Resource Center

MU Stage 3

Coordination of Care through Patient Engagement

a) Transitions of care and referrals

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:

  1. Creates a summary of care record using CEHRT, and
  2. Electronically exchanges the summary of care record

Denominator: Number of transitions of care and referrals during the EHR reporting period for which the EP was the transferring or referring provider.

Numerator: 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.

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 support@charmehr.com 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.

b) Transitions or referrals received

For more than 40 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP incorporates into the patient’s EHR an electronic summary of care document

Denominator: 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.

Numerator: Number of patient encounters in the denominator where an electronic summary of care record received is incorporated by the provider into the certified EHR technology.

ChARM EHR Workflow:

Follow the steps below for patients that are referred to you.

  1. Go to Encounter > MU > Referral/Reconciliation section
  2. Choose the option ‘This encounter is based on a Referral or Transition of Care incoming request’ or ’This is the first encounter with this patient’
  3. Incorporate CCDA file received from the patient to satisfy this measure.
  4. In case the patient does not provide a CCDA file, select the option ’CCDA Document not available due to reason below.’

c) Medication Reconciliation

For more than 80 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP performs a clinical information reconciliation. The provider must implement clinical information reconciliation for the following three clinical information sets:

  1. Medication. Review of the patient’s medication, including the name, dosage, frequency, and route of each medication.
  2. Medication allergy. Review of the patient’s known medication allergies.
  3. Current Problem list. Review of the patient’s current and active diagnoses.

Denominator: 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: 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.

ChARM EHR Workflow:

Medication reconciliation should be performed for all the patients that are transitioned to your practice.

Follow the steps below for patients that are referred to you.

  1. Go to Encounter > MU > Referral/Reconciliation section
  2. Choose the option ‘This encounter is based on a Referral or Transition of Care incoming request’ or ’This is the first encounter with this patient’
  3. Reconcile patient’s current medications, allergies and problems and record them under Patient Dashboard > Medication section.
  4. Reconciliation can be performed manually or if the patient has a CCDA file, you can incorporate the CCDA file and use the built-in reconcile feature to quickly reconcile the medications.
  5. After reconciliation, select the Clinical Reconciliation > Medication, Allergies, Problems option to satisfy this measure.