Overview 

Providing a Transition of Care (ToC)/Referral Summary when patients are transitioned to another setting of care or provider of care is a requirement for EPs in Stage 1 and Stage 2. The ToC / Referral Summary must be provided for 50% of the transitions of care in both stages, however, Stage 2 has more demanding measure requirements. 

In Stage 2 EPs must provide the ToC/Referral Summary CCDA electronically for at least 10% of transitions of care and must successfully send the summary electronically at least once to a recipient who is using a different CEHRT or successfully send the summary to a CMS designated test EHR during the reporting period.  

NOTE: At the time this document was written the development of the CMS test EHR program was still in progress. For the latest information consult the CMS website. 

User Interface 

A provider may print the ToC/Referral Summary or send electronically using Direct Messaging: sending using a direct address.

The summary may be sent direct from two places:  

  1. the Updox System Link;

  2. from referral management after saving a referral.

  3. You can also print the summary.

Remember that the system link and referral management will only display if:

NOTE: The ToC/Referral Summary cannot be customized, and all historical data will populate the summary.

Objectives

  Objective Measure
Stage 1 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 summary care record for each transition of care or referral.  
Stage 2 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 summary care record for each transition of care or referral. Measure 1: 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 percent of transitions of care and referrals. 
 
Measure 2: 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 10 percent of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the NwHIN. 
 

Measure 3: An EP must conduct one or more successful electronic exchanges of a summary of care document, as part of which is counted in "measure 2" (for EPs the measure at §495.6(j)(14)(ii)(B) with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology certified to 45 CFR 170.314(b)(2).