MU2 #9 – Electronic Exchange of Information: The Summary of Care Measure, Part 1
This is Part 9 in a series provided by Jeanne Chamberlin, Director of EMR Consulting, at MSOC Health. Visit our blog site to see articles 1 -8.
For the first time, Stage 2 of Meaningful Use requires providers to exchange information electronically. The Summary of Care Measure was a Menu Set (optional) Measure in Stage 1, which required clinical information to be sent when a patient was referred or transitioned to another setting or provider. In Stage 2, it has evolved to a three-part Core (required) Measure:
- Part 1: A Summary of Care Document is provided for over 50% of referrals/transitions of care (same as Stage 1 but with more detail on what is to be included in the document).
- Part 2: A Summary of Care Document is provided via electronic exchange for over 10% of referrals/transitions of care. Note that a fax sent from your EHR does NOT count as an electronic exchange.
- Part 3: At least one Summary of Care Document must be successfully exchanged with a recipient using an EHR technology from a different vendor; alternatively, you may document a successful test of electronic exchange with a CMS designated EHR.
- A provider who does not order at least 100 transitions of care/referrals within the reporting period can be excluded from all three parts of this measure.
The Summary of Care Measure is designed to ensure that when a patient moves between settings or providers, key clinical information is communicated to the provider who will be next treating the patient.
Transition of Care: Each time a patient is referred or transferred to another provider for evaluation or treatment, the activity is counted as a Transition of Care. Examples include:
- Primary care physician refers to a specialist
- Orthopedic surgeon refers to a physical or occupational therapist
- A provider advises a patient to go to the local Emergency Room
- A provider recommends that a patient be admitted to a hospital, SNF or rehab facility
- A specialist provides advice or treatment and refers the patient to their primary care physician for ongoing treatment, monitoring or evaluation.
Summary of Care Document: At a minimum, the document must include the patient’s current Problem List, Medication List, Medication Allergy List and Care Plan or indicate if none exists (for example: “Patient currently takes no medications.”). In addition, all of the following data items available in the EHR at the time the document is generated are to be included:
- Patient Name and Demographics (gender, DOB, race, ethnicity, language)
- Referring provider name, contact information
- Laboratory Test Results
- Vital Signs
- Smoking Status
- Functional Status, including activities of daily living, cognitive and disability status
- Care plan, including goals and instructions*
- Care team, including primary care provider and any additional known care team members
- Reason for referral
- Current Problem List*
- Current Medication List*
- Current Medication Allergy List*
In our next post, we’ll discuss the Electronic Exchange concepts embedded in Parts 2 and 3 of this Measure.
For More Information on the contents of the Summary of Care Document, view the CMS Tip Sheet.
Need help unraveling the complexities of Meaningful Use? MSOC Health can help! Contact Jeanne Chamberlin, Director of EMR Consulting at 919-442-2422 or email@example.com.