• Measure ACI_TRANS_HIE_1: Health-Information Exchange


    Reporting options: 

    • IRIS Registry web portal attestation
    • CMS Quality Payment Program website
    • EHR-based attestation

    All reporting options are available for both group and individual attestation of ACI measure

    Base Measure? Yes 

    Performance Measure Points: Up to 20% 

    Exclusions available? Clinicians (or groups if group reporting) with fewer than 100 referrals/transitions of care in the performance period can claim an exclusion for this measure.

    Measure ID: ACI_TRANS_HIE_1

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

    Definition of Terms

    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 clinician.

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

    • Patient name
    • Referring or transitioning clinician's name and office contact information (EP only)
    • Procedures
    • Encounter diagnosis
    • Immunizations
    • Laboratory test results
    • Vital signs (height, weight, blood pressure, BMI)
    • Smoking status
    • Functional status, including activities of daily living, cognitive and disability status
    • Demographic information (preferred language, sex, race, ethnicity, date of birth)
    • Care plan field, including goals and instructions
    • Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning clinician and the receiving clinician
    • Reason for referral 
    • Current problem list (Clinician may also include historical problems at their discretion) *
    • Current medication list *
    • Current medication allergy list *

    * Note: A 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 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 clinician 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).

    Attestation Requirements

    Denominator: Number of transitions of care and referrals performed by the clinician during the performance period. 

    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* (C-CDA format).

    *Note: electronic faxing does not satisfy this measure.

    Suggested Documentation

    Dated report or screenshot that documents the number of times that CEHRT was used to create a summary of care record for a patient that is being transitioned or referred to another setting of care and the summary of care record is electronically transmitted to a receiving provider of care or referral. Much like under Meaningful Use, this report should be available from your EHR vendor.  

    How CMS Scores Your Performance

    Base score: Numerator of 1 is all you need

    Performance score: Your measure performance score is based on performance rate.  For example, if your numerator/denominator is 86/100, your performance rate is 86% and that measure would contribute 18% to your ACI score.

    Performance Rates for Each Measure Worth Up to 20 Points
    Performance Rate 1 - 10 = 2% Performance Rate 51 - 60 = 12%
    Performance Rate 11 - 20 = 4% Performance Rate 61 - 70 = 14%
    Performance Rate 21 - 30 = 6% Performance Rate 71 - 80 = 16%
    Performance Rate 31 - 40 = 8% Performance Rate 81 - 90 = 18%
    Performance Rate 41 - 50 = 10% Performance Rate 91 - 100 = 20%