2018 Medicaid Meaningful Use Stage 2 Objective 5: Health Information Exchange

Overview
This measure requires that you provide a summary of care record when you transition or refer a patient to another setting or provider. The Eligible Professional (EP) who transitions or refers their patient to another setting of care or provider of care must use Certified EHR Technology (CEHRT) to create a summary of care record and electronically transmit such summary to a receiving provider for more than 10% of transitions of care and referrals.

Practice Fusion Meaningful Use Dashboard Calculation

  • Denominator: The number of transitions of care and referrals during the EHR reporting period for which the EP was the transferring or referring health care provider.    
  • Numerator: Number of transitions of care and referrals where a summary of care record  was created using CEHRT and exchanged electronically.

Exclusion (learn more)
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 excluded from this objective.

Denominator Requirements
The following EHR actions are considered a “transitions of care” or “referral” for the purposes of determining the denominator of this measure:

  • All referrals sent via the Practice Fusion referral workflow (including eFaxed referrals)
  • A signed encounter note for a patient seen during the performance period where the “Outgoing Transitions of Care” checkbox is checked under the Quality of Care section of the SOAP note

Numerator Requirements
In order for a transition of care to be included in the numerator, you must send an electronic referral using the Practice Fusion referral workflow with an attached summary of care to a verified referral recipient. For more information about verified referral recipients, please review the FAQ at the bottom of the page.

What counts towards numerator credit for this measure in Practice Fusion?

What does not count towards numerator credit for this measure in Practice Fusion?

  • Referrals sent to verified recipients* via Direct message or via the Practice Fusion referral network, with an attached Continuity of Care (CCD) clinical document or Referral Note clinical document.

  • eFaxed referrals
  • Emails
  • Referrals without an attached Continuity of Care (CCD) clinical document or Referral Note clinical document
  • Referrals sent to non-verified recipients*
*Please see the FAQ at the bottom of the page for more information about verified referral recipients  

Please follow the workflow outlined below to send an electronic referral with a numerator eligible summary of care record as an attachment.

1. Add your recipient to your Directory

Practice Fusion Recipient
Before sending a referral to another Practice Fusion provider, you must search for them within the Practice Fusion network and add them to your
Directory. To access your Directory, select the Home section from your left-hand navigation bar and select the Directory tab. Search for the provider by name and specialty, then click Add to my network.

Non-Practice Fusion Recipient
If you are sending a referral via Direct messaging to a provider outside the Practice Fusion network, you must first request a
Direct address. Once you have been verified, you can add the referral recipient as a new contact to your directory using their Direct address. You must contact the recipient to obtain their Direct address. Note: Only users who have been verified for a Direct address will see the ‘Direct Address’ field when adding a new contact.

2. Send an electronic referral that includes a summary of care record (clinical document) attachment
To send an electronic referral using the Practice Fusion referral workflow, select
Add referral from the Actions dropdown menu.

Select a recipient from the My Connections flyout pane. In order to receive numerator credit for this measure, you must send the referral electronically to a verified referral recipient.*

If you are sending the referral on behalf of another member of your practice, select the attesting provider’s name from the On Behalf Of menu. The selected provider will receive denominator credit for the referral on the Meaningful Use dashboard. Please note: To successfully send a Direct Message referral on behalf of the attesting provider, you will also need to request a Direct Address within your own account. For details on how to do so, please click here.

Click into the Attachments field and select Generate referral note to attach a Referral Note clinical document or alternatively, attach a previously generated Continuity of Care (CCD) clinical document. Both Referral Note clinical documents and CCD clinical documents count towards the “summary of care record created in CEHRT” requirement in the numerator of this measure. From the attachments pane, you may also attach any additional relevant documentation as necessary. If you do not wish to send a paper copy of the referral in addition to the electronic copy, you may uncheck the Send by fax checkbox.

Referral_summary_of_carepng

3. Review and send
Once you’ve confirmed your referral is complete, you can click Preview to review the full referral. When you’re ready, click Send to send the referral.

4. Track a sent referral
You can review a sent referral in the
Timeline tab of the patient’s chart when filtering by Referrals. Under the Status column, Digital will indicate that the referral has been sent electronically within the Practice Fusion network. Direct will indicate that it has been sent via Direct messaging. In order to receive measure numerator credit on your Meaningful Use Dashboard, the referral status must be Sent. If the status remains as Pending, please contact the recipient to see if they have received the referral and resend it if necessary. CMS has advised that the referring provider must have reasonable certainty of receipt by the receiving provider to count the action toward the measure.

FAQs

Who are verified referral recipients?
In order to receive numerator credit for this measure, you must send referrals to verified recipients. Verified referral recipients are Practice Fusion providers who have completed
e-Prescribing verification or providers using other certified EHRs who have obtained a Direct address as part of the Direct Trust network. Before sending a referral to a non-Practice Fusion provider, you must contact them to obtain their Direct address.To see a list of other EHRs that are part of the Direct Trust network, click here for those in the Direct Trust network and here for those who are partnered with Updox, a member of the Direct Trust network. You can also visit our blog post for guidance on obtaining Direct addresses from providers to whom you wish to send referrals.

What is considered a transition of care for the purposes of this measure?
CMS defines transition of care as the movement of a patient from one clinical setting (inpatient, outpatient, physician office, home health, rehab, long-term care facility, etc.) to another or from one EP to another. Stage 2 Objective 5 only looks at measures where you are transitioning patients outside of your care to another provider or another setting of care such as a long term care facility, hospital, or specialist. For complete details on the definition of a transition of care, please review the CMS stipulations
here.  

What is the minimum amount of information that is required in the summary of care?
You must verify the fields for current problem list, current medication list, and current medication allergy list are not blank and include the most recent information known by the provider as of the time of generating the Referral Note or CCD clinical documents.

How do I sign up for Direct Messaging?
Visit our
article on Direct messaging to get started.

When does the referral need to be sent in order to receive credit on the Meaningful Use Dashboard?
The referral needs to be sent within the reporting year for which you are attesting.

More information

Meaningful Use

  1. What is Meaningful Use?
  2. How do I attest for Meaningful Use?
  3. How does the Meaningful Use Dashboard work?
  4. 2018 Medicaid Meaningful Use Stage 2 Objective 1: Protect Patient Health Information
  5. 2018 Medicaid Meaningful Use Stage 2 Objective 2: Clinical Decision Support
  6. 2018 Medicaid Meaningful Use Stage 2 Objective 3: CPOE for Medication, Lab, and Radiology Orders
  7. 2018 Medicaid Meaningful Use Stage 2 Objective 4: Electronic Prescribing (eRx)
  8. 2018 Medicaid Meaningful Use Stage 2 Objective 5: Health Information Exchange
  9. 2018 Medicaid Meaningful Use Stage 2 Objective 6: Patient-Specific Education
  10. 2018 Medicaid Meaningful Use Stage 2 Objective 7: Medication Reconciliation
  11. 2018 Medicaid Meaningful Use Stage 2 Objective 8: Patient Electronic Access
  12. 2018 Medicaid Meaningful Use Stage 2 Objective 9: Secure Electronic Messaging
  13. 2018 Medicaid Meaningful Use Stage 2 Objective 10: Public Health Reporting
  14. 2017 Medicaid Meaningful Use Stage 2 Objective 1: Protect Patient Health Information
  15. 2017 Medicaid Meaningful Use Stage 2 Objective 2: Clinical Decision Support
  16. 2017 Medicaid Meaningful Use Stage 2 Objective 3: CPOE for Medication, Lab, and Radiology Orders
  17. 2017 Medicaid Meaningful Use Stage 2 Objective 4: Electronic Prescribing (eRx)
  18. 2017 Medicaid Meaningful Use Stage 2 Objective 5: Health Information Exchange
  19. 2017 Medicaid Meaningful Use Stage 2 Objective 6: Patient-Specific Education
  20. 2017 Medicaid Meaningful Use Stage 2 Objective 7: Medication Reconciliation
  21. 2017 Medicaid Meaningful Use Stage 2 Objective 8: Patient Electronic Access
  22. 2017 Medicaid Meaningful Use Stage 2 Objective 9: Secure Electronic Messaging
  23. 2017 Medicaid Meaningful Use Stage 2 Objective 10: Public Health Reporting
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  29. What patients are counted for Meaningful Use?
  30. How do the components of a chart note relate to Meaningful Use?
  31. How do I print the Meaningful Use Dashboard?
  32. How do I minimize or refresh CDS notifications?
  33. How can I send a referral using Direct Messaging?
  34. How does patient portal access and auto-invite relate to Meaningful Use?
  35. What constitutes a "unique" patient?
  36. Meaningful Use attestation for previous years
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  38. How do I apply for a Meaningful Use Hardship Exception?
  39. How do I find Practice Fusion's CMS EHR Certification ID?
  40. How do I register for the Medicaid Meaningful Use Program?
  41. Can I change, modify, or cancel my attestation?
  42. How do I choose my reporting period duration for Medicaid Meaningful Use?
  43. Is Practice Fusion a certified EHR?
  44. Patient records maintained in the EHR for Meaningful Use attestation
  45. How do I get my AIU letter from Practice Fusion?
  46. How do I report eCQMs for Medicaid Meaningful Use?
  47. Do I have to meet all 10 objectives to achieve Meaningful Use?
  48. Can I participate in both MIPS (Medicare) and Meaningful Use (Medicaid)?
  49. Are there patient education materials available in Spanish?
  50. How do I select or change my reporting period start date?
  51. When do I need to sign chart notes for Meaningful Use? Can I sign a chart after the reporting period?
  52. How do I contact my state about the Medicaid EHR Incentive Program?
  53. How do I qualify for Meaningful Use if I see patients in multiple locations?
  54. How many exclusions can each provider claim for meaningful use?
  55. How do I use multiple EHR's to qualify for Medicaid Meaningful Use?
  56. What stage of Medicaid Meaningful Use am I in?
  57. How do I prepare for the PQRS Penalty Informal Review?
  58. How do I prepare for a Meaningful Use audit?
  59. How do I batch export patient data from the EHR?
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