policies and procedures and using them with technology helps ensure that relevant information is moved with the patient when they are transitioned or referred to another provider. Workflow and technology are brought together to create the summary of care record. The goal of the summary of care record is to help providers caring for the same patient to have access to better information and more effectively coordinate the care they provide.

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

View

 

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

View

 

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

Download

[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)

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

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

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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