Objective: The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide a summary care record for each transition of care or referral.

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% of transitions of care and referrals.

For more detailed information on this measure, please click on the reference link below. This CMS documentation includes information on exclusions, attestation requirements, a definition of terms, and important additional information.

Reference CMS:  Summary of Care.

Measure1:

Denominator:  Number of transitions of care and referrals during the EHR reporting period for which the Eligible Provider was the transferring or referring provider. In SOAPware, this is the number of orders placed in Order Manager for a specific provider during the reporting period with a SNOMEDCT code of one of the following:

103697008, 103699006, 183515008, 183517000, 183528001, 183529009, 183530004, 183541002, 183555005, 183557002, 183561008, 183567007, 183569005, 183591003, 183878008, 183879000, 183880002, 183881003, 183882005, 183884006, 183885007, 183886008, 183887004, 183888009, 183889001, 183890005, 183891009, 183892002, 183893007, 183894001, 183895000, 183896004, 183897008, 183899006, 183900001, 183901002, 183902009, 183903004, 183904005, 183905006, 183906007, 183907003, 183908008, 183909000, 183910005, 183911009, 183913007, 183914001, 183915000, 183916004, 266747000, 274410002, 306160005, 306161009, 306162002, 306253008, 306254002, 306255001, 306256000, 306257009, 306258004, 306259007, 306260002, 306261003, 306262005, 306263000, 306264006, 306265007, 306266008, 306267004, 306268009, 306269001, 306270000, 306271001, 306272008, 306273003, 306274009, 306275005, 306276006, 306277002, 306278007, 306279004, 306280001, 306281002, 306282009, 306284005, 306285006, 306286007, 306287003, 306288008, 306289000, 306290009, 306291008, 306293006, 306294000, 306295004, 306296003, 306297007, 306298002, 306299005, 306300002, 306301003, 306302005, 306303000, 306304006, 306305007, 306306008, 306307004, 306308009, 306309001, 306310006, 306311005, 306312003, 306313008, 306314002, 306315001, 306316000, 306317009, 306318004, 306320001, 306338003, 306351008, 306352001, 306353006, 306354000, 306355004, 306356003, 306357007, 306358002, 306359005, 306360000, 306361001, 306736002, 307063001, 307777008, 308447003, 308449000, 308450000, 308451001, 308452008, 308453003, 308465004, 308469005, 308470006, 308471005, 308472003, 308473008, 308474002, 308475001, 308476000, 308477009, 308478004, 308479007, 308480005, 308481009, 308482002, 308483007, 308484001, 308485000, 309046007, 309627007, 309629005, 310515004, 312487009, 312488004, 390807002, 406158007, 406159004, 408285001, 415277000, 416116000, 425971006, 429365000, 54395008, 428441000124100, 428451000124103, 428461000124101, 428471000124108, 428481000124106, 428491000124109, 428541000124104

Numerator: The number of transitions of care and referrals in the denominator where a summary of care record was provided. In SOAPware, this is the number of orders in the denominator where a summary of care record was provided by printing, faxing or electronically submitting the Care Summary for the order in Order Manager.

Threshold:  The percentage must be more than 50% in order for an Eligible Provider  to meet this measure.

For more detailed information on this measure, please click on the reference link below. This CMS documentation includes information on exclusions, attestation requirements, a definition of terms, and important additional information.

Reference CMS: Transition of Care Summary

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