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.
Medicaid Promoting Interoperability Objective and Calculation
The objective is to have the EP who transitions or refers their patient to another setting or provider of care provide a summary care record for each transition of care or referral.
- The EP that transitions or refers their patient to another setting or provider of care:
- uses CEHRT to create a summary of care record; and,
- electronically transmits such summary to a receiving provider for more than 50 percent of transitions of care and referrals.
Denominator for calculations: Number of transitions of care and referrals during the EHR reporting period for which the EP was the transferring or referring provider as entered in the Referrals component of RevolutionEHR.
Numerator for calculations: The number of transitions of care and referrals in the denominator where a summary of care record was sent electronically using the “Send Transition of Care” button in the Referrals component and where confirmation of receipt was obtained.
- Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is offered an exclusion from the measure.
- Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the PI reporting period may exclude the measures.
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, outbound referrals should be logged in the “Referrals” component under the Show More tab. 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.
Selecting the “Send Transition of Care” button will open the messaging system with a compose box. Selecting the “Send” button will generate the Record Summary and automatically attach it to the outgoing Direct message. 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 is significantly challenging because the provider’s ability to transmit a document electronically depends on the recipient having Direct messaging capability. 2021 also adds the need to obtain confirmation that the document was received by the consulting provider.