Merit-Based Incentive Payment System (MIPS) Promoting

Merit-Based Incentive Payment System (MIPS)

Promoting Interoperability Performance Category

Measure

2023 Performance Period

Objective:

Provider to Patient Exchange

Measure:

Provide Patients 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 Programming Interface (API) in the MIPS eligible clinician's

certified electronic health record technology (CEHRT).

Measure ID:

PI_PEA_1

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.

Unique Patient – If a patient is seen by a MIPS eligible clinician more than once during the

performance period, then, for purposes of measurement, that patient is only counted once in the

denominator for the measure. All the measures relying on the term ‘‘unique patient’’ relate to

what is contained in the patient’s medical record. Not all of this information will need to be

updated or even be needed by the clinician at every patient encounter. This is especially true for

patients whose encounter frequency is such that they would see the same clinician multiple

times in the same performance period.

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 to 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

• Required for Promoting Interoperability Performance Category Score: Yes

• Measure Score: 25 points

• Eligible for Bonus Score: No

Note: In order to earn a score greater than zero for the Promoting Interoperability performance

category, MIPS eligible clinicians must:

o Complete the Security Risk Analysis measure

o Review the High Priority Practices SAFER Guide

o Complete the ONC Direct Review attestation

o Attest to the Actions to limit or restrict compatibility or interoperability of CEHRT

statement

o Submit their complete numerator and denominator or Yes/No data for all required

measures

The SAFER, or Safety Assurance Factors for EHR Resilience, Guides measure was added in the CY

2022 Physician Fee Schedule Final Rule.

o Submit their CMS certification identification number

o Submit their level of active engagement for the Public Health and Clinical Data

Exchange measures

o Failure to report at least a “1” in all required measures with a numerator or reporting a

“No” for a Yes/No response measure (except for the SAFER Guides measure

) will

result in a total score of 0 points for the Promoting Interoperability performance category.

Additional Information

• In 2023, MIPS eligible clinicians may use technology certified to the 2015 Edition of health IT

certification criteria and updated to the 2015 Edition Cures Update to meet the CEHRT

definition. (85 FR 84472)

• To learn more about the 2015 Edition Cures Update and the changes to 2015 Edition

certification criteria finalized in the 21

Century Cures Act final rule (85 FR 25642), we

encourage MIPS eligible clinicians to visit https://www.healthit.gov/curesrule/final-rule-

policy/2015-edition-cures-update.

• To check whether a health IT product has been certified to criteria updated for the 2015

Edition Cures Update, visit the Certified Health IT Product List (CHPL) at

https://chpl.healthit.gov/.

• Certified functionality must be used as needed for a measure action to count in the numerator

during a performance period. However, in some situations the product may be deployed

during the performance period, but pending certification. In such cases, the product must be

certified by the last day of the performance period.

• Actions included in the numerator must occur within the performance period.

• To implement an API, the MIPS eligible clinician would need to fully enable the API

functionality such that any application chosen by a patient would enable the patient to gain

access to their individual health information provided that the application is configured to

meet the technical specifications of the API. MIPS eligible clinicians may not prohibit

patients from using any application, including third-party applications, which meet the

technical specifications of the API, including the security requirements of the API. MIPS

eligible clinicians are expected to provide patients with detailed instructions on how to

authenticate their access through the API and provide the patient with supplemental

information on available applications that leverage the API.

• Similar to how MIPS eligible clinicians support patient access to view, download and

transmit (VDT) capabilities, MIPS eligible clinicians should continue to have identity

verification processes to ensure that a patient using an application, which is leveraging the

API, is provided access to their health information.

In 2023, eligible clinicians will be required to submit one “yes/no” attestation statement for completing an

annual self-assessment of the High Priority Practices SAFER Guide, and the “yes” or “no” attestation will

fulfill the measure.

• In circumstances where there is no information available to populate one or more of the

fields previously listed, either because the MIPS eligible clinicians can be excluded from

recording such information or because there is no information to record (for example, no

medication allergies or laboratory tests), the MIPS eligible clinician may have an indication

that the information is not available and still meet the objective and its associated measure.

• The patient must be able to access this information on demand, such as through a patient

portal or personal health record (PHR) or by other online electronic means. We note that

while a covered entity may be able to fully satisfy a patient's request for information through

VDT, the measure does not replace the covered entity's responsibilities to meet the broader

requirements under HIPAA to provide an individual, upon request, with access to PHI in a

designated record set.

• MIPS eligible clinicians should also be aware that while the measure is limited to the

capabilities of CEHRT to provide online access, there may be patients who cannot access

their EHRs electronically because of a disability. MIPS eligible clinicians who are covered by

civil rights laws must provide individuals with disabilities equal access to information and

appropriate auxiliary aids and services as provided in the applicable statutes and

regulations.

• For the measure, MIPS eligible clinicians must offer all four functionalities (view, download,

transmit, and access through API) to their patients. Patient health information needs to be

made available to each patient for view, download, and transmit within 4 business days of

the information being available to the clinician for each and every time that information is

generated whether the patient has been "enrolled" for three months or for three years.

• A patient who has multiple encounters during the performance period, or even in

subsequent performance periods in future years, needs to be provided access for each

encounter where they are seen by the MIPS eligible clinician.

• If a patient elects to "opt out" of participation, that patient must still be included in the

denominator.

• If a patient elects to “opt out” of participation, the MIPS eligible clinician may count that

patient in the numerator if the patient is provided all of the necessary information to

subsequently access their information, obtain access through a patient-authorized

representative, or otherwise opt-back-in without further follow up action required by the

clinician.

• The MIPS eligible clinician must continue to update the information accessible to the patient

each time new information is available.

• For view, download, and transmit functionality, the required content is:

o United States Core Data for Interoperability (USCDI)

(https://www.healthit.gov/isa/united-states-core-data-interoperability-uscdi)

o Provider's name and office contact information.

o Laboratory test report(s).

o Diagnostic image report(s).

• For API functionality the required data set is the USCDI (https://www.healthit.gov/isa/united-

states-core-data-interoperability-uscdi)

• When MIPS eligible clinicians choose to report as a group, data should be aggregated for all

MIPS eligible clinicians under one Taxpayer Identification Number (TIN). This includes those

MIPS eligible clinicians who may qualify for reweighting through an approved Promoting

Interoperability hardship exception, hospital or ASC-based status, or in a specialty which is not

required to report data to the Promoting Interoperability performance category. If these MIPS

eligible clinicians choose to report as a part of a group practice, they will be scored on the

Promoting Interoperability performance category like all other MIPS eligible clinicians.

Regulatory References

• For further discussion, please see the Medicare Access and CHIP Reauthorization Act of

2015 (MACRA) final rule: 81 FR 77228.

• For additional discussion, please see the 2018 Physician Fee Schedule final rule – Quality

Payment Program final rule: 83 FR 59789.

• In order to meet this objective and measure, MIPS eligible clinicians must use technology

certified to the criteria at 45 CFR 170.315 (e)(1), (g)(7), (g)(10), and (9).

Certification Criteria and Standards

Information about the corresponding certification criteria for electronic health record technology

that support this measure can be found below:

Certification Criteria

§170.315(e)(1) View, Download, and Transmit to 3rd Party

§170.315(g)(7) Application Access — Patient Selection

§ 170.315(g)(9) Application Access – All Data Request

§ 170.315(g)(10) - Application access — standardized API for patient and population services