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Stage 2 Core Measure 15

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Objective: The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral.
Measure:

  1. The EP 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;
  2. The EP that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either-
    1. Electronically transmitted using Certified EHR Technology to a recipient; or
    2. 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 nationwide health information network, and
  3. An EP must satisfy one of the following:
    1. Conducts one or more successful electronic exchanges of a summary of care record meeting the measure specified in Core 14 Measure B with a recipient using technology to receive the summary of care record that was designed by a different EHR developer than the sender's EHR technology certified at 45 CFR 107.314(b)(2); or
    2. Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period.
Exclusion: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period.

CMS Specification Sheet

TennCare Notes
This objective and measure aligns with Menu Measure 8 in Stage 1 Meaningful Use. Beyond the transition from the menu to core set, the measure adds Measure B and C. Measure B requires 10 percent of summaries be transmitted electronically, and Measure C tests the ability to transmit messages to EHRs by other developers.

Federal Regulations Governing This Measure

CMS' Final Rule

§ 495.6(j)(14)(ii)(A) see objective, measure and exclusion above
§ 495.6(j)(14)(ii)(B) see objective, measure and exclusion above
§ 495.6(j)(14)(ii)(C) see objective, measure and exclusion above

Standards and Certification Final Rule

§ 170.314(b)(1) Transitions of care – receive, display, and incorporate transition of care/referral summaries.
(i) Receive. EHR technology must be able to electronically receive transition of care/referral summaries in accordance with:
    A. The standard specified in § 170.202(a).
    B. Optional. The standards specified in § 170.202(a) and (b).
    C. Optional. The standards specified in § 170.202(b) and (c).
(ii) Display. EHR technology must be able to electronically display in human readable format the data included in transition of care/referral summaries received and formatted according to any of the following standards (and applicable implementation specifications) specified in: § 170.205(a)(1), § 170.205(a)(2), and § 170.205(a)(3).
(iii) Incorporate. Upon receipt of a transition of care/referral summary formatted according to the standard adopted at § 170.205(a)(3), EHR technology must be able to:
    A. Correct patient. Demonstrate that the transition of care/referral summary received is or
         can be properly matched to the correct patient.
    B. Data incorporation. Electronically incorporate the following data expressed according
         to the specified standard(s):

  • Medications. At a minimum, the version of the standard specified in § 170.207(d)(2);
  • Problems. At a minimum, the version of the standard specified in § 170.207(a)(3);
  • Medication allergies. At a minimum, the version of the standard specified in § 170.207(d)(2).
  • Section views. Extract and allow for individual display each additional section or sections (and the accompanying document header information) that were included in a transition of care/referral summary received and formatted in accordance with the standard adopted at § 170.205(a)(3).

§ 170.314(b)(2) Transitions of care – create and transmit transition of care/referral summaries.
(i) Create. Enable a user to electronically create a transition of care/referral summary formatted according to the standard adopted at § 170.205(a)(3) that includes, 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. The reason for referral; and referring or transitioning provider’s name and office contact information.
(ii) Transmit. Enable a user to electronically transmit the transition of care/referral summary created in paragraph (b)(2)(i) of this section in accordance with:
    A. The standard specified in § 170.202(a).
    B. Optional. The standards specified in § 170.202(a) and (b).
    C. Optional. The standards specified in § 170.202(b) and (c).
Depending on the type of certification issued to the EHR technology, it will also have been certified to the certification criterion adopted at 45 CFR 170.314 (g)(1), (g)(2), or both, in order to assist in the calculation of this meaningful use measure.

§ 170.202(a) Transport standards.  ONC Applicability Statement for Secure Health Transport (incorporated by reference in § 170.299).

§ 170.202(b) Transport standards.  ONC XDR and XDM for Direct Messaging Specification (incorporated by reference in § 170.299).

§ 170.202(c) Transport standards. ONC Transport and Security Specification (incorporated by reference in § 170.299).

§ 170.205(a)(1) HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, (incorporated by reference in § 170.299). The use of the “unstructured document” documentlevel template is prohibited.

§ 170.207(a)(3) Problem List. IHTSDO SNOMED CT® International Release July 2012 (incorporated by reference in § 170.299) and US Extension to SNOMED CT® March 2012 Release (incorporated by reference in § 170.299).

§ 170.207(b)(2) The code set specified at 45 CFR 162.1002(a)(5).

§ 170.207(b)(3) The code set specified at 45 CFR 162.1002(a)(5).

§ 170.207(b)(4) The code set specified at 45 CFR 162.1002(a)(5).

§ 170.207(c)(2) The code set specified at 45 CFR 162.1002(a)(5).

§ 170.207(c)(2) Laboratory tests. Logical Observation Identifiers Names and Codes (LOINC®) Database version 2.40, a universal code system for identifying laboratory and clinical observations produced by the Regenstrief Institute, Inc. (incorporated by reference in § 170.299).

§ 170.207(d)(2) Medications.  RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine, August 6, 2012 Release (incorporated by reference in § 170.299)

§ 170.207(e)(2) Immunizations. HL7 Standard Code Set CVX – Vaccines Administered, updates through July 11, 2012.

§ 170.207(f) Race and Ethnicity. The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997 (see “Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity,” available at http://www.whitehouse.gov/omb/fedreg_1997standards)

§ 170.207(g) Preferred Language. As specified by the Library of Congress, ISO 639-2 alpha-3 codes limited to those that also have a corresponding alpha-2 code in ISO 639-1. (incorporated by reference in § 170.299).

§ 170.207(h) Smoking Status. Smoking status must be coded in one of the following SNOMED CT® codes:
(1) Current every day smoker. 449868002
(2) Current some day smoker. 428041000124106
(3) Former smoker. 8517006
(4) Never smoker. 266919005
(5) Smoker, current status unknown. 77176002
(6) Unknown if ever smoked. 266927001
(7) Heavy tobacco smoker. 428071000124103
(8) Light tobacco smoker. 428061000124105

§ 170.207(i) Encounter Diagnoses. The code set specified at 45 CFR 162.1002(c)(2) for the indicated conditions.