This measure requires that you provide a summary of care record when you transition or refer a patient to another setting or provider. The 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.
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: Number of transitions of care and referrals made during the reporting period.
Numerator: Number of transitions of care and referrals where a summary of care record was created and provided electronically to the provider to whom you are referring the patient.
Practice Fusion workflow for denominator credit
In order for a transition of care to be included in the denominator, you must complete one of the following actions:
- Send a referral (see below for instructions)
- Document a referral in the Screenings/interventions/assessments section of an encounter
Practice Fusion workflow for numerator credit
In order for a transition of care to be included in the numerator, you must electronically send a referral letter with an attached summary of care to a verified referral recipient. For more information about verified referral recipients, please review the FAQ below.
*Please see the FAQ at the bottom of the page for more information about verified referral recipients
Please follow the workflow outlined below for sending an electronic referral.
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. Create a a clinical document
From the Actions drop-down menu in a patient’s chart, select Create clinical document.
3. Send an electronic referral
Once you have generated your clinical/referral summary, select Add referral from the Actions drop-down menu.
Select a recipient from the My Connections fly-out pane. In order to receive credit for this measure, you must send 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 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.
You must attach a clinical or referral summary and any other relevant documentation.
Additionally, you may uncheck the Send by fax checkbox.
4. Review the 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. You will receive credit on your Meaningful Use Dashboard when the status changes from Pending to Sent. If the status remains as Pending, please contact the recipient to see if they have received the referral and resend it if necessary.
The Meaningful Use Dashboard determines that a patient has been seen during the EHR reporting period if the patient has a signed note with a date of service that is during your EHR reporting period with any of the following encounter types:
- Office Visit
- Home Visit
- Telemedicine Visit
- Nursing Home Visit
Only the provider who signs the note receives denominator credit.
Who are verified referral recipients?
In order to receive 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 clinical or referral summary. Referral summaries automatically include problem list, medication list, and medication allergy information.
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.
Should I send a referral summary or clinical summary as part of the referral?
You may generate either a clinical or referral summary, but we recommend a referral summary for completeness.
Review the CMS specifications for more information about this measure.