Resource Center

ACI Transition

Health Information Exchange

The MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) uses certified electronic health record technology (CEHRT) to create a summary of care record; and (2) electronically transmits such summary to a receiving health care provider for at least one transition of care or referral.

Denominator: The number of transitions of care and referrals during the performance period for which the MIPS eligible clinician was the transferring or referring health care provider.

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.

ChARM EHR Workflow:

Providers should subscribe to Direct Message add-on in ChARM EHR and transmit the patient referrals electronically to outside providers.

Send a request to to enable Direct Message add-on to providers. Once enabled, each provider will be assigned a unique Direct ID using that patient records can be securely transmitted to outside provider network.

Procedure to Transmit Patient Referrals:

  1. Go to Patient Dashboard > Referrals > Referral Out
  2. Click on the ‘+ Referral Out’ button
  3. Choose the Referral From and Referral To providers
  4. Enter the referral notes and attach additional documents if required.
  5. Save and Preview the referral notes
  6. Use the Transmit > By Direct Message option
  7. Enter the Direct ID of the receiving provider and send the referral order.

Note: The provider whom you refer the patient should also have a Direct ID and he/she should have read the direct message you sent to satisfy numerator of this measure.