MU2 #9 – Electronic Exchange of Information: The Summary of Care Measure, Part 1

 In Articles, Meaningful Use

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
  • Procedures
  • Diagnosis
  • Immunizations
  • 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*

(*=Required field)

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.

Visit the CMS Specification Sheet for each Stage 2 Measure.

Need help unraveling the complexities of Meaningful Use? MSOC Health can help! Contact Jeanne Chamberlin, Director of EMR Consulting at 919-442-2422 or j.chamberlin@msochealth.com.

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