Stage 3 of the electronic health records meaningful use program significantly raises the bar for providers to improve the flow of information when patients’ care is transitioned to a different setting or patients are referred to other clinicians.

There are three measures in Stage 3 covering use of standardized summary of care documents. Providers must attest to the numerator and denominator of all three measures, but only have to successfully meet two of them to comply with the Health Information Exchange Objective. But be careful; wording of the provisions in Stage 3 can be tricky.

Also See: CIO’s First Look: Stage 3 Offers Some Challenges

Under Stage 2 Measure 1, providers transitioning or referring a patient to another care setting or provider of care are expected to provide a summary of care for a least 50 percent of transitions and referrals. As proposed, Stage 3 keeps the 50 percent mark, but requires the summary of care be created using a certified EHR and that the summary be electronically exchanged.

In Stage 2 Measure 2, providers transitioning or referring a patient have to in at least 10 percent of the cases electronically transmit the summary to the recipient using a certified EHR or through an eHealth Exchange organization that is the provider’s own organization or a third-party vendor. Now, in proposed Stage 3, in more than 40 percent of transitions or referrals received and patient encounters in which the provider has not previously encountered the patient, the provider must incorporate into the patient’s EHR “an electronic summary of care document from a source other than the provider’s EHR system.” In other words, federal officials want providers to demonstrate that they can initiate the process to receive existing summaries of care regarding new patients and complete the electronic transmission loop.

In Stage 2 Measure 3, providers must conduct at least one successful electronic exchange of a summary of care with a provider using an EHR from a different vendor, or conduct the exchange with a CMS-designated test EHR. In proposed Stage 3, the bar is significantly raised: “For more than 80 percent of transitions or referrals in which the provider has never before encountered the patient,” the provider must perform a clinical information reconciliation that includes review of medications including name, dosage, frequency and route of each; known allergies, and current problem list with current and active diagnoses.

Borrowing another rule

To accelerate health information technology interoperability among providers not eligible for the electronic health records meaningful use program, the Office of the National Coordinator for HIT on March 20 issued a separate new rule that is complementary to the Stage 3 rule. Parts of this new rule are incorporated in the summary of care proposal for Stage 3.

For instance, the ONC rule establishes new and voluntary 2015 Edition certification criteria for other health information systems such as long-term post-acute care and behavioral health, called Health IT Modules. It also creates a Common Clinical Data Set that includes required elements for the summary of care document. The proposed Stage 3 rule calls for summary of care documents to include the requirements and specifications in the Common Clinical Data Set.

Following stakeholder requests for more streamlined and flexible rulemaking, CMS in the Stage 3 proposed rule also offers some ways to ease the regulatory burden. For instance, the agency encourages providers to send a list of items “pertinent and relevant to the patient’s care, “rather than a list of all problems, whether active or resolved, that have ever populated the problem list,” according to the rule. “While a current problem must always be included, the provider can use his or her judgment in deciding which items historically present on the problem list, medication history list (if it exists in CEHRT), or surgical history list are relevant given the clinical circumstances.”

Further, CMS in the rule is deferring to providers’ discretion in including only clinically relevant lab rest results and clinical notes, rather than having all past such information in the summary.

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