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Meaningful Use
Transition of Care
March 2015
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Another Change (NOT Stage 3)
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Regulations
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Transition of Care
Transition Out
Transition in
Medication Reconciliation
Requirement
Summary of Care Document
Requirement
When
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What is a Transition of Care
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What is a Transition of Care
Ran by MCEITA, no useful feedback from CMS/ONC MU hotline
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What is NOT a Transition of Care
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Summary of Care
Data Requirements
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* New in Final Rule i State has option to make required for Medicaid
CCDA From GloStreams
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CCDA From eCw
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CCDA From Next Gen
Longitudinal verses encounter CCDA
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* New in Final Rule i State has option to make required for Medicaid
Table of Content (Interactive)
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Summary of Care
Technical Piece
This of this as “medical
grade email”.
Direct Email: Everyone is
using this (that we can tell).
Only sending to those that do not have access to Munson Healthcare
Cerner (Powerchart/Firstnet) . May be applicable if multiple
locations
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Department of Defense
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Summary of Care
Direct Emails Only
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Test between EHRs
http://www.munsonhealthcare.org/meaningfuluse (Summary or Care, CCDA Test in eCw)
Suggest waiting until eCw is Direct Trust Certified
https://ehr-randomizer.nist.gov/ehr-randomizer-app/#/home
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Testing with Munson
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Additional Items
• Transition of Care/Summary of Care/CCDA must be
sent (not just a referral note - federal government)
• Most are using as referral. In some cases, this is more
work.
• For Referrals, additional information needed:
• Signed order
• Additional forms
• Insurance information
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Referral from GloStreams (NOT CCDA)
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Addresses Built
http://www.munsonhealthcare.org/meaningfuluse
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MMC Department
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MMC Referrals
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In Progress (DO NOT USE)
In progress, but not tested and trained
• Advanced Wound Care and Advanced Wound
Center/Hyperbaric Oxygen Therapy
• Agility PT (Cadillac and Grayling, Roscommon,
Prudenville), Various emails.
• PT (POMH and KMH) not up installed but coming
• Munson Oncology (Medical and Radiation)
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The REAL Benefit - Receiving
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The REAL Benefit - Receiving
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The REAL Benefit - Receiving
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TEST, TEST, TEST before live
Figure out who you
transition your patients to
Contact them and find out
what their address is
What other forms are
needed
Do a test, or two, or
three….
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Miscellaneous
• eCw uses P2P
• Sending outside of P2P, difficult.
• Becoming direct Trust Certified in April, 2015
• Forms at MMC:
http://www.munsonhealthcare.org/physicianforms
• Next Gen: uses Next Gen Share and that is working in
production mode. John Rokos can test with you if
interested (MMC)
• MMC Oncology addresses are set up but not yet tested
• Sending to physician or sending to practice
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Miscellaneous
• CMS/ONC hotline says it must happen BEFORE the
patient arrives at their new location
• Federal Regulations do not specify
• Trinity says within the reporting period
• Must understand your software and how it defines a
Transition of Care (aka, denominator)
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Stage 3 (Advisory Group)
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Stage 3 (CHIME Table)
From CHIME: Officials from the Department of Health and Human Services (HHS) unveiled their vision for MU Stage 3, including changes
that support "efforts to increase simplicity and flexibility in the program while driving interoperability and a focus on patient outcomes in the
meaningful use program," CMS said. The proposed MU rule would establish a single reporting period for all providers based on the calendar
year and require all hospitals to meet 18 measures across 8 objective areas and all eligible professionals to meet 17 measures across the same
objective areas. Stage 3 will begin in 2017, but the proposed rule allows most providers the option to wait until 2018 to move from Stage 2 to
Stage 3. Below is a snapshot of proposed objectives for Stage 3:
Protect ePHI
Perform a security risk analysis
eRx
> 80%
> 25% of hospital discharges medication orders query drug formulary
Clinical Decision Support
5 CDS alerts
Enabled drug/drug; drug/allergy interaction
CPOE
80% medication orders
60% lab orders
60% diagnostic
Patient Electronic Access to Health Information
Provide access w/in 24 hours (can be through API)
> 35% Education resources
Coordination of Care through Patient Engagement (meet 2 of 3)
> 25% View, Download or Transmit or > 25% use API to access their information
> 35% use secure messaging
> 15% PGHD is incorporated
Health Information Exchange (2 of 3)
> 50% of ToC transmit electronic summary of care record (SoCR)
> 40% of ToC recipients incorporate SoCR into their EHR
> 80% of ToC perform "clinical information reconciliation"
Public Health
6 measures; EPs choose 3 of measures 1-5; EHs choose 4 of measures 1-6
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Questions