Final MU Objectives: Information Exchange, Medication Reconciliation, Transfer of Summary Care Records
This is the sixth in a series of hospital-focused summaries of the final Stage 1 meaningful use objectives and measures. The goal of these entries is to support rural community hospital personnel in their efforts to meet specific meaningful use objectives. Notations marked “implications…” are my interpretations, which may or may not be correct.
Objectives # 1-21 were covered in previous blogs.
Objective #22: Electronically Exchange Key Clinical Information (Core Set)
The proposed “information exchange” objective for EPs was: “Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.” And for hospitals was: “Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, allergies, diagnostic test results), among providers of care and patient authorized entities electronically.”
The final “information exchange” objective for EPs is: “Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.” And for hospitals is: “Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, medication allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.”
CMS supporting language: “By “clinical information”, we mean all data needed to diagnose and treat disease, such as blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, and pulmonary function tests. We leave it to the provider’s clinical judgment as to identifying what clinical information is considered key clinical information for purposes of exchanging clinical information about a patient at a particular time with other providers of care. The examples we provided in the proposed rule and the final rule below are not intended to be exhaustive. ONC in their final rule provides a minimum set of information that certified EHR technology must be able to exchange in order to be certified. A provider’s determination of key clinical information could include some or all of this information as well as information not included in the ONC final rule at 45 CFR 170.304(i) for EPs and 45 CFR 170.306(f) for eligible hospitals and CAHs.”
The objective must be achieved using certified EHR technology as defined in the final certification rule. The definition of “capability to exchange key clinical information” in the final certification rule is:
For EPs: “(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 §170.205(a)(1) or §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:(i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used: (A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2); (B) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and (C) Medications. The standard specified in §170.207(d).”
For hospitals: “(1) Electronically receive and display: Electronically receive and display a patient’s summary record from other providers and organizations including, at a minimum, diagnostic test results, problem list, medication list, medication allergy list, and procedures in accordance with the standard (and applicable implementation specifications) specified in §170.205(a)(1) or §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’s summary record to other providers and organizations including, at a minimum, diagnostic results, problem list, medication list, medication allergy list, and procedures in accordance with: (i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used: (A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2); (B) Procedures. The standard specified in §170.207(b)(1) or §170.207(b)(2); (C) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and (D) Medications. The standard specified in §170.207(d).”
ONC supporting language: “we recognize that neither CCD nor CCR specifically supports the inclusion of discharge summary. In the Medicare and Medicaid EHR Incentive Program final rule, CMS references discharge summary in the meaningful use objective as an example of “key clinical information” but further clarifies within the preamble of that rule that it is up to an eligible professional or eligible hospital to determine what constitutes key clinical information. In that regard, CMS notes that we specify the minimum set of information that Certified EHR Technology must be capable of electronically transmitting. Given our prior statements regarding the ability of CCD and CCR to support the inclusion of the discharge summary and the principle expressed by CMS that we specify a minimum set of information in the adopted certification criterion, we believe that in this instance it is appropriate to exclude discharge summary from the certification criterion.”
Implications of the above: Community hospital information systems (HIS) may face some challenges in meeting the information exchange standards specified in the ONC final certification rule. Providers should verify that existing vendors can (or at least are working to) meet the certification and standards (CCD or CCR) requirements as defined. The objective’s seemingly flexible measure to perform one (not necessarily successful) test of electronic exchange will mitigate the challenges relating to this core requirement for providers.
The proposed “information exchange” measure for EPs and hospitals was: “Perform at least one test of certified EHR technology’s capacity to electronically exchange key clinical information.”
The final “information exchange” measure for EPs and hospitals is: No change: finalized as proposed.
CMS supporting language: “In developing the associated measure for this objective, we have ensured that eligible providers will be able to meet this objective as long as there is one other entity with which they can test their capability. As electronic exchange is not constrained by distance, we are confident that every provider seeking to test their system will be able to find another entity with which to conduct such test.” Additionally, “…EPs, eligible hospitals, and CAHs should attempt to identify one other entity with whom to conduct a test of the submission of electronic data. This test must include the transfer of either actual or “dummy” data to the chosen other entity. The testing could occur prior to the beginning of the EHR reporting period, but must occur prior to the end of the EHR reporting period and every payment year would require its own, unique test as infrastructure for health information exchange is expected to mature over time … To be considered an “exchange” for this objective and measure the clinical information must be sent between different legal entities with distinct certified EHR technology or other system that can accept the information and not between organizations that share certified EHR technology. CMS will accept a yes/no attestation to verify all of the above for EPs, eligible hospitals, and CAHs.”
The ability to calculate the measure will be included in the certified EHR technology as a certification requirement.
Exclusion: “As the measure already accounts for the possibility of a failed test and we are confident that everyone will be able to identify an entity with which to conduct a test, we do not believe an exception is required for EPs, eligible hospitals or CAHs.”
Objective #23: Perform Medication Reconciliation (Menu Set)
The proposed “medication reconciliation” objective for EPs and hospitals was: “Perform medication reconciliation at relevant encounters and each transition of care.”
The final “medication reconciliation” objective is: “The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation.”
CMS definition of “medication reconciliation:” “… the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency and route, by comparing the medical record to an external list of medications obtained from a patient, hospital or other provider.
CMS definition of “relevant encounter:” “…an encounter during which the EP, eligible hospital or CAH performs a medication reconciliation due to new medication or long gaps in time between patient encounters or for other reasons determined appropriate by the EP, eligible hospital or CAH. Essentially an encounter is relevant if the EP, eligible hospital, or CAH judges it to be so.”
CMS definition of “transition of care:” “We believe that different settings within one hospital using certified EHR technology would have access to the same information so reconciliation would not be necessary. We modify our clarification to account for some of the revisions provided. We clarify “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. We also clarify that the receiving eligible hospital or EP would conduct the medication reconciliation.”
The objective must be achieved using certified EHR technology as defined in the final certification rule. The definition of “medication reconciliation” functionality in the final certification rule is: “Medication reconciliation: Enable a user to electronically compare two or more medication lists.”
ONC supporting language: “We recognize that the technical foundation and safety checks are not currently in place for automated medication reconciliation. We did not intend to imply that automated reconciliation needed to occur through our use of the word “electronically.” We used the term “electronically” to express our expectation that eligible professionals and eligible hospitals would be able to use Certified EHR Technology to complete this task. Accordingly, we have revised this certification criterion to require that Certified EHR Technology be capable of providing a user with the ability to electronically compare two or more medication lists (e.g., between an externally provided medication list and the current medication list in Certified EHR Technology). We expect that this could be done in a number of ways and we do not want to preclude Complete EHR and EHR Module developers from innovating, provided that the desired outcome is reached.”
Implications of the above: Community hospital information system (HIS) vendors generally have some ability to allow providers to compare medication lists (as when a patient’s home medication list is inputted, presented through the EHR, and then utilized to develop an inpatient medication list). However, the medication reconciliation functions may or may not be flexible enough to import medication lists from outside entities. Providers should verify that existing vendors can (or at least are working to) meet the certification requirements as defined.
The proposed “medication reconciliation” measure for EPs and hospitals was: “Perform medication reconciliation for at least 80 % of relevant encounters and transitions of care.”
The final “medication reconciliation” measure is: “The EP, eligible hospital or CAH performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23)”.”
CMS supporting language: “We agree that the inclusion of relevant encounter creates a burden that one commenter described as “non-value-added work”. We also believe that when the EP, eligible hospital, or CAH identifies the encounter as relevant, it is unlikely that the EP, eligible hospital, or CAH would then not carry out the medication reconciliation. For these reasons, we are removing relevant encounters from the measure for this objective.”
The ability to calculate the measure will be included in the certified EHR technology as a certification requirement.
The Denominator is: “Number of transitions of care 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 receiving party of the transition.” (The only patients that are included in the denominator are those patients whose records are maintained using certified EHR technology).
The Numerator is: “The number of transitions of care in the denominator where medication reconciliation was performed.”
The Threshold is: “The resulting percentage must be more than 50% in order for an EP, eligible professional, or CAH to meet this measure.”
Exclusion: “If an EP was not on the receiving end of any transition of care during the EHR reporting period they would be excluded … We do not believe that any eligible hospital or CAH would be in a situation where they would not need to know the precise medications their patients are taking.”
Objective #24: Summary Care Records for Transfers (Menu Set)
The proposed “summary care record transfer” objective for EPs and Hospitals was: “Provide summary care record for each transition of care or referral.”
The final “summary care record transfer” objective is: “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.”
CMS supporting language: “If the provider to whom the referral is made or to whom the patient is transitioned to has access to the medical record maintained by the referring provider then the summary of care record would not need to be provided. The most common example cited by commenters was a referral during which the patient remains an inpatient of the hospital. Finally, unlike with medication reconciliation, where the receiving party of the transfer conducts the action, the transferring party would provide the summary care record to the receiving party.”
CMS definition of “transition of care:” “…transition of care means a transfer of a patient from one clinical setting (inpatient, outpatient, physician office, home health, rehab, long-term care facility, etc) to another or from one EP, eligible hospital, or CAH (as defined by CMS Certification Number (CCN) to another. We believe that different settings within a hospital using certified EHR technology would have access to the same information so providing a clinical care summary would not be necessary. We further clarify 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.”
CMS allows the use of paper care summaries: “While we highly encourage all EPs, eligible hospitals, and CAHs to explore ways to accomplish the transfer using electronic exchange, we realize that this capability is still in the development stages. Therefore, an EP, 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.”
The objective must be achieved using certified EHR technology as defined in the final certification rule. ONC’s definition of summary care record transfer is identical to its definition of clinical information exchange:
For EPs: “(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 §170.205(a)(1) or §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:(i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used: (A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2); (B) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and (C) Medications. The standard specified in §170.207(d).”
For hospitals: “(1) Electronically receive and display: Electronically receive and display a patient’s summary record from other providers and organizations including, at a minimum, diagnostic test results, problem list, medication list, medication allergy list, and procedures in accordance with the standard (and applicable implementation specifications) specified in §170.205(a)(1) or §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’s summary record to other providers and organizations including, at a minimum, diagnostic results, problem list, medication list, medication allergy list, and procedures in accordance with: (i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used: (A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2); (B) Procedures. The standard specified in §170.207(b)(1) or §170.207(b)(2); (C) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and (D) Medications. The standard specified in §170.207(d).”
ONC supporting language: “we recognize that neither CCD nor CCR specifically supports the inclusion of discharge summary. In the Medicare and Medicaid EHR Incentive Program final rule, CMS references discharge summary in the meaningful use objective as an example of “key clinical information” but further clarifies within the preamble of that rule that it is up to an eligible professional or eligible hospital to determine what constitutes key clinical information. In that regard, CMS notes that we specify the minimum set of information that Certified EHR Technology must be capable of electronically transmitting. Given our prior statements regarding the ability of CCD and CCR to support the inclusion of the discharge summary and the principle expressed by CMS that we specify a minimum set of information in the adopted certification criterion, we believe that in this instance it is appropriate to exclude discharge summary from the certification criterion.”
Implications of the above: Community hospital information systems (HIS) may face some challenges in meeting the summary care record exchange standards specified in the ONC final certification rule. Providers should verify that existing vendors can (or at least are working to) meet the certification and standards (CCD or CCR) requirements as defined. The CMS clarification that different care settings within a hospital do not require summary of care record exchange, as well as the clarification that the summary of care record can be produced on paper and given to the patient, are welcome.
The proposed “summary care record transfer” measure for EPs was: “Provide summary of care record for at least 80% of transitions of care and referrals.”
The final “summary care record transfer” measure is: “The EP, 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”
The ability to calculate the measure will be included in the certified EHR technology as a certification requirement (“as long as an EP, eligible hospital, or CAH records the order for a referral or transfer as structured data and a record is made that the summary care record was provided…”)
The Denominator is: “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 that are included in the denominator are those patients whose records are maintained using certified EHR technology).
The Numerator is: “The number of transitions of care and referrals in the denominator where a summary of care record was provided.”
The Threshold is: “The percentage must be more than 50 percent in order for an EP, eligible hospital, or CAH to meet this measure.”
Exclusion: “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 … We do not believe that any eligible hospital or CAH would be in a situation where they would never transfer a patient to another care setting or make a referral to another provider.”
{ 3 comments… read them below or add one }
My partner and I head two hospitalists groups in the Boston area, one acute care, the other a rehab hospital. For years our handoff communications went through paper mail or fax. We were very diligent about communication. Even so, specialist from acute care settings and primary care physicians in the community complained that our group was like a black box – that they were not getting good communication about the care we were providing. The hospital even setup a physician portal so that any on-staff doctor could log in remotely and access their patient’s information. But this “pull” model never caught on, as most doctors expect data to be “pushed” out to them.
One of our new physicians suggested we look at Concentrica, which is an online network for secure clinical communication. This is free to physicians to communicate with each other. The national directory of physicians meant that we could quickly send to any physician, without having to know their fax or email. Like an online email system, recipients can reply and forward messages, so now we could get immediate feedback from colleagues in other locations, and in important cases, have a real dialog about patient care. The “Group Discussions” feature allows the specialist in town, the hospitalist, and the PCP to all join in an online dialog about one patient.
The application works well on our smartphones.
When our group wanted to send documents on our behalf, we upgraded to the subscription version, which cost less than paying someone in our office to fax the documents. There is an audit trail so we can see who received their messages. One feature we really liked was that if the message was not accessed online it was faxed, so we knew our clinical work was getting there.
For our group it made it easy to communicate with other physicians, to get our documents out, gave a way for others to respond, and was cost effective.
Arthur Williams, MD
forgot to say, that is http://www.concentrica.com
Does the Exchange Key Clinical Information objective require that the electronic transmission be structured data or would electronic faxing through the EHR systems satisfy the electronic transmission requirement of this core objective?