Successful Summaries of Care

Ask Joy: This Week – Successful Summaries of Care

When your refer a patient to a specialist or another doctor, you must send along a Summary of Care that describes the patient’s condition and offers insight into her pertinent health history. Effective transitions of patients between care settings is one element that can directly influence quality, safety, and cost of health care. This week, we’ll review the requirements for providing complete Summary of Care records when transferring patients to another setting for both Stage 1 and Stage 2 of Meaningful Use.

What do I need to know to be successful in the Summary of Care objective?  

If you’re in Stage 1, reporting your summary of care details is optional, as it’s a menu objective. However, should you choose to report it, you will need to provide a summary of care for 50% of transitions of care and referrals.

If you’re starting Stage 2, reporting your summary of care data has been promoted to a core objective with two additional measures in place to evaluate your performance. This is part of a strategic effort to streamline the process for transmitting these documents electronically. The measures include:

  1. Provide for more than 50% of transitions of care and referrals
  2. More than 10% must be completed either (a) electronically using certified EHR technology or (b) via NwHIN exchange participant
  3. Conduct Measure 2 with a different EHR developer or by a successful test with a CMS-designated test EHR 

The summary of care document is thought to improve communication among providers, having a positive influence on quality and safety. The purpose of this objective is to ensure that providers who transition a patient to someone else’s care give the receiving provider the most up-to-date information available. It also helps to organize the concluding clinical and administrative activities for the transferring care team.

The three measures encourage providers to utilize the EHR in a meaningful way, to increase communication among other EHRs, and to engage with a health information exchange. To do all of this effectively requires careful consideration to creating complete summary of care records.

A complete summary of care record requires that a minimum data set, outlined below, is capable of being captured as structured data in Consolidated Clinical Document Architecture (CCDA) format, which looks very similar to an Excel document. Most importantly, providers must verify that the following information is entered into the EHR before generating the summary of care:

  • Problem list
  • Medication list
  • Medication allergy list
  • Care plan

Leaving any of these fields blank within the EHR would not allow you to meet the objective. If the patient has none of these items, make sure a specific notation is included in the record.

The complete list of requirements for summary of care follows:

  • Patient name
  • Referring or transitioning provider’s name and office contact info (EP only)
  • Procedure
  • Encounter diagnosis
  • Immunizations
  • Lab test results
  • Vital signs (height, weight, blood pressure, BMI)
  • Smoking status
  • Functional status, including activities of daily living, cognitive and disability status
  • Demographic info (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
  • Reason for referral
  • Current problem list (EPs may also include historical problems at their discretion)
  • Current medication list
  • Current medication allergy list

A typical workflow to complete this objective looks something like this:

  1. Enter information into the certified  EHR technology
  2. Withhold any information that the provider determines could cause possible harm
  3. Verify presence of elements: problem list, medication list, and medication allergy list
  4. Create Continuity of Care Document (CCD)
  5. Provide summary of care record when the patient is transferred to another setting of care or referred to another provider

For more information, check out the CMS publication on this core objective and’s comparison between Stage 1 and Stage 2.

About the Author: Joy Rios has worked directly with multiple EHRs to develop training programs for both trainers and practice staff. She has successfully attested to Meaningful Use for multiple ambulatory practices in both Medicare and Medicaid. She also authored the Certified Professional Meaningful Use course for Joy holds an MBA with a focus in sustainability. She is Health IT certified with a specialty in Workflow Redesign, holds HIPAA security certification, and is a great resource for information regarding government incentive programs.Ask Joy is a regular column on 4Medapproved HIT Answers.