Core 15: Summary of Care

Objective 

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

Measures

Eligible professionals must satisfy both Measures 1 and Measure 2 in order to meet the objective. 

Measure 1

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% of transitions of care and referrals.

  • DENOMINATOR: Number of transitions of care and referrals during the EHR reporting period for which the eligible professional was transferring or referring provider. 
  • NUMERATOR: The number of transitions of care and referrals in the denominator where a summary of care record was provided. 
  • THRESHOLD: The percentage must be more than 50% in order for an eligible professional to meet this measure
  • EXCLUSION: Any eligible professional who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from measure 1.

How To (Website):

  1. Go to Message center > Outbound referrals > New Referral > Select a patient.
  2. Fill or attach, whatever information need to be sent along with the referral form and check “Include clinical Summary” and hit “Send Referral”.

Measure 2

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 10% of such transitions and referrals either (a) electronically transmitted using 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.

  • DENOMINATOR: Number of transitions of care and referrals during the EHR reporting period for which the eligible professional was the transferring or referring provider. 
  • NUMERATOR: The number of transitions of care and referrals in the denominator where a summary of care record was a) electronically transmitted using CEHRT to a recipient, or b) where the recipient received 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 nationwide health information network. The organization can be a third-party, or the sender's own organization.
  • THRESHOLD: The percentage must be more than 10% in order for an EP to meet this measure.
  • EXCLUSION: Any eligible professional who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from measure 2.

How To (Website):

  1. Go to Message center > Outbound referrals > New Referral > Select a patient.
  2. Please make sure the direct address information is already updated in the contacts for the recipient.
  3. Fill or attach, whatever information need to be sent along with the referral form and check “Send direct message” and hit “Send Referral”.

Measure 3

An eligible professional must attest yes to meet one of the two following criteria:

  1. Conducts one or more successful electronic exchanges of a summary of care document, as part of which it counted in "measure 2" (for eligible professional's the measure at 495.6(j)(14)(ii)(b) with a recipient who has EHR technology developer than the sender's EHR technology certified to 45 CFR 170.314(b)(2)
  2. Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period. 
  • EXCLUSION: Any eligible professional who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from measure 3.

Exclusions

Please see exclusionary details under each measure. 

For additional information from the CMS regarding Core 15: Summary of Care click here.

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