When a patient is transitioned from the provider’s practice to that of another provider, a summary of care record should be provided in electronic format to assist the receiving provider in the coordination of care.
PI Objective and Calculation
The objective is to have the EC who transitions or refers a patient to another setting or provider of care provide a summary care record for each transition of care or referral.
- For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider — (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.
Denominator for calculation:
Number of transitions of care and referrals during the performance period for which the MIPS eligible clinician was the transferring or referring clinician.
Numerator for calculation:
The number of transitions of care and referrals in the denominator where
- A summary of care record was created using CEHRT; and
- The summary of care record was securely and electronically exchanged with the consulting provider; and
- “Confirmation of Receipt” is indicated by the sending provider.
- Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.
EXCLUSION POINT SHIFT:
In the event an exclusion is claimed for this measure, the potential points for this measure are reallocated to the Provide Patients Electronic Access to Their Health Information measure.
Promoting Interoperability Discussion
A transition of care is the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. Optometrists and ophthalmologists may transition or refer patients into many of these types of settings.
For RevolutionEHR to track this data for reporting, transitions of care out of provider’s practice for referral or consultation with another health care provider should be documented using the “Referrals” component under the left menu. The user should click Add to start documenting an outbound referral and build the referral fields.
Electronic transmission of the Summary of Care document from within the “Referrals” screen is accomplished by using the “Send Transition of Care” button.
This button is only available if:
- the practice has Direct messaging enabled via RevDirect,
- the "Referred To" provider has a Direct address entered in their external provider file,
- the "Referred By" provider has a Direct address entered in their employee file.
Steps, in order, necessary for numerator credit:
- Click the 'Send Transition of Care' button to open the messaging system with a compose box.
- Click the 'Send' button to generate the Record Summary and automatically attach it to the outgoing Direct message.
- Save Referral.
- Open Referral to click 'Confirmation of Receipt.'
- Save Referral.
The numerator will NOT trigger until the user actually sends the message and indicates “Confirmation of Receipt” by the consulting provider: See Example
Meeting this objective can be challenging given the electronic communication and workflow as well as the associated documentation. Persistent efforts to obtain Direct addresses from doctors in the referral network of the clinician will be required to achieve success.