In 2018, there are 2 measure set options for submission depending on the Certified EHR Technology (CEHRT) edition a clinician is using:

• Promoting Interoperability Measures           
• Promoting Interoperability (PI) Transition Measures                     
  

Depending on the CEHRT Edition, there will be different objectives from which the MIPS eligible clinician may choose to report. This article outlines the measure details and specifications for the 2018 PI Transition Measure: Health Information Exchange.

• Numerator: The number of outgoing transitions of care and referrals in the denominator where a summary of care record was created using CEHRT and exchanged electronically.
• Denominator: The number of outgoing transitions of care and referrals during the performance period for which the MIPS eligible clinician was the transferring or referring health care clinician.
• Exclusion: Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period. A MIPS eligible clinician may claim this exclusion if the exclusion criteria are met, but is not required to do so and may report on the measure if he or she chooses.

Scoring Requirements
To earn base score credit for this measure, a MIPS eligible clinician must meet the numerator requirements for at least one denominator eligible patient during the 2018 calendar year. To meet numerator requirements for this measure, a MIPS eligible clinician who transitions or refers his or her patient to another setting of care or health care clinician must 1) use CEHRT to create a summary of care record, 2) electronically transmit such summary to a receiving health care clinician, and 3) must have reasonable certainty of receipt by the receiving clinician to count the action toward the measure.

Measure Requirements: Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to help ensure that you meet the workflow requirements for this measure within the Practice Fusion EHR. See the Detailed Information about the Practice Fusion Suggested Workflow section below for screenshots of each step.

1. Ensure that your referral recipient is a contact in your Directory: Ensure that the referral recipient is added as a contact in your Directory and, if the recipient is not a verified Practice Fusion provider (i.e. the provider uses a different EHR system), that a Direct address has been entered into the recipient’s contact information.
   
2. Send an electronic referral that includes a summary of care record (clinical document) attachment: Initiate an electronic referral by selecting Add referral from the Actions dropdown menu in the patient chart and completing the appropriate fields. 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. Send the referral once you have confirmed that the referral details are complete.
   
3. After the referral is sent: Obtain reasonable certainty that the receiving clinician has received the referral and the attached summary of care, and once you have done so, indicate this confirmation by checking the Receipt checkbox in the Referrals section of the patient Timeline.

Detailed information about the Practice Fusion Suggested Workflow
1. Ensure that your recipient is a contact in your Directory

Practice Fusion Recipient
Before sending a referral to another verified Practice Fusion provider, you will need to ensure that they are added as a contact in your Practice Fusion EHR Directory. To access your Directory, select the Home button from your left-hand navigation bar and click the Directory tab at the top of the page. If the recipient is not listed as an existing contact in your Directory, you can add a new contact using the workflow outlined here.

Non-Practice Fusion Recipient
If you are sending a referral via Direct message to a provider outside the Practice Fusion network (i.e. a provider using a different EHR system), you and the receiving provider must each have a Direct address. If you do not have a Direct address, you can request one using the steps detailed here. Once you have obtained your Direct address, you can manually add your referral recipient as a new contact to your Directory, making sure to add their Direct address in the appropriate field. Please note that you will need to contact the recipient to obtain their Direct address. Furthermore, only Practice Fusion providers who have been verified for a Direct address will see the Direct Address field when adding a new contact to their Directory.

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.

If you are sending the referral on behalf of another member of your practice, select the MIPS eligible clinician’s name from the On Behalf Of menu. Please note: to successfully send a referral via Direct Message on behalf of the clinician, you will also need to request a Direct Address within your own account. For details on how to do so, please click here.

Per the CMS measure specifications, the MIPS eligible clinician must verify that 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 MIPS eligible clinician at the time of generating the summary of care document or include a notation of no current problem, no medication and/or no medication allergies. For a complete list of information that should be included in the summary of care record if known by the referring provider, please review FAQ #3 at the end of this article.

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 un-check the Send by fax checkbox.

3. Confirm referral receipt
Obtain reasonable certainty that the receiving clinician has received the referral and the attached summary of care, and once you have done so, navigate to the patient Timeline and select Referrals from the dropdown menu. Use the “Confirmed” checkbox in the Receipt column to indicate receipt confirmation.

Receipt confirmation may also be indicated in the Referrals section of Messages.

FAQs

1. Who are verified referral recipients?

In order to gain numerator credit for this measure using Practice Fusion, you will need to send referrals to verified recipients. Verified referral recipients who use Practice Fusion are providers who have completed e-Prescribing verification within the Practice Fusion EHR. These providers will appear as searchable contacts in the Practice Fusion Directory. Practice Fusion providers who have not completed e-Prescribing verification will not appear in the Practice Fusion Directory, but will count as verified referral recipients if they have obtained a Direct address as part of the Direct Trust network. Please note that you will need to contact them to obtain their Direct address before sending a referral.

Verified referral recipients who use other certified EHR systems are those who have obtained a Direct address as part of the Direct Trust network. Before sending a referral to a non-Practice Fusion provider, you will need to contact them to obtain their Direct address. To see a list of other EHR systems 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 suggested guidance on obtaining Direct addresses from providers to whom you wish to send referrals.

2. What is considered a transition of care for the purposes of this measure?

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. Within Practice Fusion, a transition of care for the purposes of this measure is recorded upon the transition of a patient from your care to an outside setting of care, e.g. another provider, specialist, a long term care facility, or hospital.

3. What is the minimum amount of information that is required in the summary of care?

CMS indicates that all summary of care documents used to meet this measure must include the following information if known by the MIPS eligible clinician:

• Patient name
• Referring or transitioning healthcare provider’s name and office contact information (MIPS eligible clinician only)
• Procedures
• Encounter diagnosis
• Immunizations
• Lab test results
• Vital signs (height, weight, blood pressure, BMI)
• Smoking status
• Functional status, including activities of daily living, cognitive and disability status
• Demographic information (preferred language, sex, race, ethnicity, date of birth)
• Care plan field, including goals and instructions
• Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider
• Reason for referral (MIPS eligible clinician only)
• Current problem list (Providers may also include historical problems at their discretion)
• Current medication list
• Current medication allergy list

More information

• Review the CMS specifications   for more information about this measure.
• For more information on the Merit-based Incentive Payment System (MIPS) program, you can visit Practice Fusion’s Quality Payment Program Center.