[ { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "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.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides beginning with the 2022 performance period.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": [ "PI_LVPP_1" ] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "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.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "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.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5" ], "measureSpecification": null, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "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, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5" ], "measureSpecification": null, "measureSets": [], "exclusion": [ "PI_LVITC_2" ] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4" ], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "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).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "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).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who 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.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who 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.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who 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.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3", "PI_PHCDRR_3_EX_4" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3", "PI_PHCDRR_3_EX_4" ], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who 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.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3", "PI_PHCDRR_3_EX_4" ], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who 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.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_4" ], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_4", "title": "Electronic Case Reporting Exclusion", "description": "For the CY 2022 performance period/CY 2024 MIPS payment year only, the MIPS eligible clinician uses CEHRT that is not certified to the electronic case reporting certification criterion at CFR 170.315(f)(5) prior to the start of the performance period they select in CY 2022.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null } ]