Excerpted from “MIPS 2024, Part 2—What’s New With PI, Improvement Activities, and Cost" (EyeNet, February 2024), posted online ahead of print.
PI’s Longer Performance Period
Promoting interoperability (PI) is the MIPS performance category that is based on your use of certified EHR technology (CEHRT).
A 180-day performance period. For 2024, CMS has extended the PI performance period to 180 consecutive days (up from 90 days in previous years). The agency stated that its long-term goal is to “ensure the meaningful use of CEHRT and information exchange throughout the year, for all data, all clinicians, and all patients.”
PI’s New CEHRT Policy
New EHR certification policy introduces Base EHR. From 2017 through 2023, the PI performance category involved three different levels of CEHRT certification:
- in 2017, you needed a minimum of 2014-edition certification;
- in 2019, you needed a minimum of 2015-edition certification; and
- in 2023, you needed 2015 Cures Update–certification.
Four of those seven years were transition years, where you could choose whether to continue using a CEHRT with an old certification or move to one with the latest certification.
Starting in 2024, the Office of the National Coordinator for Health IT (ONC) will use just one set of CEHRT certification criteria—Base EHR certification. Instead of jumping to a new level of certification with large-scale updates every several years, Base EHR will undergo more frequent, incremental changes.
New timeline mandate for CEHRT developers. To support the new EHR certification policy, ONC plans to provide CEHRT developers with mandatory timelines for implementing updates and providing them to practices, as outlined in the Health Data, Technology, and Interoperability: Certification Programs Updates, Algorithm Transparency, and Information Sharing (HTI-1) final rule. How will you know that your EHR vendor is keeping up with those updates? CMS has said that you will be able to track that by using its Certified Health IT Product List at https://chpl.healthit.gov.
PI’s Query of PDMP Measure: Flawed Exclusions Get Fixed
Some PI measures include exclusions. As in previous years, for example, the e-Prescribing measure has an exclusion for clinicians who “write fewer than 100 permissible prescriptions during the performance period.” If you report that this exclusion applies to you, you don’t have to perform the e-Prescribing measure and the points that are associated with it will be reallocated to one or more other PI measures.
In 2022, the Query of PDMP measure had no exclusions. In 2022, the Query of Prescription Drug Monitoring Program (PDMP) measure focused only on Schedule II opioid drugs and it was an optional bonus measure, which meant that it didn’t need any exclusions.
In 2023, the Query of PDMP measure had three exclusions. In 2023, the Query of PDMP measure was expanded to include Schedule III and IV substances and it was no longer optional. Exclusions for the measure were available to: 1) “Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period,” 2) “Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period,” and—for 2023 only—3) any MIPS eligible for whom querying a PDMP would “impose an excessive workflow or cost burden” prior to the start of their performance period.
Fixing a flaw in the 2023 exclusions. If clinicians wrote more than 100 permissible prescriptions during their 2023 PI performance period but didn’t prescribe any Schedule II, III, or IV drugs during that time (even though they were allowed to do so), none of the exclusions would have applied. To address that for 2024, the second exclusion is being changed to “Any MIPS eligible clinician who does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs during the performance period.”
A Timetable for Public Health and Clinical Data Exchange Measures
Measures in PI’s Public Health and Clinical Data Exchange objective typically involve reporting to a public health agency (PHA) or a registry. For example, if you integrate your EHR with the IRIS Registry, you can report the Clinical Data Registry Reporting measure.
For the 2023 performance year, CMS added a new requirement—you needed to start reporting your level of engagement with the PHA or registry.
These measures include two levels of engagement:
- preproduction and validation, which involves being registered with a PHA or registry, and testing and validating the electronic submission of data, or
- validated data production, which involves electronically submitting production data.
For the 2024 performance year, the agency added a timetable for full engagement. For a given measure, you can report the first level of engagement (preproduction and validation) just once before moving on to the second level (validated data production) if you report that measure for the next performance year. This assumes that you are involved with the same registry or PHA in both years; if you switch to a different PHA or registry, you will be able to spend an additional year in preproduction and validation.
(Note: CMS has said that it won’t take into account your level of engagement for 2023. If you were in preproduction and validation in 2023, you will be able to stay at that level of engagement in 2024 before being obligated to move to validated data production in 2025.)
PI’s SAFER Guides Measure Is Now Mandatory
Since 2014, the ONC has encouraged health care organizations of all sizes to use the Safety Assurance Factors for EHR Resilience (SAFER) Guides. These are a set of nine self-assessment tools that focus on best practices for EHR safety. One of them, the High Priority Practices Guide, provides an overview of the other eight. To further promote use of these guides, CMS added a SAFER Guides measure to PI in 2022.
In 2022 and 2023, you could attest “yes” or “no.” To score more than zero for the PI performance category, you must attest to whether you used the High Priority Practices Guide to conduct a self-assessment of the practice’s EHR. However, in 2022 and 2023 it didn’t matter whether you attested “yes” or “no” to conducting the self-assessment.
In 2024, you must attest affirmatively. In 2024, you must attest that your practice did conduct a self-assessment based on the High Priority Practices Guide. If you attest “no” or don’t attest at all, you will receive a score of zero for the PI performance category.
CMS tips for the SAFER Guides measure. CMS has provided the following guidance:
- CMS encourages your practice to complete the self-assessment using a team approach that involves clinicians, administrative staff, and the EHR vendor.
- Completing the self-assessment involves filling out the checklist and practice worksheet that appear at the beginning of the High Priority Practices Guide.
- The agency recognizes that some of the recommendations in the SAFER Guides won’t apply to all health care organizations. Consequently, it doesn’t require you to attest to whether you have implemented any best practices “fully in all areas,” as described in the High Priority Practices Guide.
- The self-assessment doesn’t have to be done during your 180-day PI performance period, but it must be completed during the 2024 calendar year.
- The SAFER Guides measure isn’t scored and doesn’t contribute any points to your PI score.
- If you are participating in MIPS as part of a group, CMS doesn’t require each individual clinician to make this attestation—the group’s attestation will apply to all of the group’s MIPS eligible clinicians.
Look for the 2024 High Priority Practices SAFER Guide Fact Sheet in the Resource Center at qpp.cms.gov.
PI’s Automatic Exceptions
In 2024, five categories of clinician continue to be eligible for an automatic exception from PI: clinicians in small practices, hospital-based clinicians, ambulatory surgery center (ASC)–based clinicians, nonpatient facing clinicians, and clinical social workers.
However, the following clinician types no longer qualify for an automatic exception: physical therapists, occupational therapists, qualified speech-language pathologists, clinical psychologists, and registered dieticians or nutrition professionals.
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