Support Electronic Referral Loops by Sending Health Information

Measure: For at least one transition of care or referral, the MIPS ECClosed Eligible Clinician: a Medicare provider who qualifies for MIPS participation that transitions or refers their patient to another setting of care or health care provider — (1) creates a summary of care record using CEHRTClosed Certified EHR Technology, an EHR that conforms to the ONC's Health IT Certification Program criteria and standards; and (2) electronically exchanges the summary of care record.
Denominator Number of transitions of care and referrals during the performance period for which the MIPS eligible clinician was the transferring or referring clinician.
Numerator The number of transitions of care and referrals in the denominator where a summary of care record was created using CEHRT and exchanged electronically.
Exclusion Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.

CMS defines a transition of care as 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. At a minimum, this includes all transitions of care and referrals that are ordered by the MIPS eligible clinician.

To be included in the denominator:

  • Patient must have a referral documented during the performance period

OR

  • Patient's clinical summary must be sent electronically during the performance period
  1. From the Referrals tab in the chart or the Orders/Referrals tab in the encounter, click Add
  2. Populate the following sections:
    1. Date Requested (chart level only)
    2. Requested By
      1. Requested By must be EC
    3. Refer To
      1. Refer To must be a secure contactClosed Clinic or User contact with a Direct exchange address entered in the Secure Email field
    4. Reason for Referral/Notes
    5. ICD Code or CPT/HCPCS
  3. Click Add
  1. From the patient chart go to Chart Tools > Send Clinical Summary
  2. Populate the Provider field
    1. Provider selected must be EC
  3. Select Summary of care record or Clinical summary from selected encounter(s)
    1. Optional: If sending a Clinical summary from selected encounter(s), Include selected E-Labs can be selected
  4. Populate the To, Subject, and message body fields
  5. Optional: Click Add in the Scanned/Imported Labs section to attach one or more scanned or imported lab results
  6. Click OK to send
    1. If sending a Clinical summary from selected encounter(s), follow the encounter and e-Lab selection prompts to send the clinical summary

To be included in the numerator:

  • Patient referral must be sent electronically during the performance period

OR

  • Patient's clinical summary must be sent electronically during the performance period
  1. From the Referrals tab in the chart or the Orders/Referrals tab in the encounter, select the referral to be sent
  2. Click Send
  3. Populate the Subject and message body fields
  4. If sending from the patient chart, click Add in the Referral Summary for Selected Encounter(s) section to select one or more encounters to send with the referral
    1. If sending from the encounter, the patient information from the open encounter will be included with the referral

    2. Optional: If sending from the encounter, select Include clinical summary from additional encounter(s) checkbox to send one or more additional encounters with the referral

  5. Optional: Click Add in the Labs section to attach one or more lab results
  6. Click OK to send

A clinical summary can be sent electronically by following the steps outlined in the denominator.

  • The electronic transmission of the clinical summary or referral must be successful in order to count toward the numerator
    • Transmissions that are not successful will generate an “Undeliverable” message in the Direct Message Inbox

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