Support Electronic Referral Loops by Sending Health Information | MIPS PI Measures for 2021 Reporting

For use with CEHRT certified to the 2015 edition.

Measure Description

For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider — (1) creates a summary of care record using certified electronic
health record technology (CEHRT); and (2) electronically exchanges the summary of care record.

Reporting Requirements

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.

Denominator

Number of transitions of care and referrals during the performance period for which the MIPS eligible clinician was the transferring or referring clinician.

Exclusions

Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.

Definition of Terms & Additional Information

Transition of Care – 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.

Referral – Cases where one provider refers a patient to another, but the referring provider maintains his or her care of the patient as well.

Summary of Care Record – All summary of care documents used to meet this objective must include the following information if the MIPS eligible clinician knows it:

• Patient name
• Demographic information (preferred language, sex, race, ethnicity, date of birth)
• Smoking status
• Current problem list (eligible clinicians may also include historical problems at their discretion)*
• Current medication list*
• Current medication allergy list*
• Laboratory test(s)
• Laboratory value(s)/result(s)
• Vital signs (height, weight, blood pressure, BMI)
• Procedures
• Care team member(s) (including the primary care provider of record and any additional known
  care team members beyond the referring or transitioning clinician and the receiving clinician)*
• Immunizations
• Unique device identifier(s) for a patient’s implantable device(s)
• Care plan, including goals, health concerns, and assessment and plan of treatment
• Referring or transitioning clinician’s name and office contact information
• Encounter diagnosis
• Functional status, including activities of daily living, cognitive and disability status
• Reason for referral

*Note: A 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 as of the time of generating the summary of care document or include a notation of no current problem, medication and/or medication allergies.

Current problem lists – At a minimum a list of current and active diagnoses.

Active/current medication list – A list of medications that a given patient is currently taking.

Active/current medication allergy list – A list of medications to which a given patient has known allergies.

Allergy – An exaggerated immune response or reaction to substances that are generally not harmful.

Care Plan – The structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).