Promoting Interoperability Checklist (2019)

The following is a checklist of items practices need to address to avoid a total score of zero points or an unanticipated low score in the Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category.

CMS performed an “overhaul” of the objectives, measures and performance requirements for Promoting Interoperability in 2019. It will be significantly more difficult to obtain high scores in the MIPS performance category in 2019.

At the time this article was written there is still time to prepare. The MIPS Promoting Interoperability category reporting period needs to be over a continuous 90-day period in calendar year 2019. The latest possible date to start a performance period is October 3, 2019.

At the bottom of this page are links to various resources intended to help clinicians and practices as they navigate this now challenging performance category of MIPS.

CHECKLIST ITEMS

General Considerations:

Make sure your practice is using 2015 Edition Certified EHR Technology (CEHRT) to meet the requirements for all Promoting Interoperability measure requirements, including modular components. The 2015 Ed. CEHRT must be implemented no later than the start of the reporting period. The product must then be certified no later than the end or chosen reporting period. The EHR needs to be certified as 2015 Edition Certified EHR Technology before the end of the reporting period. This is applicable to all modules if the EHR uses third-party modules (e.g., a third-party e-prescribing application).
Make sure you address all requirements of Promoting Interoperability during the 2019 calendar year. In addition to the objective and measure detailed below, practices, when reporting, must:
1. Submit a “yes” to the Prevention of Information Blocking Attestation
2. Submit a “yes” to the ONC Direct Review Attestation; and
3. Submit a “yes” for the security risk analysis measure

There are five objectives in the 2019 Promoting Interoperability performance category of the MIPS:

Protecting Patient Health Information (limited to the Security Risk Analysis attestation noted above)
e-Prescribing
Provider to Patient Exchange
Health Information Exchange
Public Health and Clinical Data Exchange

We will review considerations for the four objective that have associated measures:

Objective: e-Prescribing

e-Prescribing Measure
1. As noted above, ensure that you are using 2015 Edition Certified EHR Technology (CEHRT), including third party e-prescribing modules that may be integrated with your EHR. Unless you qualify for the exclusion for this measure (defined as a clinician or group that writes fewer than 100 permissible prescriptions during the performance period) you have to report data that shows you wrote at least one prescription using 2015 edition CEHRT or you will receive zero points for the entire Promoting Interoperability performance category.
2. The e-Prescribing measure has been changed from a yes/no attestation measure in 2018 to a performance measure in 2019. Practices can earn up to 10 points in this measure, however that would require that every prescription written was done so using 2015 Edition CEHRT.
3. Review how your system records all permissible prescriptions that are written in all settings of care. CMS requires practices to aggregate all data on all prescriptions written during the 90 day performance period. This can create significant challenges when providers see patients at multiple settings of care, potential using disparate EHR products. Based on a personal communications with CMS and the specification document for this measure, all prescriptions written, including handwritten prescriptions and prescriptions written by all eligible clinicians using older or uncertified e-prescribing platforms are included in the denominator for this measure. Only prescriptions written using 2015 edition CEHRT are counted in the numerator.
  1. If the above becomes significantly burdensome the practice may wish to consider applying for a hardship exception. Detailed information on hardship exemptions and how to apply is available at Promoting Interoperability Hardship Exceptions.
For completeness there are two optional five point bonus measures in the e-prescribing objective. Both have created technical challenges for EHR vendors who may or may not have implemented them for 2019.
1. Query of Prescription Drug Monitoring Program (PDMP).
  1. If this technology is available to practices consider reviewing its requirements and make sure that the PDMP is queried for at least one patient in the practice during the reporting period.This measure only requires the user to query a prescription drug monitoring program for one patient to receive five bonus points. Many vendors have not developed this new technology, however.
2. Verify Opioid Treatment Agreement.

If this measure is available via your EHR vendor, review the requirements and ensure that performance is met for at least one patient during the reporting period. This measure tracks how frequently providers seeks a signed opioid agreement and then incorporates it into the EHR for all patients prescribed Schedule II opioid prescriptions. However, 5 points will be awarded if the practice only incorporates the opioid treatment agreement for one patient.

Objective: Health Information Exchange

There are two measures under this objective:

Support Electronic Referral Loops by Sending Health Information.
1. Meet this measure’s performance requirements for at least one patient during the reporting period. If this does not occur, unless an exclusion is claimed, the entire Promoting Interoperability performance category will receive a score of zero points.
  1. This measure is worth up to 20 points in this category. It requires that a summary of care document be sent electronically for a minimum of one patient who was transferred to another setting of care or referred to another clinician using 2015 Edition CEHRT.
2. Put in place workflows that minimize the number patients that are sent by a practice in transitions of care or as referrals that do not have an accompanying electronic summary of care document.
  1. This is a performance measure, meaning that the score is based on a numerator/denominator ratio. The denominator is the number of patients sent by the practice in transitions of care or as referrals during the performance period. The numerator is populated by patients that were sent by the practice in transitions of care or as referrals where the clinician exported and sent an electronic summary of care document using required standards to the receiving facility/clinician.
3. Create a list of practices or settings of care you send patients to in referrals or transitions of care and reach out to them to obtain their secure messaging addresses, access to their health information exchange, or other secure messaging method.
  1. In order to meet the performance required for this measure, the clinician must send a summary of care document electronically and be reasonably assured that it can be received by the other party and incorporated into their electronic health record. Since many practices may not have secure messaging in place, this may create a challenge. Clinicians that make a good-faith effort to send the electronic summary of care document using current standards will essentially be penalized if receiving organizations and clinicians do not have secure messaging platform in place.
    1. Confirmed by CMS Quality Support (after escalation):
      1. Question: If there are no available query-based exchanges, secure email formats, Health Information Service Provider (HISP), or third party HIEs available to send the C-CDA, does this encounter count in the denominator?
      2. CMS response: Yes, based on the information you provided the encounter would count in the denominator. The denominator is defined as the “Number of transitions of care and referrals during the performance period for which the MIPS eligible clinician was the transferring or referring clinician.” The numerator is “The number of transitions of care and referrals in the denominator where a summary of care record was created using CEHRT and exchanged electronically.” There also must be reasonable certainty of receipt by the receiving clinician to count the action in the numerator. If a MIPS eligible clinician sends a C–CDA and the receiving clinician converts the C–CDA into a pdf or a fax or some other format, the sending provider may still count the transition or referral in the numerator. If the sending MIPS eligible clinician converts the file to a format the receiving clinician could not electronically receive and incorporate as a C–CDA, the initiating clinician may not count the transition in their numerator. Please note, faxing is not an acceptable transmission method.
4. Provide training and monitor performance on this measure.
  1. Provide educations to clinicians and clinical staff members to recognized transitions of care and referrals (based on the definitions for this measure). Note: as per CMS, the denominator for this measure includes all transitions of care and referrals, even when the patient has been seen previously at the receiving facility or practice. For example, instructing the patient follow up with their primary care provider for general healthcare concerns (as long as the “sending” provider is still providing care for the patient) would count as a referral based on the definition of this measure. This may not be intuitive to your practice.
5. Be aware of the exclusion for this measure, which is applied at the individual clinician or group level. Any MIPS eligible clinician who transfers a patient to another setting of care refers a patient fewer than 100 times during the performance period is excluded from this measure. Since clinicians are allowed to report as a group and as individuals simultaneously this exclusion may influence your strategy for reporting.
Support Electronic Referral Loops by Receiving and Incorporating Health Information
1. Make sure that you address the requirements for this measures for at least one patient during the reporting period.
  1. If this does not occur for at least one patient, the practice will receive a score of zero for the entire Promoting Interoperability performance category.
2. Take steps to improve performance on this measure by establishing workflows and secure communication channels with facilities and providers that send patients to your practice in transitions of care and referrals.
  1. This measure is also worth up to 20 points in the Promoting Interoperability performance category.
  2. It requires that patients referred to the practice or patients that have never been encountered before by the clinician have an electronic Summary of Care document imported into the electronic health record and reconciled, using 2015 ed. CEHRT.
  3. The score is based on the number of patients received by the practice in transitions of care or referrals AND patients never before encountered by the clinician. This number serves as the denominator. The numerator reflects the number of patients in the denominator where the clinician or practice received and imported a Summary of Care document, and then performed reconciliation of data. If the clinician does not have access to an electronic Summary of Care document, the performance for this measure will not be met, negatively impacting the score for this measure.
3. Review, test and practice how electronic Summary of Care (C-CDA documents) are received or accessed by your practice.
4. Review, test and practice the import and reconciliation process. Information imported from an external Summary of Care document must be reconciled with information already in the EHR, if there is preexisting information. At a minimum this measure requires that the following types of information be reconciled: current medications, medication allergies and the problem list.
  1. The reconciliation can be performed by a clinician or by clinical staff member under the supervision of the clinical staff member.
5. Beware of the two exclusions for this measure:
  1. The first exclusion reads “Any MIPS eligible clinician who is unable to implement the measure for the MIPS performance period in 2019.” This is subject to interpretation is no additional information is provided, but will be applicable in some settings. If you feel your situation may be applicable to this exclusion contact the Quality Payment Program for specific guidance: QPP@CMS.hhs.gov
  2. The second exclusion reads “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.” As per the 2020 Physician Fee Schedule Proposed Rule these numbers are added together. In other words, if the practice receives 50 transitions of care, 50 referrals, and has 50 encounters with patients they have never encountered previously they would not qualify for the exclusion.
  3. As noted previously these exclusions are applicable at the individual clinician or group level. These exclusions may be relevant to consider when deciding whether to report as a group, to have clinicians report as individuals, or to have eligible providers report as both individuals and as a group.

Objective: Provider to Patient Exchange

This objective has one measure titled: Provide Patients Electronic Access to Their Health Information

Make sure that for at least one patient seen during the performance period that the requirements for this measures have been met. Failing to meet the measure for at least one patient will result in an entirePromoting Interoperability score or zero.
1. This measure uses all patients seen by the practice during the reporting period as its denominator population.
2. Performance for this measure is met (and the numerator is populated) when the following two requirements are met:
  1. Providing the patient or their authorized representative with timely access (defined as 4 business days after the information becomes available to the provider) to view, download and transmit the patient’s health information, and
  2. The practice ensures that 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).
3. This is a performance based measure worth up to 40 points of your total score in the Promoting Interoperability category or MIPS
Establish workflows in your office that ensure that each patient seen during the reporting period is provided with or offered access to their electronic information.
1. Patient portals and EHR-based applications meet the requirements for this measure. Ensure that patients are provided with the opportunity on each visit during the reporting period to become set up on the portal or application.
Start enrolling patients prior to the reporting period.
1. Patients that were previously enrolled in a patient portal or application that provides access to their electronic health information (information specific to your practice) do not need to re-enrolled, they will count as performance met. For this reason it is helpful to start enrolling patients prior to the reporting period.
Review the enrollment requirements and ensure that they are met for each enrolled patient, or patient that was given the opportunity to enroll.
1. Patients need to have all the necessary information to view, download and transmit their information. If the patient do not exercise the options to access their information, the practice still get credit for this patient.
  1. Instructions for patients could include written or electronic instructions (e.g, email), a website address, or other methodology. The instructions must include all the information the patient needs to access their information securely.
Make sure that requirements are met for patients that “opt-out” of the opportunity to access their information.
1. Patients may “opt-out” of participating with online access to their information. These patients are still counted in the denominator for this measure. If the patient is provided with “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” they will meet the performance requirement for this measure (and be included in the numerator).
Ensure that the information provided to the patients via their electronic access includes all the required fields. Work with your vendor(s) if any of these fields are not available to your patients after you provide access.
1. As per the CMS specification document, the information listed below must be made available to patients. However, if there is no information available or the provider does not record that type of information (e.g., certain clinician types), an indication that no information is available is sufficient.
  1. Patient name
  2. Provider’s name and office contact information
  3. Current and past problem list
  4. Encounter diagnosis
  5. Procedures
  6. Laboratory test results
  7. Current medication list and medication history
  8. Current medication allergy list and medication allergy history
  9. Vital signs (height, weight, blood pressure, BMI, growth charts)
  10. Smoking status
  11. Immunizations
  12. Functional status, including activities of daily living, cognitive and disability status
  13. Unique device identifier(s) for a patient’s implantable device(s)
  14. Demographic information (preferred language, sex, race, ethnicity, date of birth)
  15. Care plan field(s), including goals, health concerns, assessment, plan of treatment and instructions
  16. Any known care team members including the primary care provider (PCP) of record
Group reporting: Make sure that all MIPS eligible clinician types in the group are aware that their actions are also used to determine performance in the Promoting Interoperability performance category of MIPS. For example, clinical psychologists are not required to report data in the Promoting Interoperability performance category unless they are a member of a group that includes one or more physicians, in which case their actions for this and other Promoting Interoperability measures count the same as those of physicians and other clinician types.
Be compliant with other requirements for this measure, including:
1. Do not limit access to one preferred application or portal. Practices cannot prohibit patients from using any application of their choice that meet the technical specifications of the practice’s EHR (i.e., via the EHR’s Application Programming Interface (API). As per the CMS specification document for this measure “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.”
2. Be aware of the potential need to accommodate patients with disabilities. As per the specification document for this measure “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.”
3. Provide patients with ongoing access to every encounter. Information must be made available to the patient within 4 business days of it being available to the clinician for all patients on an ongoing basis. For example, if patient seen during the reporting period has been on a portal for several months, the information from the encounter needs to be made available to the patient within the required time period.

Objective: Public Health and Clinical Data Registry

The objective has five measures, listed below. In order to avoid a score of zero for the entire Promoting Interoperability performance category practices will need to attest to meeting the requirements for at least one of these measures. Each measure has a value of five points. Up to two measures can be reported and attesting to meeting the requirements of two measures will achieve the maximum of 10 points from this objective. As with all measures in the Promoting Interoperability performance category of MIPS, 2015 ed. CEHRT must be used to perform all actions.

If an exclusion is claimed for one measure but the practice attests to another measure the practice will receive all 10 points from this objective.If the practice qualifies for an exclusion only one measure from this objective needs to be reported. If the practice qualifies for exclusions for two measures under this objective they will not be required to attest to meeting the requirements for any measures in this category. The 10 points will be redistributed to the Provide Patients Electronic Access to Their Health Information measure.

These five measures have the following attributes in common:

Reporting is through “yes” or “no” attestation
They all require active engagement and the sharing of production data between the clinician and the clinical data registry or public health agency, with the exceptions of practices currently testing and validating data with a registry or waiting for the registry to begin testing and validation. Production data refers to data generated through clinical processes involving patient care.
Each registry or public health database needs to have an established interface with your EHR product
They all refer to registries and public health databases in the practices “jurisdiction.” CMS provides the following information for this term in the context of this objective:
1. “The definition of jurisdiction is general, and the scope may be local, state, regional or at the national level. The definition will be dependent on the type of registry to which the provider is reporting. A registry that is ‘‘borderless’’ would be considered a registry at the national level and would be included for purposes of this measure.”
Practices qualify for meeting the measure’s requirement if they are in an active process of testing and validating the electronic submission of data with a clinical data registry or public health agency.
Practices qualify for meeting the measure’s requirement if they have have registered to submit data to a registry but are waiting to start testing and validation due to lack of registry/public health agency resources.

Checklist items and supporting information for the five measures in this objective are listed below:

Establish which clinical data registries and/or public health agencies your EHR vendor currently has available for implementation and they meet the 2015 edition CEHRT requirements.
Review the types of data or conditions the available registries or public health agencies exchanges and if this information is relevant for your practice.
Review the exclusion criteria for each applicable measures (listed below under each measure in this objective)

Public Health and Clinical Data Exchange Measure Exclusions:

Clinical Data Registry Reporting
1. The exclusions for this measure are listed below:
  1. Exclusion 1. The practice does not diagnose or directly treat any disease or condition associated with the clinical data registry in their jurisdiction during the reporting period.
  2. Exclusion 2. The practice 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. Exclusion 3. The practice 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.
Electronic Case Reporting
1. The following exclusions are available for this measure:
  1. The clinician/group 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. The clinician/group operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.
  3. The clinician/group 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.
Immunization Registry Reporting
1. The following exclusions are available for this measure:
  1. The clinician/group 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. The clinician/group operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.
  3. The clinician/group 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.
Public Health Registry Reporting
1. The following exclusions are available for this measure:
  1. The clinician/group 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. The clinician/group 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. The clinician/group 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.
Syndromic Surveillance Reporting
1. The following exclusions are available for this measure:
  1. The clinician/group 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. The clinician/group 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. The clinician/group 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.

Additional Resources

Fact Sheet and Guide:

Measures Specification Documents

Security Risk Analysis

2019MIPSPIMeasuresSecurityRiskAnalysis 2019

Information Blocking Fact Sheet

2019 PI Information Blocking Fact Sheet

Disclaimer: The information presented on this page represent the interpretations of available CMS documentation, feedback from CMS, and experience with working with clients. Please review the official CMS documents provided above for additional details.

For questions or assistance please contact us at info@apollohit.com

Updated: August 23, 2019