Health Information Exchange (Medicaid)

The objective of this measure is to provide a summary of care record when transitioning or referring a patient to another setting of care, receive or retrieve a summary of care record upon the receipt of a transition or referral or upon the first patient encounter with a new patient, and incorporate the summary of care information from other providers into the patient's health record using the functions of a certified EHR.

This page provides information related to the Medicaid Promoting Interoperability program. If you're looking for Medicare MIPS information, go to Support Electronic Referral Loops by Receiving and Incorporating Health Information and Support Electronic Referral Loops by Sending Health Information.

This objective of this measure is to encourage you to generate and send a summary of care for your outbound referrals. This measure also encouraged you to incorporate patient health information sent by other clinicians into the patient’s record. You should, whenever possible, transmit and request the summary of care (CCD) electronically via secure messaging.

Start asking your fellow providers for their direct addresses so you can achieve this measure early in your performance period. The direct address may also be known as a secure messaging address or HISP address.

As you collect these addresses, add them to your referral contacts in Eyefinity EHR. Log in to Eyefinity EHR on the web. Click the Document Management tab, add a new referral contact or edit an existing one, enter the provider’s direct address in the HISP Address text box, and click Save.

This measure requires three tasks:

Sending Summaries of Care

  1. Within the patient’s exam, click Patient Hx.

    The patient’s Patient Information Center window opens.

  2. On the Exam Hx tab, click New Referral.
  3. Select the Referring Provider, Refer to Provider, Reason, SNOMED, Referral Date, and Expected Return Date and click Save.
  4. Click Create CDA Transition of Care and click Exit.

    Your message and the patient’s CDA are sent securely.

Receiving Summaries of Care

To complete this task, you will need a secure message with a summary of care (CCD) attached, and a preliminary visit with which to associate the CCD. When you receive a secure message containing a CCD file, perform the following steps:

  1. In Eyefinity EHR, tap Mail.
  2. Select the Direct Mail Inbox.
  3. Tap the subject of the message.
  4. In the Attachments section, locate the CCD and tap Associate with Patient.
  5. The Document Management page opens.
  6. Enter the name of the Patient, select the Visit, and ensure the Category displays CCD.
  7. Tap Save.

Incorporating Summaries of Care into Patient Records

Once you’ve associated the summary of care with an exam, you’ll need to incorporate the medication, medication allergy, and problem list data into the patient’s record:

  1. Open the preliminary visit.
  2. Open the patient clipboard:
    1. Tap More.
    2. Select Patient Clipboard.
  3. Tap Edit.
  4. Reconcile any medications:
    1. Tap the Medications tab.
    2. Tap Import.
    3. Select Transition of Care (CCD).
    4. Review the medications.
    5. Tap Select All or tap to select individual medications manually, as needed, and tap Accept.

      OR

      Tap Reject to not incorporate any of the medications into the patient’s record.

      A summary page lists the patient’s current medications and highlights the medications that will be imported from the CCD.

    6. Tap Accept.
    7. Tap Back to exit medications and return to the patient clipboard.
  5. Reconcile any medication allergies:
    1. Tap the Allergies tab.
    2. Tap Reconcile.
    3. Select Transitions.
    4. Review the allergies.

      The left side of the screen displays the allergies currently in the patient record. The right side of the screen lists the allergies included in the CCD, including the date recorded, the author, reaction, and severity. You may need to swipe up to see additional allergies.

    5. Tap Select All or tap to select individual allergies manually, as needed, and tap Accept.

      OR

      Tap Reject to not incorporate any of the allergies into the patient’s record.

      A summary page lists the patient’s current allergies and highlights the allergies that will be imported from the CCD.

    6. Tap Accept.
    7. Tap Back to exit allergies and return to the patient clipboard.
  6. Reconcile the problem list:
    1. Tap the Problem List tab.
    2. Tap Reconcile.
    3. Select Transitions.
    4. Review the problems.

      The left side of the screen displays the problems currently in the patient record. The right side of the screen lists the problems included in the CCD, including the date recorded and author. You may need to swipe up to see additional problems.

    5. Tap Select All or tap to select individual problems manually, as needed, and tap Accept.

      OR

      Tap Reject to not incorporate any of the problems into the patient’s record.

      A summary page lists the patient’s current problems and highlights the problems that will be imported from the CCD.

    6. Tap Accept.
    7. Tap Done to exit medications and the patient clipboard.

    The reconciliation is now complete. Continue documenting the exam.

An EP must meet the threshold for two measures for this objective. If the EP meets the criteria for exclusion from two measures, they must meet the threshold for the one remaining measure. If they meet the criteria for exclusion from all three measures, they may be excluded from meeting this objective.

  • Measure 1. For more than 50 percent of transitions of care and referrals, the EP that transitions or refers their patient to another setting of care or provider of care:
    • Creates a summary of care record using a certified EHR; and
    • Electronically exchanges the summary of care record
  • Measure 2. For more than 40 percent of transitions or referrals received and patient encounters in which the EP has never before encountered the patient, he/she incorporates into the patient’s EHR an electronic summary of care document.
  • Measure 3. For more than 80 percent of transitions or referrals received and patient encounters in which the EP has never before encountered the patient, he/she performs a clinical information reconciliation. The EP must implement clinical information reconciliation for the following three clinical information sets:
    • Medication. Review of the patient’s medication, including the name, dosage, frequency, and route of each medication.
    • Medication allergy. Review of the patient’s known medication allergies.
    • Current Problem list. Review of the patient’s current and active diagnoses

Denominator

  • Measure 1. Number of transitions of care and referrals during the EHR reporting period for which the EP was the transferring or referring provider.
  • Measure 2. Number of patient encounters during the EHR reporting period for which an EP was the receiving party of a transition or referral or has never before encountered the patient and for which an electronic summary of care record is available.
  • Measure 3. Number of transitions of care or referrals during the EHR reporting period for which the EP was the recipient of the transition or referral or has never before encountered the patient.

Numerator

  • Measure 1. The number of transitions of care and referrals in the denominator where a summary of care record was created using certified EHR technology and exchanged electronically.
  • Measure 2. Number of patient encounters in the denominator where an electronic summary of care record received is incorporated by the provider into the certified EHR.
  • Measure 3. The number of transitions of care or referrals in the denominator where the following three clinical information reconciliations were performed: medication list, medication allergy list, and current problem list.

Threshold

  • Measure 1. The resulting percentage must be more than 50 percent in order for an EP to meet this measure.
  • Measure 2. The resulting percentage must be more than 40 percent in order for an EP to meet this measure.
  • Measure 3. The resulting percentage must be more than 80 percent in order for an EP to meet this measure.
  • Measure 1. An EP may take an exclusion if either or both of the following apply:
    • He or she transfers a patient to another setting or refers a patient to another provider fewer than 100 times during the EHR reporting period.
    • He or she conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4 Mbps broadband availability according to the latest information available from the Federal Communications Commission (FCC) on the first day of the EHR reporting period.
  • Measure 2. An EP may take an exclusion if either or both of the following apply:
    • The total transitions or referrals received and patient encounters in which he or she has never before encountered the patient, is fewer than 100 during the EHR reporting period.
    • He or she conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4 Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period.
  • Measure 3. An EP may take an exclusion if the total transitions or referrals received and patient encounters in which he or she has never before encountered the patient, is fewer than 100 during the EHR reporting period.

This measure is required to achieve a promoting interoperability score. This measure is worth up to 20 points.

The following are suggested roles for completing this measure:

  • Doctor
  • Technician
  • Scribe