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How do I provide summary care records for each transition of care referral?

Providing a summary of health care activities to a patient’s other provider is an important step for improving care coordination.  Currently, many providers who receive new patients receive no guidance from the patient’s previous providers.  Providers may be forced to repeat tests were previously performed and may lack the information needed to immediately begin treating a new patient in the most effective and safe manner.  Also, medical charts may contain large amounts of information that can challenge providers to quickly assess essential data.  Thus, a timely and concise summary of critical health information can communicate important information that the patient may not have been able to provide.  A care summary record can assist providers who receive summaries of their new patients to make well-informed decisions about how to treat a patient.  

Below are the key benefits to clinical care summaries:  

• Allows providers to receive critical health data at transfer of care
• Improves speed and accuracy of data absorption into new providers’ EHR
• Reduces costs in reproducing and transporting paper records
• Reduces hassle to patients in completing new providers’ registration materials
• Improves quality of care through more complete and timely information
• Can provide patients with an accurate, readable record of a visit or encounter

(AHRQ State Health Information Exchange (HIE) Technical Assistance Program Webinar, Patient Care Summary Exchange, August 6, 2010)   

The Meaningful Use objective below addresses the importance of summary of care records for effective and efficient transition of care from one provider to another.  

Menu Set Objective for Eligible Professionals and Eligible Hospitals:  

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

Measure:

• The eligible professional or hospital that 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.  

Exclusion:

• Any eligible professional that does not transfer a patient to another setting or refer a patient to another provider during the EHR reporting period

The purpose of this objective is to ensure a summary of care record is provided to the receiving provider when a patient transitions to a new provider or has been referred to another provider while still remaining under the care of the referring provider.

CMS defines “summary care record” as a record that includes, at a minimum, diagnostic test results, problem list, medication list, and medication allergies.  Eligible hospitals should also include procedures in this record.  

“Transition of care” is defined as a transfer of a patient from one clinical setting to another (inpatient, outpatient, physician office, home health, rehabilitation, long-term care, etc.) and from one setting of care to another (hospital, ambulatory primary care practice, ambulatory, specialty care practice, long-term care, home health, rehabilitation facility).

Although CMS prefers that the summary care record is transferred electronically, it is understood that the technologies necessary for this may still be in development.  Therefore, the eligible professional or hospital can also either send a paper copy of the summary care record to the next provider or have the patient deliver the summary care record to the next provider themselves.  However, a certified EHR system must be used to generate the summary care record and record whether it was given directly to the provider or given to the patient to deliver to the provider.

If the provider to whom the referral is made or to whom the patient is transitioned to has access to the medical record maintained by the referring provider, then the summary of care record does not need to be provided.  

Under the ONC’s Standards and Certification Final Rule, a certified EHR must be able to electronically receive and display a patient’s summary record from other providers and organizations, including at a minimum, diagnostic tests results, problem list, medication list, and medication allergy list and enable a user to electronically transmit a patient summary record to other providers and organizations including, at a minimum, diagnostic tests results, problem list, medication list, and medication allergy list.

The ability to calculate the measure is included in the certified EHR technology.  The denominator for the measure of the threshold of summary care records is the number of transitions of care and referrals during the EHR reporting period for which the eligible professional or hospital’s inpatient or emergency department was the transferring or referring provider.  The numerator for the measure of the threshold of summary care records is the number of transitions of care and referrals in the denominator where a summary of care record was provided.  If an eligible professional or hospital does not transfer a patient to another setting or refer a patient to another provider during the EHR reporting period, they would be excluded from this requirement.  

Related Resources:

EHR Incentive Program Final Rule – CMS’ rules and regulations for demonstrating Meaningful Use.  See pages 44363-44364 for detailed information on the summary care record objective and measure.
Standards and Certification Final Rule – ONC’s requirements for the certification of EHR technologies.  See pages 44362- 44635 for more complete information.

For technical information on the implementation of care summaries:

Patient Care Summary Exchange – Presentation at the Patient Care Summary Exchange Guidance webinar provides information on care summaries, State strategies for implementation, issues and resources.
Care Record Summary: HL7 Implementation Guides for CDA Release 2 – Presentation by the Dictaphone Corporation presents technical information on the implementation of the care record summary.