What elements should our facility be documenting on the summary of care for Meaningful Use?

Recently, we have been provided with the following correspondence from CMS. While problems, medication list  and medication allergy list are the key components to populate the numerator of the summary of care measure, CMS now states they will be looking for the CCD to have all of the below elements populated below, if known.  If your facility has attested, Evident recommends that your facility reviews all of the patients in your attestation period contained in the numerator, and make sure the data elements below are documented If known, since this information has recently been made available to us.

We apologize for any inconvenience this FAQ has caused but want to make sure you are aware of recent CMS information. Please also note that any FAQs that are released after the final rule are regarded as “sub-regulatory guidance” by CMS and must be followed within a reasonable amount of time. CMS also communicates the updated FAQs to auditors who utilize the information for  Meaningful Use audits.

FAQ response from CMS: 

Thank you for your recent inquiry. Below is the information you requested regarding the meaningful measures for transitions of care. Our response focuses on the measure for eligible hospitals (EHs), but the eligible professional (EP) measure is essentially the same.

As adopted by CMS, the Stage 1 and Stage 2 objectives require hospitals that transition their patient to another setting of care or provider of care or refer their patients to another provider of care (including long-term care) to provide a summary care record for more than 50 Percent or transitions of care and referrals.

For the Stage 1 measure, CMS did not specify the contents of the summary of care record. While the hospital can send an electronic or paper copy of the summary care record directly to the next provider or can provide it to the patient to deliver to the next provider, if the patient can reasonably expected to do so. However, beyond the CMS requirements, in order to meet this objective and its measures, the hospital must use the capabilities and standards of certified EHR technology (CEHRT) established by the Office of National Coordinator for Health IT (ONC), specifically, the standards found at 45 CFR 170. 205(a)(1) and (2). The ONC has defined the content of a summary of care record to include at a minimum, diagnostic results, problem list, medication list, medication allergy list, and procedures.

For the Stage 2 measure, CMS specifies that the summary of care record must include the following elements:
* 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
* Current problem list (Hospitals may also include historical problems at their discretion).
* Current medication list, and
* Current medication allergy list.

If the provider does not have the information available to populate one or more of the fields listed, either because they can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the provider may leave the field(s) blank. The only exception to this is the problem list, medication list, and medication allergy list. In the event that there are no current or active diagnoses for a patient, the patient is not currently taking any medications, or the patient has no known medication allergies, confirmation of no problems, no medications, or no medication allergies would satisfy the measure of this objective. In circumstances where there is no information available to populate one or more of the fields listed previously, either because the eligible hospital or CAH can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the eligible hospital or CAH may leave the field(s) blank and still meet the objective and its associated measure.

Beyond the CMS requirements, in order to meet the Stage 2 objective and its three measures, the hospital must use the capabilities and standards of certified EHR technology (CEHRT) established by the Office of National Coordinator for Health IT (ONC), specifically, the standards found at 45 CFR 170.314(b)(2), (g)(1), (g)(2). The ONC has defined the content of a summary of care record to include “at a minimum, the Common MU Data Set and the following data expressed, where applicable, according to the specified standard(s):
(A) Encounter diagnoses. The standard specified in § 170.207(i) or, at a minimum, the version of the standard specified § 170.207(a)(3);
(B) Immunizations. The standard specified in § 170.207(e)(2);
(C) Cognitive status;
(D) Functional status; and
(E) Ambulatory setting only. The reason for referral; and referring or transitioning provider’s name and office contact information.
(F) Inpatient setting only. Discharge instructions.”

For further information regarding the certification and standards criteria, you should contact the ONC at: 
• (202) 690-7385;
• E-mail: onc.request@hhs.gov; or
• Visit its Web site at http://healthit.hhs.gov.

The purpose of providing the summary of care records is to assure that the provider to whom the patient is transferred or referred obtains the  most recent information on the patient that may be crucial to his/her care.  A summary of care record that does not include the required contents as defined by the ONC could not be counted in the numerator of the measure.

The tracking number for this inquiry is 330002. If you have further questions, please visit the CMS Medicare & Medicaid EHR Incentive Programs Website located at http://cms.gov/EHRIncentivePrograms/. You will find accurate and up-to-date information about the programs, including eligibility, payment amounts, requirements, upcoming events and more. Bookmark the above link and check back often to learn more about these programs, or contact the EHR Information Center at (888) 734-6433.

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Thank you,

The EHR Information Center