The Department of Health and Human Services has issued two new frequently asked questions regarding the Stage 2 meaningful use measure for transitions of care.

The measure is: “The eligible professional (EP), eligible hospital, or critical access hospital (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.”

QUESTION: What certification approaches would satisfy the 2014 Edition transitions of care certification criteria adopted at 45 CFR 170.314(b)(1) and (b)(2) as well as permit an eligible provider to have EHR technology that meets the Certified EHR Technology (CEHRT) definition?  Please emphasize how the adopted transport standards fit in.

ANSWER: In general, EHR technology developers can take the three approaches outlined in the table below to meet the transitions of care certification criteria and their included transport standard(s).  EHR technology certified according to any one of these three approaches could then be used by eligible providers to meet the CEHRT definition.

As additional context, it is important to keep in mind the “scope of a certification criterion” in the 2014 Edition EHR certification criteria (see 77 FR 54168).  In the final rule, we describe that in order for a certification criterion to be met, all specific capabilities expressed under the second regulation text paragraph (e.g., everything under 170.314(b)(1)) would need to be demonstrated for certification.  In other words, if EHR technology was presented for certification and could only perform the specific “create a CCDA” capability expressed in 170.314(b)(2)(i), that EHR technology would not meet this certification criterion.

With respect to transport standards, both certification criteria at 170.314(b)(1) and (b)(2) follow the same framework.  At a minimum, EHR technology presented for certification must be able to electronically receive and transmit (in the respective certification criteria) transitions of care/referral summaries according to the Applicability Statement for Secure Health Transport.  EHR technology developers are also able to seek certification to two optional transport standards:

• The Applicability Statement for Secure Health Transport specification and the XDR and XDM for Direct Messaging specification; and

• The Simple Object Access Protocol (SOAP)-Based Secure Transport Requirements Traceability Matrix (RTM) version 1.0 standard and the XDR and XDM for Direct Messaging specification.
 
Approach Descriptions

Approaches 1 and 2:  The EHR technology presented for certification can perform all of the specific capabilities expressed by the certification criterion, including the required capabilities for content and transport standard (and any optional transport standards) (e.g., for 170.314(b)(1), receipt according to transport standards, display of CCD/C32, CCR, and CCDA, and incorporation of CCDA sections). The EHR technology presented for certification could either be from an EHR technology developer that likely includes other clinical capabilities or from an EHR technology developer (e.g., HIE/HISP) that focuses on transition of care/transmission related capabilities.

Approach 3:  The EHR technology presented for certification can perform most of the capabilities expressed by the certification criterion (e.g., CCDA creation for 170.314(b)(2)), but also relies on a health information exchange (HIE) organization, health information service provider (HISP), or other 3rd party’s technology to perform the required transport standard capability (and any optional transport standards).  Under this approach and to meet the certification criterion:

1.      The EHR technology must be presented for certification together with the technology supplied by the other entity to perform the transport capability (this other technology would be treated as “relied upon” software under ONC’s certification rules (see FAQ 16)).  

2.      The certification issued would represent the unique pairing of the EHR technology and the other entity’s transport technology.

Finally, we note that these certification approaches could also be pursued in combination so long as the full scope of the certification criterion is met.  For example, in order for an EHR technology developer to get its EHR technology certified to meet the required transport standard capability it could pursue the second approach and also seek certification for its EHR technology’s native capability to perform to the second optional transport requirement (i.e., the SOAP-based RTM + XDR/XDM), which would enable its customers to have additional transport capabilities as part of their CEHRT.

QUESTION: For meaningful use Stage 2's transitions of care and referrals objective, in what ways can I meet the second measure that requires more than 10% of the summary care records I provide for transitions of care and referrals to be electronically transmitted?

ANSWER: An EP, eligible hospital, or CAH could use 3 distinct approaches (which could also be used in combination) to meet this measure.  The first two rely solely on the use of CEHRT, while the third is slightly different.

For the first two approaches, this measure can only be met if the EP, eligible hospital, or CAH uses the capabilities and standards included as part of its Certified EHR Technology (CEHRT) to electronically transmit summary care records for transitions of care and referrals  (specifically those capabilities certified to the certification criterion adopted by ONC at 45 CFR 170.314(b)(2) “transitions of care – create and transmit transition of care/referral summaries,” which specifies standards for data content and transport). 

For the third approach, the EP, eligible hospital, or CAH must use its CEHRT to create a summary care record for transitions of care and referrals, but instead of using a transport standard specified in ONC’s certification criterion at 45 CFR 170.314(b)(2) (included as part of its CEHRT) to electronically transmit the summary care record, the EP, eligible hospital, or CAH may use a NwHIN Exchange participant to facilitate the electronic transmission to the recipient.  The NwHIN Exchange is now known as “eHealth Exchange” and a list of participants can be found here. 

The following are more detailed explanations of each permitted approach.  We also emphasize that regardless of the way an EP, eligible hospital, or CAH chooses to transmit the summary of care record, such a transmission will only count in the numerator if it is received by the provider to whom the sending provider is referring or transferring the patient.

1. Use of the transport standard capability required for certification.  As required by ONC to meet the CEHRT definition, every EP, eligible hospital, and CAH, must have EHR technology that is capable of electronically transmitting a summary care record for transitions of care and referrals according to the primary Direct Project specification (the Applicability Statement for Secure Health Transport).  Thus, EPs, eligible hospitals, or CAHs that electronically transmit summary care records using their CEHRT’s “Direct” capability (natively or combined with an intermediary) would be able to count all such electronic transmissions in their numerator.

2. Use of the SOAP-based optional transport standard capability permitted for certification.  As part of certification, ONC permits EHR technology developers to voluntarily seek certification for their EHR technology’s capability to perform SOAP-based electronic transmissions.  EHR technology developers who take this approach would enable their customers to also use this approach to meet the measure.  Thus, EPs, eligible hospitals, or CAHs that electronically transmit summary care records using their CEHRT’s “SOAP-based” capability (natively or combined with an intermediary) would be able to count all of those transmissions in their numerator.

3. Use of CEHRT to create a summary care record in accordance with the required standard (i.e., Consolidated CDA as specified in 45 CFR 170.314(b)(2)), and the electronic transmission is accomplished through the use of an eHealth Exchange participant who enables the electronic transmission of the summary care record to its intended recipient.  Thus, EPs, eligible hospitals, or CAHs who create standardized summary care records using their CEHRT and then use an eHealth Exchange participant to electronically transmit the summary care record would be able to count all of those transmissions in their numerator. 

We note that for this third approach, the regulation also permits an EP, eligible hospital, or CAH to count in their numerator instances where a summary care record for transitions of care or referrals was received via electronic exchange facilitated in a manner consistent with the governance mechanism ONC establishes for the nationwide health information network.  ONC has not yet established a governance mechanism for the nationwide health information network.  Until ONC establishes such a governance mechanism, this specific option will not be available.

All meaningful use FAQs are available here.

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