RevolutionEHR Insights ™

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MIPS - Promoting Interoperability

Support Electronic Referral Loops by Sending Health Information
Posted: December 25, 2018


When a patient is transitioned from the provider’s practice to that of another provider, a summary of care record should be provided in electronic format to assist the receiving provider in the coordination of care.

PI Objective and Calculation

The objective is to have the EC who transitions or refers a patient to another setting or provider of care provide a summary care record for each transition of care or referral.


  • 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.

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

Numerator for calculation: The number of transitions of care and referrals in the denominator where a summary of care record was created using CEHRT and exchanged electronically.


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


In the event an exclusion is claimed for this measure, the potential points for this measure disappear.  CMS plans to issue further guidance in future rule making.

Promoting Interoperability Discussion

A transition of care is 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.   Optometrists and ophthalmologists may transition or refer patients into many of these types of settings.

For RevolutionEHR to track this data for reporting, any patient who is undergoing a transition of care out of provider’s practice for a referral or consultation with another health care provider should use the “Referrals” component under the Show More tab.  The user should click Add to start documenting an outbound referral and build the referral fields.

Electronic transmission of the Summary of Care document from within the “Referrals” screen is accomplished by using the “Send Transition of Care” button.

This button is only available if:

  • the practice has Direct messaging enabled via RevDirect,
  • the referred to provider has a direct address entered in their external provider file,
  • the referred by provider has a direct address entered in their employee file.

Selecting the “Send Transition of Care” button will open the messaging system with a compose box.  Selecting the “Send” button will generate the Record Summary and automatically attach it to the outgoing Direct message.  The numerator will NOT trigger until the user actually sends the message and indicates “Confirmation of Receipt” by the consulting provider:

Video Discussion

Official CMS Fact Sheet


Meeting this objective can be challenging because the provider’s ability to transmit a document electronically depends on the recipient having Direct messaging capability.  2019 also adds the need to obtain confirmation that the document was received by the consulting provider.





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Updates Prior to 2018