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Measure at a Glance

Type: calculated percentage

Denominator: transitions of care and referrals for which for the EP was the transferring or referring provider, which should be limited to patients maintained by CEHRT

Duration: calculated over the entire EHR reporting period

Objective: The EP who transitions their patient to another setting of care or provider of care or refers their patients to another provider of care should provide summary of care records for each transition of care or referral.
Measure: The EP 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.
Exclusion: Any EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period.

CMS Technical Specification

TennCare Notes

The attestation portal will require the EP to enter the numerator and denominator of the measure as defined in the technical specification.

Please note this measure requires more than 50% of transitions of care include the provision of a summary of care. The numerators and denominators are calculated to the hundredths place in the attestation portal, so while a proportion of 50.01% will be evaluated as a successful attestation, 50.00% will not.

Relevant CMS FAQs

None at this time.

Additional Resources

None at this time.

Federal Regulations Governing This Measure

CMS' Final Rule

§ 495.6(e)(8) see objective and measure above

Standards and Certification Final Rule

§ 170.304 (i) Exchange clinical information and patient summary record

  1. Electronically receive and display. Electronically receive and display a patient's summary record, from other providers and organizations including, at a minimum, diagnostic tests results, problem list, medication list, and medication allergy list in accordance with the standard (and applicable implementation specifications) specified in Sec. 170.205(a)(1) or Sec. 170.205(a)(2). Upon receipt of a patient summary record formatted according to the Alternative standard, display it in human readable format.
  2. Electronically transmit. Enable a user to electronically transmit a patient summary record to other providers and organizations including, at a minimum, diagnostic test results, problem list, medication list, and medication allergy list in accordance with:
    1. The standard (and applicable implementation specifications) specified in Sec. 170.205(a)(1) or Sec. 170.205(a)(2); and
    2. For the following data elements the applicable standard must be used:
      1. Problems. The standard specified in Sec. 170.207(a)(1) or, at a minimum, the version of the standard specified in Sec. 170.207(a)(2);
      2. Laboratory test results. At a minimum, the version of the standard specified in Sec. 170.207(c); and
      3. Medications. The standard specified in Sec. 170.207(d).

§ 170.205(a) Patient summary record

  1. Standard. Health Level Seven Clinical Document Architecture (CDA) Release 2, Continuity of Care Document (CCD) (incorporated by reference in Sec. 170.299). Implementation specifications. The Healthcare Information Technology Standards Panel (HITSP) Summary Documents Using HL7 CCD Component HITSP/C32 (incorporated by reference in Sec. 170.299).
  2. Standard. ASTM E2369 Standard Specification for Continuity of Care Record and Adjunct to ASTM E2369 (incorporated by reference in Sec. 170.299).

§ 170.207(a) Problems

  1. Standard. The code set specified at 45 CFR 162.1002(a)(1) for the indicated conditions.
  2. Standard. International Health Terminology Standards Development Organization (IHTSDO) Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT ®) July 2009 version (incorporated by reference in Sec. 170.299).

§ 170.207(c) Laboratory test results. Standard. Logical Observation Identifiers Names and Codes (LOINC ®) version 2.27, when such codes were received within an electronic transaction from a laboratory (incorporated by reference in Sec. 170.299).

§ 170.207(d) Medications. Standard. Any source vocabulary that is included in RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine.