EHR System and MU 2 and 3

The EHR system works its magic and puts all of this information into a file using a standard format called C-CDA (Consolidated Clinical Document Architecture)

Under the 10/16/2015 change to Meaningful Use for 2015 through 2017, the Health Information Exchange measure, now Measure #5, is a simplified version of the original Measure 15, previously titled “Summary of Care”.  This objective is retained as part of the federal government’s commitment to moving the health care community toward interoperability.  Under the measure, when referring or transitioning a patient to another provider or setting of care, an electronic record must be transmitted to the other provider at least 10% of the time.

To break open this rule, we will explore exactly what providers must include in this Summary of Care document.

What remains mostly unchanged from the original rule is the contents of the “Summary of Care” document, which all certified electronic record systems are capable of creating.  These records must include:

  • Patient name
  • Referring or transitioning provider’s name and office contact information (EP only)
  • Procedures
  • Encounter diagnosis
  • Immunizations
  • Laboratory test results
  • Vital signs (height, weight, blood pressure, BMI)
  • Smoking Status
  • Functional status, including activities of daily living, cognitive and disability status
  • Demographic information (preferred language, sex, race, ethnicity, date of birth)
  • Care plan field, including goals and instructions
  • Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider
  • Discharge instructions (Hospital only)
  • Reason for referral (EP only)

Based on new flexibility in Stage 2 to not gather certain information, if there is no information to populate one of the above fields, it may be left blank!  Regarding laboratory results, a provider must transmit all lab results if requested by the recipient, although may include only the most clinically relevant subset of the available lab results.

To complete the Summary of Care record, the following must be included, and must include the most recent information:

  • Current problem list (providers may also include historical problems at their discretion)
  • Current medication list, and
  • Current medication allergy list.

The EHR system works its magic and puts all of this information into a file using a standard format called C-CDA (Consolidated Clinical Document Architecture).  Once this is created, it is ready to send to the referring provider, whose EHR system has the capability of reading this file and attaching the information into the patient’s record.

The rule allows some flexibility regarding how this file is transmitted to the other provider.  See our post, Meaningful Use Stage 2, Measure 5:  Health Information Exchange, now More Flexible.

Editor’s Note: Subsequent to the publication of this article, CMS has renamed the “Meaningful Use” programs and MIPS “Advancing Care Information” category to “Promoting Interoperability”.

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