Closing the Referral Loop: Receipt of Specialist Report

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Measure Information	2023 Performance Period	2024 Performance Period	2025 Performance Period
Title	Closing the Referral Loop: Receipt of Specialist Report	Closing the Referral Loop: Receipt of Specialist Report	Closing the Referral Loop: Receipt of Specialist Report
CMS eCQM ID	CMS50v11	CMS50v12	CMS50v13
CBE ID*	Not Applicable	Not Applicable	Not Applicable
MIPS Quality ID	374	374	374
Measure Steward	Centers for Medicare & Medicaid Services (CMS)	Centers for Medicare & Medicaid Services (CMS)	Centers for Medicare & Medicaid Services (CMS)
Description	Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred	Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred	Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred
Measure Scoring	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process	Process	Process
Stratification	*See CMS50v11.html	None	None
Risk Adjustment	*See CMS50v11.html	None	None
Rationale	*See CMS50v11.html	Problems in the outpatient referral and consultation process have been documented, including lack of timeliness of information and inadequate provision of information between the specialist and the requesting physician (Gandhi et al., 2000; Forrest et al., 2000; Stille et al., 2005). In... a study of physician satisfaction with the outpatient referral process, Gandhi et al. (2000) found that 68% of specialists reported receiving no information from the primary care provider prior to referral visits, and 25% of primary care providers had still not received any information from specialists 4 weeks after referral visits. In another study of 963 referrals (Forrest et al., 2000), pediatricians scheduled appointments with specialists for only 39% and sent patient information to the specialists for only 51% of referrals. In a 2006 report to Congress, the Medicare Payment Advisory Commission (MedPAC) found that care coordination programs improved quality of care for patients, reduced hospitalizations, and improved adherence to evidence-based care guidelines, especially among patients with diabetes and coronary heart disease. Associations with cost-savings were less clear; this was attributed to how well the intervention group was chosen and defined, as well as the intervention put in place. Additionally, cost-savings were usually calculated in the short-term, while some argue that the greatest cost-savings accrue over time (MedPAC, 2006). Improved mechanisms for information exchange could facilitate communication between providers, whether for time-limited referrals or consultations, on-going co-management, or during care transitions. For example, a study by Branger, van’t Hooft, van der Wouden, Moorman & van Bemmel (1999) found that an electronic communication network that linked the computer-based patient records of physicians who had shared care of patients with diabetes significantly increased frequency of communications between physicians and availability of important clinical data. There was a 3-fold increase in the likelihood that the specialist provided written communication of results if the primary care physician scheduled appointments and sent patient information to the specialist (Forrest et al., 2000). Care coordination is a focal point in the current health care reform and our nation's ambulatory health information technology framework. The National Priorities Partnership (2008) recently highlighted care coordination as one of the most critical areas for development of quality measurement and improvement. Show more > Problems in the outpatient referral and consultation process have been documented, including lack of timeliness of information and inadequate provision of information between the specialist and the requesting physician (Gandhi et al., 2000; Forrest et al., 2000; Stille et al., 2005). In a study of physician satisfaction with the outpatient referral process, Gandhi et al. (2000) found that 68% of specialists reported receiving no information from the primary care provider prior to referral visits, and 25% of primary care providers had still not received any information from specialists 4 weeks after referral visits. In another study of 963 referrals (Forrest et al., 2000), pediatricians scheduled appointments with specialists for only 39% and sent patient information to the specialists for only 51% of referrals. In a 2006 report to Congress, the Medicare Payment Advisory Commission (MedPAC) found that care coordination programs improved quality of care for patients, reduced hospitalizations, and improved adherence to evidence-based care guidelines, especially among patients with diabetes and coronary heart disease. Associations with cost-savings were less clear; this was attributed to how well the intervention group was chosen and defined, as well as the intervention put in place. Additionally, cost-savings were usually calculated in the short-term, while some argue that the greatest cost-savings accrue over time (MedPAC, 2006). Improved mechanisms for information exchange could facilitate communication between providers, whether for time-limited referrals or consultations, on-going co-management, or during care transitions. For example, a study by Branger, van’t Hooft, van der Wouden, Moorman & van Bemmel (1999) found that an electronic communication network that linked the computer-based patient records of physicians who had shared care of patients with diabetes significantly increased frequency of communications between physicians and availability of important clinical data. There was a 3-fold increase in the likelihood that the specialist provided written communication of results if the primary care physician scheduled appointments and sent patient information to the specialist (Forrest et al., 2000). Care coordination is a focal point in the current health care reform and our nation's ambulatory health information technology framework. The National Priorities Partnership (2008) recently highlighted care coordination as one of the most critical areas for development of quality measurement and improvement. Show less	Problems in the outpatient referral and consultation process have been documented, including inadequate care pathways between specialty and primary care. Studies suggest that both specialists and primary care providers (PCPs) are not satisfied with current processes (Institute for... Healthcare Improvement / National Patient Safety Foundation, 2017; Greenwood-Lee et. al, 2018). Breakdowns in referral communication leads to worse health outcomes, increased cost, and appointment delays (Patel et. al, 2018; Odisho et. al, 2020). A 2018 analysis of primary care referrals to specialists found that of the 103,737 referral scheduling attempts analyzed, only 36,072 (34.8%) resulted in documented complete appointments, defined by the specialty clinician providing report to the PCP after the referral visit (Patel et. al, 2018). Technological and process-based updates can improve the referral loop process and increase rates of closing the referral loop. Ramelson et. al (2018) enhanced an EHR's Referral Manager module to meet the Controlled Risk Insurance Company’s best practice steps and the requirements of both the CMS EHR Incentive Program and the National Committee for Quality Assurance Patient-Centered Medical Home program. Following the updates, 76.8% of referrals were completed and all defined referral process steps were easier to accomplish. Odisho et. al (2020) developed a referrals automation software to simplify the fax to referral process. Feedback from key stakeholder interviews noted that the software enhanced the referrals process by further streamlining and organizing the patient referral process. The Institute for Healthcare Improvement and the National Patient Safety Foundation (2017) reviewed the referrals process in the ambulatory care setting and found that organizational leaders, EHR vendors, regulatory agencies, clinicians, and patients all play a role in creating a referrals system that is effective, safe, convenient, and patient-centered. Show more > Problems in the outpatient referral and consultation process have been documented, including inadequate care pathways between specialty and primary care. Studies suggest that both specialists and primary care providers (PCPs) are not satisfied with current processes (Institute for Healthcare Improvement / National Patient Safety Foundation, 2017; Greenwood-Lee et. al, 2018). Breakdowns in referral communication leads to worse health outcomes, increased cost, and appointment delays (Patel et. al, 2018; Odisho et. al, 2020). A 2018 analysis of primary care referrals to specialists found that of the 103,737 referral scheduling attempts analyzed, only 36,072 (34.8%) resulted in documented complete appointments, defined by the specialty clinician providing report to the PCP after the referral visit (Patel et. al, 2018). Technological and process-based updates can improve the referral loop process and increase rates of closing the referral loop. Ramelson et. al (2018) enhanced an EHR's Referral Manager module to meet the Controlled Risk Insurance Company’s best practice steps and the requirements of both the CMS EHR Incentive Program and the National Committee for Quality Assurance Patient-Centered Medical Home program. Following the updates, 76.8% of referrals were completed and all defined referral process steps were easier to accomplish. Odisho et. al (2020) developed a referrals automation software to simplify the fax to referral process. Feedback from key stakeholder interviews noted that the software enhanced the referrals process by further streamlining and organizing the patient referral process. The Institute for Healthcare Improvement and the National Patient Safety Foundation (2017) reviewed the referrals process in the ambulatory care setting and found that organizational leaders, EHR vendors, regulatory agencies, clinicians, and patients all play a role in creating a referrals system that is effective, safe, convenient, and patient-centered. Show less
Clinical Recommendation Statement	*See CMS50v11.html	None	None
Improvement Notation	A higher score indicates better quality	A higher score indicates better quality	A higher score indicates better quality
Definition	*See CMS50v11.html	Referral: A request from one clinician to another clinician for evaluation, treatment, or co-management of a patient's condition. This term encompasses referral and consultation as defined by Centers for Medicare & Medicaid Services. Report: A written document prepared by the eligible... clinician (and staff) to whom the patient was referred and that accounts for his or her findings, provides summary of care information about findings, diagnostics, assessments and/or plans of care, and is provided to the referring eligible clinician. Show more > Referral: A request from one clinician to another clinician for evaluation, treatment, or co-management of a patient's condition. This term encompasses referral and consultation as defined by Centers for Medicare & Medicaid Services. Report: A written document prepared by the eligible clinician (and staff) to whom the patient was referred and that accounts for his or her findings, provides summary of care information about findings, diagnostics, assessments and/or plans of care, and is provided to the referring eligible clinician. Show less	Referral: A request from one clinician to another clinician for evaluation, treatment, or co-management of a patient's condition. This term encompasses referral and consultation as defined by Centers for Medicare & Medicaid Services. Report: A written document prepared by the eligible... clinician (and staff) to whom the patient was referred and that accounts for his or her findings, provides summary of care information about findings, diagnostics, assessments and/or plans of care, and is provided to the referring eligible clinician. Show more > Referral: A request from one clinician to another clinician for evaluation, treatment, or co-management of a patient's condition. This term encompasses referral and consultation as defined by Centers for Medicare & Medicaid Services. Report: A written document prepared by the eligible clinician (and staff) to whom the patient was referred and that accounts for his or her findings, provides summary of care information about findings, diagnostics, assessments and/or plans of care, and is provided to the referring eligible clinician. Show less
Guidance	The clinician who refers the patient to another clinician is the clinician who should be held accountable for the performance of this measure. Only the first referral made between January 1 – October 31 of the measurement period will be considered for this measure to allow adequate time... for the referring clinician to collect the consult report by the end of the measurement period. If there are multiple referrals for a patient during the measurement period, use the first referral. The clinician to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same clinician who would report on the measure. The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring clinician which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible clinicians reporting on this measure should note that all data for the performance period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who refer patients towards the end of the performance period (i.e., October), should request that clinicians to whom they referred their patients share their consult reports as soon as possible in order for those patients to be counted in the measure numerator during the measurement period. When clinicians to whom patients are referred communicate the consult report as soon as possible with the referring clinician, it ensures that the communication loop is closed in a timely manner and that the data are included in the submission to CMS. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show more > The clinician who refers the patient to another clinician is the clinician who should be held accountable for the performance of this measure. Only the first referral made between January 1 – October 31 of the measurement period will be considered for this measure to allow adequate time for the referring clinician to collect the consult report by the end of the measurement period. If there are multiple referrals for a patient during the measurement period, use the first referral. The clinician to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same clinician who would report on the measure. The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring clinician which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible clinicians reporting on this measure should note that all data for the performance period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who refer patients towards the end of the performance period (i.e., October), should request that clinicians to whom they referred their patients share their consult reports as soon as possible in order for those patients to be counted in the measure numerator during the measurement period. When clinicians to whom patients are referred communicate the consult report as soon as possible with the referring clinician, it ensures that the communication loop is closed in a timely manner and that the data are included in the submission to CMS. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show less	The clinician who refers the patient to another clinician is the clinician who should be held accountable for the performance of this measure. Only the first referral made between January 1 – October 31 of the measurement period will be considered for this measure to allow adequate time... for the referring clinician to collect the consult report by the end of the measurement period. If there are multiple referrals for a patient during the measurement period, use the first referral. The clinician to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same clinician who would report on the measure. The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring clinician which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible clinicians reporting on this measure should note that all data for the performance period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who refer patients towards the end of the performance period (i.e., October), should request that clinicians to whom they referred their patients share their consult reports as soon as possible in order for those patients to be counted in the measure numerator during the measurement period. When clinicians to whom patients are referred communicate the consult report as soon as possible with the referring clinician, it ensures that the communication loop is closed in a timely manner and that the data are included in the submission to CMS. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show more > The clinician who refers the patient to another clinician is the clinician who should be held accountable for the performance of this measure. Only the first referral made between January 1 – October 31 of the measurement period will be considered for this measure to allow adequate time for the referring clinician to collect the consult report by the end of the measurement period. If there are multiple referrals for a patient during the measurement period, use the first referral. The clinician to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same clinician who would report on the measure. The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring clinician which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible clinicians reporting on this measure should note that all data for the performance period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who refer patients towards the end of the performance period (i.e., October), should request that clinicians to whom they referred their patients share their consult reports as soon as possible in order for those patients to be counted in the measure numerator during the measurement period. When clinicians to whom patients are referred communicate the consult report as soon as possible with the referring clinician, it ensures that the communication loop is closed in a timely manner and that the data are included in the submission to CMS. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show less	The clinician who refers the patient to another clinician is the clinician who should be held accountable for the performance of this measure. Only the first referral made between January 1 – October 31 of the measurement period will be considered for this measure to allow adequate time... for the referring clinician to collect the consult report by the end of the measurement period. If there are multiple referrals for a patient during the measurement period, use the first referral. The clinician to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same clinician who would report on the measure. The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring clinician which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible clinicians reporting on this measure should note that all data for the measurement period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who refer patients towards the end of the measurement period (i.e., October), should request that clinicians to whom they referred their patients share their consult reports as soon as possible in order for those patients to be counted in the measure numerator during the measurement period. When clinicians to whom patients are referred communicate the consult report as soon as possible with the referring clinician, it ensures that the communication loop is closed in a timely manner and that the data are included in the submission to CMS. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show more > The clinician who refers the patient to another clinician is the clinician who should be held accountable for the performance of this measure. Only the first referral made between January 1 – October 31 of the measurement period will be considered for this measure to allow adequate time for the referring clinician to collect the consult report by the end of the measurement period. If there are multiple referrals for a patient during the measurement period, use the first referral. The clinician to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same clinician who would report on the measure. The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring clinician which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible clinicians reporting on this measure should note that all data for the measurement period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who refer patients towards the end of the measurement period (i.e., October), should request that clinicians to whom they referred their patients share their consult reports as soon as possible in order for those patients to be counted in the measure numerator during the measurement period. When clinicians to whom patients are referred communicate the consult report as soon as possible with the referring clinician, it ensures that the communication loop is closed in a timely manner and that the data are included in the submission to CMS. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show less
Initial Population	Number of patients, regardless of age, who had an encounter during the measurement period and were referred by one clinician to another clinician on or before October 31	Number of patients, regardless of age, who had an encounter during the measurement period and were referred by one clinician to another clinician on or before October 31	Number of patients, regardless of age, who had an encounter during the measurement period and were referred by one clinician to another clinician on or before October 31
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	None	None	None
Numerator	Number of patients with a referral on or before October 31, for which the referring clinician received a report from the clinician to whom the patient was referred	Number of patients with a referral on or before October 31, for which the referring clinician received a report from the clinician to whom the patient was referred	Number of patients with a referral on or before October 31, for which the referring clinician received a report from the clinician to whom the patient was referred
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS50v12	CMS50v13	No Version Available
Previous Version	No Version Available	CMS50v11	CMS50v12

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Specifications

Additional Resources for CMS50v12

CMS50v12-TRN.xlsx

Header

Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section: Rationale
Source of Change: Annual Update

Logic

Revised the logic to capture referrals through the end of the day on October 31 to better align with the measure language and intent.
Measure Section: Definitions
Source of Change: ONC Project Tracking System (JIRA): CQM-5442
Updated the timing precision in definitions by adding 'day of' to align with the measure intent.
Measure Section: Definitions
Source of Change: Measure Lead

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

Value set Consultant Report (2.16.840.1.113883.3.464.1003.121.12.1006): Added 13 LOINC codes based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Referral (2.16.840.1.113883.3.464.1003.101.12.1046): Added 1 SNOMED CT code (1186918003) based on terminology update. Deleted 1 SNOMED CT code (306294000) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update