OBJECTIVE: The EP, eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral.
ASSOCIATED MEASURE: The EP or eligible hospital or CAH 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 percent of transitions of care and referrals.
METHOD OF MEASURE CALCULATION: Denominator is based on counting actions for patients whose records are maintained using certified EHR technology.
NUMERATOR: The number of transitions of care and referrals in the denominator where a summary of care record was provided
DENOMINATOR: Number of transitions of care and referrals during the EHR reporting period for which the EP or eligible hospital’s or CAH’s inpatient or emergency department (POS 21 to 23) was the transferring or referring provider. The only patients whose transitions of care and referrals are included in the denominator are those patients whose records are maintained using certified EHR technology.
THRESHOLD: The percentage must be more than 50 percent in order for an EP,eligible hospital, or CAH to meet this measure.
EXCLUSIONS: If an EP does not transfer a patient to another setting or refer a patient to another provider during the EHR reporting period then they would have a situation of a null denominator as described would be excluded from this requirement.
ADDITIONAL REGULATORY LANGUAGE: CMS definition "transition of care as the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory, specialty care practice, long-term care, home health, rehabilitation facility) to another."
An eligible hospital, or CAH could send an electronic or paper copy of the summary care record directly to the next provider or could provide it to the patient to deliver to the next provider, if the patient can reasonably expected to do so. Certified EHR technology would be used to generate the summary of care record and to document that it was provided to the patient or receiving provider
HEALTH OUTCOMES POLICY PRIORITY: Improve care coordination