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.
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
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?
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.
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.
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.
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.
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.