Objective: Protect Patient Health Information

Measure: Security Risk Analysis 

Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312 (a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician’s risk management process.

Reporting Requirements (YES/NO)

• To meet this measure, MIPS eligible clinician must attest YES to conducting or reviewing a security risk analysis and implementing security updates as necessary and correcting identified security deficiencies.

Scoring Information
Failure to complete a security risk analysis will result in 0 points for the PI performance category. Eligible clinicians do not receive points for this measure towards their final PI category score.

How do I achieve this measure?

To qualify for this measure, the provider must have a security management process in place to “implement policies and procedures to prevent, detect, contain and correct security violations.” The specifications require the practice to conduct an analysis of potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic health information.

Some examples of this may include, but are not limited to:

• Perform Security Risk Analysis/ Assessment
• Implement Security Policies, such as providing passwords to computers and installing anti-virus software, screensaver for auto-log off, changing options in Preferences > User Security in ChartMaker Clinical
• Appoint a Security Official – Prepare and Implement Job Responsibilities
• Implement Audit Control Policies& Procedures
• Implement Automatic Log-off Processes
• Install Virus Protection Software
• Implement Firewall Technology
• Review and Implement Computer Backup Policies and Procedures
• Implement Facility Maintenance Log
• Develop Facility Security and Contingency Plans
• Create Computer Workstation Use Policies and Procedures
• Obtain Signed Workforce Confidentiality Agreements form all Physicians and Staff
• Create Workforce Termination Procedures
• Implement Sanction Policy

As part of the process in creating such a manual, STI Managed Services can perform a basic Security Risk Analysis on network and hardware vulnerability for your office by request. The practice is responsible for maintaining HIPAA compliance; however, STI will work with you to assure the Information Technology portion of the Security Risk Analysis is complete. Upon completion of your analysis, you will be informed of STI findings whether positive or negative.  The analysis will include some, but not all, of the examples listed above.

This service is provided free of charge for Platinum level maintenance clients and for a fee for all other clients. Contact STI Managed Services (800-487-9135; option 2) for more information.

Please keep in mind that the analysis completed by STI or another IT vendor is only a subset of this measure. There are other requirements that must be completed by the practice itself. If your practice would like a more thorough analysis, we can recommend a vendor to do so.

Tools to complete the assessment:

HIT Security Risk Assessment Tool (Downloadable Tool to Complete Assessment -** MUST BE COMPLETED DURING YOUR REPORTING PERIOD DATE RANGE**)

Objective: E-Prescribing

Measure: e-Prescribing

At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified electronic health record technology (CEHRT).

Definition of Terms
Permissible Prescriptions: All drugs meeting the current definition of a prescription as the authorization by a clinician to dispense a drug that would not be dispensed without such authorization and may include electronic prescriptions of controlled substances where creation of an electronic prescription for the medication is feasible using CEHRT and where allowable by state and local law.

Reporting Requirements (Numerator/Denominator or Exclusion):

• NUMERATOR: The number of prescriptions in the denominator generated, queried for a drug formulary, and transmitted electronically using CEHRT.
• DENOMINATOR: The number of prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances during the performance period; or number of prescriptions written for drugs requiring a prescription in order to be dispensed during the performance period.
• Exclusion: Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.

Scoring Information: 

• Maximum of 10 Points
• Performance Rate (Numerator/Denominator %) x Total # of points (10) = Measure Score
• Claiming Exclusion: Points will be redistributed to the following measures – 5 points added to Support Electronic Referral Loops by Sending Health Information, and 5 points added to Support Electronic Referral Loops by Receiving & Incorporating Health Information.

How do I achieve this measure?

The clinician needs to enter a new or renewed prescription in the patient’s EMR and send it electronically during their performance period. The denominator is achieved when the prescription is entered in a patient’s chart. The numerator is achieved when the prescription is sent electronically. ChartMaker’s Drug Formulary function is automatically turned on.

NOTE: Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period can report that they meet the exclusion.

NOTE: As electronic prescribing of controlled substances is now possible, MIPS eligible clinicians may choose to include these prescriptions in their permissible prescriptions where feasible and allowable by state and local law. If a MIPS eligible clinician chooses to include such prescriptions, he or she must do so uniformly across all patients and across all allowable schedules for the duration of the performance period. If you want to include controlled substances for this measure be sure that the Include controlled substances in the E-Prescribing measure option is checked in the Promoting Interoperability dialog accessed from the MIPS Dashboard.

Also note, that the EPCS functionality works in conjunction with an IdenTrust USB token and certificate to ensure proper security (two-factor authentication protocol) per DEA regulations. All providers that perform EPCS must have a valid DEA number and be in good standing. For more information about EPCS and obtaining an IdenTrust USB token see our E-Prescribing page here.

Enter a new prescription in the patient’s EMR and send it electronically:

1. Open a chart note for the patient, then click the Medication button, and then click Add Medication to prescribe a new medication.

2. Enter the medication in the search window, then click the Search button.

3. Highlight the medication in the results window, and then click the Select button.

4. In the Prescribe Medication dialog, enter or select information for all appropriate fields. If the clinician’s preference is set to E-Prescribe, then the Transmission method will default to E-Prescribe. If not, click the Transmission drop-down, and select E-Prescribe.

5. When all the information has been configured, click the Next button.

6. Select the patient’s Pharmacy, if they have more than one on file, and then, if e-prescribing a non-controlled substance medication, click the Confirm and Send button.

If you are e-prescribing a controlled substance, you must complete the two-factor authentication protocol. Check the Ready to sign option which will activate the Sign and Send button. You must now have your IndenTrust token plugged into your computer.

Once the token is plugged in, click the Sign and Send button. The system will then validate the security certificate with the IdenTrust token inserted into the USB port of your computer. If the certificate and token match, you will be promoted to enter your token password. Once the password has been entered, click the OK button.

 

Enter a renewed prescription in the patient’s EMR and send it electronically:

1. Open a chart note for the patient, then click the Medication button, then click Renew Medication, and then select the applicable Medication from the list.

2. In the Prescribe Medication dialog, all the appropriate fields will populate as it was previously prescribed. If the clinician’s preference is set to E-Prescribe, then the Transmission method will default to E-Prescribe. If not, click the Transmission drop-down, and select E-Prescribe.

3. When all the information has been configured, click the Next button.

4. Select the patient’s Pharmacy, if they have more than one on file, and then, if e-prescribing a non-controlled substance medication, click the Confirm and Send button.

If you are e-prescribing a controlled substance, you must complete the two-factor authentication protocol. Check the Ready to sign option which will activate the Sign and Send button. You must now have your IndenTrust token plugged into your computer. Once the token is plugged in, click the Sign and Send button. The system will then validate the security certificate with the IdenTrust token inserted into the USB port of your computer. If the certificate and token match, you will be promoted to enter your token password. Once the password has been entered, click the OK button.

 

Set Clinician’s preference to “E-Prescribe” (Optional)

1. The clinician will have to log into Clinical.

2. Click Edit > Preferences.

3. In the Preferences dialog, click the Prescription tab.

4. In the Default Destination field, select E-Prescribe.

5. Click the Set button, and then click the OK button.

Objective: E-Prescribing

Measure: Query of Prescription Drug Monitoring Program (PDMP)

For at least one Schedule II opioid electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history, except where prohibited and in accordance with applicable law.

Reporting Requirements (Numerator/Denominator):

• NUMERATOR: The number of Schedule II opioid prescriptions in the denominator for which data from CEHRT is used to conduct a query of a PDMP for prescription drug history except where prohibited and in accordance with applicable law. A numerator of at least one is required to fulfill this measure.
• DENOMINATOR: Number of Schedule II opioids electronically prescribed using CEHRT by the MIPS eligible clinician during the performance period.

Scoring Information: 

• 5 Bonus Points – A numerator of at least one is required to fulfill this measure.
• This measure is optional. No exclusion is available.

Enrollments and Additional Information

• Prescription Drug Monitoring Program (PDMP) Enrollment: see https://sticomputer.com/pdmp-enrollment/ for further details and information about enrolling with PDMP.

How do I achieve this measure?

STI, in conjunction with Appriss Health, offers you the option of having PDMP report information integrated into the ChartMaker® Clinical system to allow for easy access, as well as minimize workflow disruption, to provide near-instant and seamless access to critical prescription history information, thereby allowing you to make more informed decisions when prescribing medications (specifically controlled substances) for patients.

Prior to receiving a PDMP report information for a patient electronically through ChartMaker Clinical, your practice and physicians must be enrolled and enabled for PDMP. Likewise, you will need to have a Prescribing Privilege of Prescriber to access the PDMP Report dialog.

NOTE: Enrolling for the STI PDMP program, with Appriss Health EHR integration, that incorporates PDMP report information into your Clinical system, is not required to fulfill this measure. If you receive PDMP report information from another source you can still achieve this measure within the Clinical system. However, the options for accessing the PDMP Report for patients listed below will not be available.

A PDMP Report will display any applicable prescription history data for the patient, thereby allowing you to make more informed decisions when prescribing medications (specifically controlled substances) for that patient.

The PDMP Report can be accessed via the PDMP Report button in the Prescribe Medication dialog.

Or via Chart > PDMP Report when in a patient’s chart.

Each message included with the PDMP report will contain the state, or states, in which the message and/or report was generated. Also, any messages or warnings that prevented the report in part, or in whole, from displaying, or both messages and the report.

If you obtain a PDMP report outside of ChartMaker Clinical, you can indicate this action by manually checking the PDMP queried checkbox in the Prescribe Medication dialog. Do note, whenever you click the PDMP Report button to access the PDMP report for this patient in the Prescribe Medication dialog, the PDMP queried option will be automatically checked.

DENOMINATOR credit for this measure is obtained when Schedule II opioid(s) are electronically prescribed during the performance period.

NUMINATOR credit is obtained when the PDMP queried option is checked in the Prescribe Medication dialog, either by manually checking it, or clicking the PDMP Report button to access the PDMP report which will automatically check the PDMP queried checkbox.

Objective: E-Prescribing

Measure: Verify Opioid Treatment Agreement

For at least one unique patient for whom a Schedule II opioid was electronically prescribed by the MIPS eligible clinician using CEHRT during the performance period, if the total duration of the patient’s Schedule II opioid prescriptions is at least 30 cumulative days within a 6-month look-back period, the MIPS eligible clinician seeks to identify the existence of a signed opioid treatment agreement and incorporates it into the patient’s electronic health record using CEHRT.

Reporting Requirements (Numerator/Denominator):

• NUMERATOR: The number of unique patients in the denominator for whom the MIPS eligible clinician seeks to identify a signed opioid treatment agreement and, if identified, incorporates the agreement in CEHRT. A numerator of at least one is required to fulfill this measure.
• DENOMINATOR: Number of unique patients for whom a Schedule II opioid was electronically prescribed by the MIPS eligible clinician using CEHRT during the performance period and the total duration of Schedule II opioid prescriptions is at least 30 cumulative days as identified in the patient’s medication history request and response transactions during a 6-month look-back period.

Scoring Information: 

• 5 Bonus Points – A numerator of at least one is required to fulfill this measure.
• This measure is optional. No exclusion is available.

How do I achieve this measure?

The Opioid Treatment Agreement widget (available in ChartMaker 2018.2, fv6.3.6), can be added to applicable chart note templates in the Template Editor. Once the widget has been added to a template, simply click the Opioid Treatment Agreement button from inside a chart note to access the Opioid Treatment Agreement dialog.

When the Opioid Treatment Agreement widget is accessed in the chart note, a Opioid Treatment Agreement dialog will appear allowing you to answer questions regarding whether the patient has had a Schedule II opioid prescription for at least 30 cumulative days as identified in the patient’s medication history request and response transactions during a 6-month look-back period, and whether they have a signed opioid treatment agreement that has been incorporated in the chart. Likewise, you can access their medication history by clicking the Medication History button.

When the first question is answered in the affirmative Yes, the system will place this patient into the DENOMINATOR count for this performance measure. Answering Yes to the first question will also activate the Yes and No options in the second question. If Not Asked or No is selected for this first question, then the patient will not be included in the denominator.

When the second question is answered in the affirmative Yes, the system will place this patient in NUMERATOR count for this performance measure. If Not Asked or No is selected for the second question, then the patient will not be included in the numerator.

Objective: Health Information Exchange

Measure: Support Electronic Referral Loops by Sending Health Information

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.

Reporting Requirements (Numerator/Denominator or Exclusion)

• 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.
• DENOMINATOR: The number of transitions of care and referrals during the performance period for which the MIPS eligible clinician was the transferring or referring clinician.
• EXCLUSION: Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.

Scoring Information

• Maximum of 20 Points
• Performance Rate (Numerator/Denominator %) x Total # of points (20) = Measure Score
• Claiming Exclusion: Points will be redistributed to the following measures – TBD by CMS at a later date.

How do I achieve this measure?

The clinician must electronically send a Transition of Care (CDA) document to the provider they have referred their patient to. The denominator count is captured when a TOC is generated or the clinician documents who they are referring their patient to through the use of the Referral button. You receive credit towards the numerator once the TOC is sent electronically to that provider. The two requirements, create a TOC and send it electronically, can both be achieved through Direct Messaging.

To generate and send a Transition of Care Summary through Direct Messaging

When generating a Transition of Care Summary (CDA) through Direct Messaging, you can either be in a patient’s chart, or outside a patient’s chart. When in a patient’s chart, the patient will default into the Patient field of the New Direct Message dialog. If you are outside a patient’s chart, you will have to select the patient in the New Direct Message dialog.

1. Click To-Do > Direct Messaging > Send New Message.

2. In the New Direct Message dialog, click the To button.

 

3. Enter the Last Name of the provider you are sending the document to.  You can enter a City, State,  and information in the addition fields to narrow the search results.

4. Click the Search button.

5. Click the provider in the search result window to highlight, and then click the To button.

6. When finished adding recipients, click the OK button.

 

7. Click the From drop-down arrow, and select the Provider who is sending the document.

8. You must enter a Subject in the corresponding field.

9. Click the Patient button, if you accessed the New Direct Message dialog outside of a patient’s chart. Do note, that if you accessed the New Direct Message dialog when in a patient’s chart, that patient will default into the Patient field and you can skip to step 11.

10. In the Patient Search dialog, enter a few letters of the patient’s last name,  then locate and highlight that patient, and then click the OK button.

11. After the patient appears in the New Direct Message dialog, click the Generate and Attach CDA button.

 

12. In the Export Patient Data dialog, modify the Date Range, if needed, then  select the Provider, and then  click the Attach button.

 

13. In the New Direct Message dialog, the Transition of Care (CDA) document will appear in the Attach field. You can then enter any Message, as needed, and then click the Send button.

14. The direct message must be successfully delivered for credit to be given. To check the status of direct messages, click the To-Do > Direct Messaging > View Sent Messages.

15. In the User field in the Direct Messages Sent dialog, change the User to the person who sent the message. A status of Delivered in the Status column is required to get credit for this measure.

To document the transition of care through the Referral Button (Optional):

NOTE: You may use the Referral button in an office visit note to document who you are referring your patient but this will only get you in the denominator. You must generate and send the Transition of Care Summary through Direct Messaging to receive credit in the numerator.

1. In an office visit note, click the Referral button.

2. In the Referrals dialog, click the New button.

 

3. Click the Choose Provider button, then search and highlight the applicable provider name, and then click the OK button.

4. Select at least one Diagnosis in the corresponding fields.

5. Enter any Comments, if applicable.

6. To add SNOMED codes for the referral, if needed, click the Search button.

7. When finished, click the OK button.

8. In the Referrals dialog, click the OK button.

 

Objective: Health Information Exchange

Measure: Clinical Information Reconciliation
For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, mediation allergy, and current problem list.

Reporting Requirements (Numerator/Denominator or Exclusion)

• NUMERATOR: The number of electronic summary of care records in the denominator for which clinical information reconciliation is completed using CEHRT 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; and (3) Current Problem List – Review of the patient’s current and active diagnoses.
• DENOMINATOR: Number of electronic summary of care records received using CEHRT for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, and for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient.
• EXCLUSIONS: (1) Any MIPS eligible clinician who is unable to implement the measure for a MIPS performance period in 2019 would be excluded from this measure. (2) Any MIPS eligible clinician who receives fewer than 100 transitions of care or referrals or has fewer than 100 encounters with patients never before encountered during the performance period.

Scoring Information

• Maximum of 20 Points
• Performance Rate (Numerator/Denominator %) x Total # of points (20) = Measure Score
• Claiming Exclusion: Points will be redistributed to the following measures – 20 points added to Support Electronic Referral Loops by Sending Health Information

How do I achieve this measure?

When importing a CDA (via the Import into chart button in the Direct Messaging dialog, or via the Import Document dialog, or via the Import Document from HIE dialog) the chart note that contains the document import will include a Patient Assignment button (available in ChartMaker 2018.2, fv6.3.7) along with the Reconcile button. This will allow you to easily enter and capture patient assignment information for incoming transition of care patients, as well as reconcile their information in the same note.

Click the Patient Assignment button and select the appropriate patient status. You will receive DENOMINATOR credit when selecting Yes to any one of the top 3 questions.

NOTE: This is the only way to receive denominator credit for this measure.

Next, click the Reconcile button to open the Clinical Information Reconciliation (CIR)dialog.

After clicking the Reconcile button, a Clinical Information Reconciliation (CIR) dialog will appear containing three panes of information. The left pane contains diagnoses, medications, or allergies that are already in the chart. The middle pane displays the information available in the document you are reconciling. And the right pane shows the final merged list. Items are added to the final list by selecting them in the center pane, and then clicking the Add button, or by clicking the Add All button. The Medications, Diagnoses, and Allergies tabs at the top of the dialogue allow you to alternate between the three different categories.

To receive NUMERATOR credit for Clinical Information Reconciliation, you must click the Confirm button in all three tabs. If the Confirm button is not clicked for Medications, Diagnoses, and Allergies, numerator credit will not be given. All other functions/actions are up to the discretion of the ECs and will have no impact on the measure.

When an incoming transition of care patient is seen, but you have not received a CDA file, you will need to capture this in the Patient Assignment dialog. You can add a Patient Assignment button to any applicable chart note templates in template editor.

Within the chart note, click the Patient Assignment button. In the Patient Assignment dialog, select the appropriate status for the transitioning patient, and then select YES for the denominator exclusion.

Objective: Provider to Patient Exchange  

Measure: Provide Patient Electronic Access to their Health Information

For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient’s health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programing Interface (API) in the MIPS eligible clinician’s certified electronic health record technology (CEHRT).

Definition of Terms

API or Application programming Interface – A set of programming protocols established for multiple purposes. APIs may be enabled by a health care provider or provider organization to provide the patient with access to their health information through a third-party application with more flexibility than is often found in many current “patient portals.”

Provide Access – When a patient possesses all of the necessary information needed to view, download, or transmit their information. This could include providing patients with instructions on how to access their health information, the website address they must visit for online access, a unique and registered username or password, instructions on how to create a login, or any other instructions, tools, or materials that patients need in order to view, download, or transmit their information.

Timely Access – We define “timely” as within 4 business days of the information being available to the MIPS eligible clinician.

Reporting Requirements (Numerator/Denominator)

• NUMERATOR: The number of patients in the denominator (or patient authorized representative) who are provided timely access to health information to view online, download, and transmit to a third party and to access using an application of their choice that is configured meet the technical specifications of the API in the MIPS eligible clinician’s CEHRT.
• DENOMINATOR: The number of unique patients seen by the MIPS eligible clinician during the performance period.

Scoring Information

• Maximum of 40 Point
• Performance Rate (Numerator/Denominator %) x Total # of points (40) = Measure Score

 

How do I achieve this measure?

You must be enrolled with ChartMaker® PatientPortal service and provide API Access.

The EC must have completed and signed an office note with a valid CPT code.

Authorization must be sent to either the patient, or patient’s authorized representative, for them to register for the PatientPortal, and API Access must be granted, prior to sending of any data and can be done prior to the patient being seen.

Likewise, the patient must be provided timely access (within 4 days) to their health information every time they are seen (where a note is created or a lab/result is imported) within the performance period. If there is one instance where a patient did not receive online access, then they can never get numerator credit for that reporting period.

Finally, each patient must be enabled for API access. API (Application Programming Interface) is a set of protocols that can allow different software systems to communicate with each other. APIs may be enabled by a health care provider to provide the patient with access to their health information through a third-party application.

To enroll to receive ChartMaker® PatientPortal service:

Go to: https://sticomputer.com/register-patientportal/ and complete the Register PatientPortal enrollment form to register your practice for the ChartMaker PatientPortal service.

To enroll/authorize the patient for the PatientPortal (with or without an email) and provide API access:

1. In Practice Manager, click the Patient tab, and then access the patient’s account.

2. In the Patient tab, click the Patient Access button.

3. In the Patient Portal account settings section of the Patient Access dialog, click the first Authorize button option if the patient provides you with their email address; or, click the second Authorize option if the patient does not have an email address.

NOTE: If the patient does not have an email address – Give printed instructions to the patient and encourage them to complete registration later.

 

4. After you click the Authorize button, an Authorize Patient dialog will appear outlining the option selected. Click the Yes button to confirm you want to authorize the patient to use the Patient Portal.

 

 

5. In the API Access section, check the Enable this patient for API access. A new Authentication code will be generated.

6. Check the Print this patient’s authentication code option if you want to print the authentication code for the patient after saving; or check the Send an email to this patient with their authentication code option if you want the system to send an email to the email address on the Patient screen after saving. Do note, that when the Send an email option is selected, the email sent will not be encrypted, therefore, we suggest that you only use this option for API access if the patient authorizes you to send it that way.

NOTE: If an email address is not entered for a patient, you will only have the option to print the authentication code. If an email is entered, you can choose whichever manner the patient wishes to receive the code.

7. When finished, click the OK button in the Patient Access dialog.

 

8. The Patient Access button will now show as blue, indicating a pending Patient Portal registration and an enabled API access. The button will turn green once the patient completes the Patient Portal registration process. In the Patient screen, click the Save button to close the patient’s account.

 

 

Steps taken by the patient to complete registration and login to the Patient Portal

NOTE: This does not need to be completed by the patient for the EC to receive credit for this measure.

1. The patient will receive an email regarding their Patient Portal registration.

2. Click the link to access the Patient Portal to complete registration.

3. Fill out the required information (Username, Date of Birth, Password, Confirm Password, Security Question and Answer).

NOTE: The Date of Birth must match what is documented in Practice Manager/Clinical.

4. Accept the Terms of Use along with typing the security characters that are displayed in the picture.

5. When finished, click Register.

Additional Information

The timely access to health information requirement of four days only applies to sending notes generated in Clinical and electronic lab results. These notes must include some form of structured data to be counted, such as allergies, procedures, medications, or diagnoses. Scans and notes that do not include this structured data (such as telephone messages) are not included and do not need to be sent to the Patient Portal within four days.

For patients that are in a Pending status (Blue) for the Patient Portal, numerator credit will be given if all signed notes were done within 4 days. As with patients that have Active status (Green), if a note is not signed within 4 days, that patient can never receive numerator credit during the reporting period.

Enabling API access for a patient generates a unique case-sensitive code for that individual. This code can be used with participating third-party applications to view an up-to-date summary of that patient’s health information.

Objective: Public Health and Clinical Data Exchange

Measure: Immunization Registry Reporting 

The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).

Definition of Terms

Active engagement – The MIPS eligible clinician is in the process of moving towards sending “Production data” to a public health agency or clinical data registry, or is sending production data to a public health agency (PHA) or clinical data registry (CDR). Active engagement may be demonstrated in one of the following ways:

• Option 1 – Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the MIPS performance period; and the MIPS eligible clinician is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows MIPS eligible clinicians to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. MIPS eligible clinicians that have registered in previous years do not need to submit an additional registration to meet this requirement for each MIPS performance period.
• Option 2 – Testing and Validation: The MIPS eligible clinician is in the process of testing and validation of the electronic submission of data. MIPS eligible clinicians must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a MIPS performance period would result in that MIPS eligible clinician not meeting the measure.
• Option 3 – Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

Production data – Refers to data generated through clinical processes involving patient care, and it is used to distinguish between data and “test data” which may be submitted for the purposes of enrolling in and testing electronic data transfers.

Reporting Requirements (Yes/No or Exclusion)

The MIPS eligible clinician must attest YES to being in active engagement with a PHA to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).

EXCLUSIONS: Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Immunization Registry Reporting measure if the MIPS eligible clinician:
1. Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction’s immunization registry or immunization information system during the performance period.
2. Operates in a jurisdiction for which no immunization registry or immunization information system can accept the specific standards required to meet the CEHRT definition at the start of the performance period.
3. Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.
Scoring Information

• MIPS eligible clinicians will earn 10 points for satisfying two different measures associated with the Public Health & Clinical Data Exchange objective.
• Eligible clinician would receive the full credit for reporting two “Yes” responses, or for submitting a “Yes” for one measure and claiming an exclusion for another measure under the objective.
• Claiming Exclusions on two different measures under the Public Health & Clinical Data Exchange objective: Points will be redistributed to the following measure – 10 points added to Provided Patient Electronic Access to Their Health Information.

 

Enrollments and Additional Information

• Immunization Registry Reporting: see https://sticomputer.com/immunizations/ for enrollment and further details.

Objective: Public Health and Clinical Data Exchange

Measure: Electronic Case Reporting

The MIPS eligible clinician is in active engagement with a public health agency (PHA) to electronically submit case reporting of reportable conditions.

Definition of Terms

Active engagement – The MIPS eligible clinician is in the process of moving towards sending “Production data” to a public health agency or clinical data registry, or is sending production data to a public health agency (PHA) or clinical data registry (CDR). Active engagement may be demonstrated in one of the following ways:

• Option 1 – Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the MIPS performance period; and the MIPS eligible clinician is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows MIPS eligible clinicians to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. MIPS eligible clinicians that have registered in previous years do not need to submit an additional registration to meet this requirement for each MIPS performance period.
• Option 2 – Testing and Validation: The MIPS eligible clinician is in the process of testing and validation of the electronic submission of data. MIPS eligible clinicians must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a MIPS performance period would result in that MIPS eligible clinician not meeting the measure.
• Option 3 – Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

Production data – Refers to data generated through clinical processes involving patient care, and it is used to distinguish between data and “test data” which may be submitted for the purposes of enrolling in and testing electronic data transfers.

Reporting Requirements (Yes/No or Exclusion)

The MIPS eligible clinician must attest YES to being in an active engagement with a public health agency to electronically submit case reporting of reportable conditions.

EXCLUSIONS: Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Electronic Case Reporting measure if the MIPS eligible clinician:

1. Does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction’s reportable disease system during the performance period.
2. Operates in a jurisdiction for which no public health agency can receive electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.
3. Operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.

Scoring Information

• MIPS eligible clinicians will earn 10 points for satisfying two different measures associated with the Public Health & Clinical Data Exchange objective.
• Eligible clinician would receive the full credit for reporting two “Yes” responses, or for submitting a “Yes” for one measure and claiming an exclusion for another measure under the objective.
• Claiming Exclusions on two different measures under the Public Health & Clinical Data Exchange objective: Points will be redistributed to the following measure – 10 points added to Provided Patient Electronic Access to Their Health Information.

Objective: Public Health and Clinical Data Exchange

Measure: Public Health Registry Reporting

The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit data to public health registries.

Definition of Terms

Active engagement – The MIPS eligible clinician is in the process of moving towards sending “Production data” to a public health agency or clinical data registry, or is sending production data to a public health agency (PHA) or clinical data registry (CDR). Active engagement may be demonstrated in one of the following ways:

• Option 1 – Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the MIPS performance period; and the MIPS eligible clinician is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows MIPS eligible clinicians to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. MIPS eligible clinicians that have registered in previous years do not need to submit an additional registration to meet this requirement for each MIPS performance period.
• Option 2 – Testing and Validation: The MIPS eligible clinician is in the process of testing and validation of the electronic submission of data. MIPS eligible clinicians must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a MIPS performance period would result in that MIPS eligible clinician not meeting the measure.
• Option 3 – Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

Production data – Refers to data generated through clinical processes involving patient care, and it is used to distinguish between data and “test data” which may be submitted for the purposes of enrolling in and testing electronic data transfers.

Reporting Requirements (Yes/No or Exclusion)

The MIPS eligible clinician must attest YES to being in active engagement with a PHA to submit data to public health registries.

Exclusion: Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Public Health Reporting measure if the MIPS eligible clinician:
1. Does not diagnose or directly treat any disease or condition associated with a public health registry in the MIPS eligible clinician’s jurisdiction during the performance period.
2. Operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the performance period.
3. Operates in a jurisdiction where no public health registry for which the MIPS eligible clinician is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the performance period.

Scoring Information

• MIPS eligible clinicians will earn 10 points for satisfying two different measures associated with the Public Health & Clinical Data Exchange objective.
• Eligible clinician would receive the full credit for reporting two “Yes” responses, or for submitting a “Yes” for one measure and claiming an exclusion for another measure under the objective.
• Claiming Exclusions on two different measures under the Public Health & Clinical Data Exchange objective: Points will be redistributed to the following measure – 10 points added to Provided Patient Electronic Access to Their Health Information.

Enrollments and Additional Information

• Public Health Registry Reporting: see https://sticomputer.com/premier-registry-registration-form/ for further details regarding Premier Inc. (formerly CECity) and enrollment information.

Objective: Public Health and Clinical Data Exchange

Measure: Clinical Data Registry Reporting

The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.

Definition of Terms

Active engagement – The MIPS eligible clinician is in the process of moving towards sending “Production data” to a public health agency or clinical data registry, or is sending production data to a public health agency (PHA) or clinical data registry (CDR). Active engagement may be demonstrated in one of the following ways:

• Option 1 – Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the MIPS performance period; and the MIPS eligible clinician is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows MIPS eligible clinicians to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. MIPS eligible clinicians that have registered in previous years do not need to submit an additional registration to meet this requirement for each MIPS performance period.
• Option 2 – Testing and Validation: The MIPS eligible clinician is in the process of testing and validation of the electronic submission of data. MIPS eligible clinicians must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a MIPS performance period would result in that MIPS eligible clinician not meeting the measure.
• Option 3 – Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

Production data – Refers to data generated through clinical processes involving patient care, and it is used to distinguish between data and “test data” which may be submitted for the purposes of enrolling in and testing electronic data transfers.

Reporting Requirements (Yes/No or Exclusion)

The MIPS eligible clinician must attest YES to being in active engagement to submit data to a clinical data registry.

EXCLUSIONS: Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Clinical Data Registry Reporting measure if the MIPS eligible clinician:
1. Does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction during the performance period.
2. Operates in a jurisdiction for which no clinical data registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the performance period.
3. Operates in a jurisdiction where no clinical data registry for which the MIPS eligible clinician is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the performance period.

Scoring Information

• MIPS eligible clinicians will earn 10 points for satisfying two different measures associated with the Public Health & Clinical Data Exchange objective.
• Eligible clinician would receive the full credit for reporting two “Yes” responses, or for submitting a “Yes” for one measure and claiming an exclusion for another measure under the objective.
• Claiming Exclusions on two different measures under the Public Health & Clinical Data Exchange objective: Points will be redistributed to the following measure – 10 points added to Provided Patient Electronic Access to Their Health Information.

Objective: Public Health and Clinical Data Exchange

Measure: Syndromic Surveillance Reporting

The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.

Definition of Terms

Active engagement – The MIPS eligible clinician is in the process of moving towards sending “Production data” to a public health agency or clinical data registry, or is sending production data to a public health agency (PHA) or clinical data registry (CDR). Active engagement may be demonstrated in one of the following ways:

• Option 1 – Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the MIPS performance period; and the MIPS eligible clinician is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows MIPS eligible clinicians to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. MIPS eligible clinicians that have registered in previous years do not need to submit an additional registration to meet this requirement for each MIPS performance period.
• Option 2 – Testing and Validation: The MIPS eligible clinician is in the process of testing and validation of the electronic submission of data. MIPS eligible clinicians must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a MIPS performance period would result in that MIPS eligible clinician not meeting the measure.
• Option 3 – Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

Production data – Refers to data generated through clinical processes involving patient care, and it is used to distinguish between data and “test data” which may be submitted for the purposes of enrolling in and testing electronic data transfers.

Reporting Requirements (Yes/No or Exclusion)

The MIPS eligible clinician must attest YES to being in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.

EXCLUSIONS: Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Syndromic Surveillance Reporting measure if the MIPS eligible clinician:
1. Is not in a category of health care providers from which ambulatory syndromic surveillance data is collected by their jurisdiction’s syndromic surveillance system.
2. Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required to meet the CEHRT definition at the start of the performance period.
3. Operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from MIPS eligible clinicians as of 6 months prior to the start of the performance period.

Scoring Information

• MIPS eligible clinicians will earn 10 points for satisfying two different measures associated with the Public Health & Clinical Data Exchange objective.
• Eligible clinician would receive the full credit for reporting two “Yes” responses, or for submitting a “Yes” for one measure and claiming an exclusion for another measure under the objective.
• Claiming Exclusions on two different measures under the Public Health & Clinical Data Exchange objective: Points will be redistributed to the following measure – 10 points added to Provided Patient Electronic Access to Their Health Information.

Enrollments and Additional Information

• Syndromic Surveillance Reporting: availability varies by state; you will need to check with your state to see if any public health agencies exist.