Clinical Data Registry Reporting
The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.
Measure ID
PI_PHCDRR_5
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
Yes
Performance Score Weight
None
Clinical Data Registry Reporting Exclusion
Any MIPS eligible clinician who 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.
Measure ID
PI_PHCDRR_5_EX_3
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Clinical Data Registry Reporting Exclusion
Any MIPS eligible clinician who does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction during the performance period.
Measure ID
PI_PHCDRR_5_EX_1
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Clinical Data Registry Reporting Exclusion
Any MIPS eligible clinician who 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.
Measure ID
PI_PHCDRR_5_EX_2
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Clinical Data Registry Reporting for Multiple Registry Engagement
Report as true if, active engagement with more than one Clinical Data Registry in accordance with PI_PHCDRR_5.
Measure ID
PI_PHCDRR_5_MULTI
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
Up to 10%
e-Prescribing
At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using CEHRT.
Measure ID
PI_EP_1
Objective Name
Electronic Prescribing
Required for Base Score?
Yes
Performance Score Weight
Up to 10%
e-Prescribing exclusion
Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.
Measure ID
PI_LVPP_1
Objective Name
Electronic Prescribing
Required for Base Score?
No
Performance Score Weight
0
Electronic Case Reporting
The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.
Measure ID
PI_PHCDRR_3
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
Yes
Performance Score Weight
None
Electronic Case Reporting Exclusion
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.
Measure ID
PI_PHCDRR_3_EX_3
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Electronic Case Reporting Exclusion
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.
Measure ID
PI_PHCDRR_3_EX_2
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Electronic Case Reporting Exclusion
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.
Measure ID
PI_PHCDRR_3_EX_1
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Electronic Case Reporting for Multiple Registry Engagement
Report as true if, active engagement with more than one Electronic Case Reporting registry in accordance with PI_PHCDRR_3.
Measure ID
PI_PHCDRR_3_MULTI
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
Up to 10%
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).
Measure ID
PI_PHCDRR_1
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
Yes
Performance Score Weight
None
Immunization Registry Reporting Exclusion
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.
Measure ID
PI_PHCDRR_1_EX_1
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Immunization Registry Reporting Exclusion
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.
Measure ID
PI_PHCDRR_1_EX_3
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Immunization Registry Reporting Exclusion
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.
Measure ID
PI_PHCDRR_1_EX_2
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Immunization Registry Reporting for Multiple Registry Engagement
Report as true if active engagement with more than one immunization registry in accordance with PI_PHCDRR_1.
Measure ID
PI_PHCDRR_1_MULTI
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
Up to 10%
ONC Direct Review Attestation
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.
Measure ID
PI_ONCDIR_1
Objective Name
None
Required for Base Score?
Yes
Performance Score Weight
0
ONC-ACB Surveillance Attestation
I have (1) Acknowledged the option to cooperate in good faith with ONCÔøΩACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONCÔøΩACB surveillance is received; and (2) If requested, cooperated in good faith with ONCÔøΩACB 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.
Measure ID
PI_ONCACB_1
Objective Name
None
Required for Base Score?
No
Performance Score Weight
0
Prevention of Information Blocking Attestation
I attest to CMS that I – (A) did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology. (B) Implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified EHR technology was, at all relevant times: (1) Connected in accordance with applicable law; (2) Compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria adopted at 45 CFR part 170; (3) Implemented in a manner that allowed for timely access by patients to their electronic health information; and (4) Implemented in a manner that allowed for the timely, secure, and trusted bi-directional exchange of structured electronic health information with other health care providers (as defined by 42 U.S.C. 300jj(3)), including unaffiliated health care providers, and with disparate certified EHR technology and vendors. (C) Responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers (as defined by 42 U.S.C. 300jj(3)), and other persons, regardless of the requestor’s affiliation or technology vendor.
Measure ID
PI_INFBLO_1
Objective Name
None
Required for Base Score?
Yes
Performance Score Weight
0
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 Programing Interface (API) in the MIPS eligible clinician’s certified electronic health record technology (CEHRT).
Measure ID
PI_PEA_1
Objective Name
Provider To Patient Exchange
Required for Base Score?
Yes
Performance Score Weight
Up to 40%
Public Health Registry Reporting
The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.
Measure ID
PI_PHCDRR_4
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
Yes
Performance Score Weight
None
Public Health Registry Reporting Exclusion
Any MIPS eligible clinician who 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.
Measure ID
PI_PHCDRR_4_EX_3
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Public Health Registry Reporting Exclusion
Any MIPS eligible clinician who 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.
Measure ID
PI_PHCDRR_4_EX_2
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Public Health Registry Reporting Exclusion
Any MIPS eligible clinician who 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.
Measure ID
PI_PHCDRR_4_EX_1
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Public Health Registry Reporting for Multiple Registry Engagement
Report as true if, active engagement with more than one Public Health Registry in accordance with PI_PHCDRR_4.
Measure ID
PI_PHCDRR_4_MULTI
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
Up to 10%
Query of the 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 Prescription Drug Monitoring Program (PDMP) for prescription drug history, except where prohibited and in accordance with applicable law.
Measure ID
PI_EP_2
Objective Name
Electronic Prescribing
Required for Base Score?
No
Performance Score Weight
Up to 5%
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 CEHRT in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 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.
Measure ID
PI_PPHI_1
Objective Name
Protect Patient Health Information
Required for Base Score?
Yes
Performance Score Weight
0
Support Electronic Referral Loops By Receiving and Incorporating Health Information
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.
Measure ID
PI_HIE_4
Objective Name
Health Information Exchange
Required for Base Score?
Yes
Performance Score Weight
Up to 20%
Support Electronic Referral Loops By Receiving and Incorporating Health Information Exclusion
Any MIPS eligible clinician who is unable to implement the measure for a MIPS performance period in 2019 would be excluded from having to report this measure.
Measure ID
PI_CUITC_1
Objective Name
Health Information Exchange
Required for Base Score?
No
Performance Score Weight
0
Support Electronic Referral Loops By Receiving and Incorporating Health Information Exclusion
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.
Measure ID
PI_LVITC_2
Objective Name
Health Information Exchange
Required for Base Score?
No
Performance Score Weight
0
Support Electronic Referral Loops By Sending Health Information
For at least one transition of care or referral to a provider of care other than a MIPS eligible clinician, the MIPS eligible clinician creates a summary of care record using CEHRT; and electronically exchanges the summary of care record.
Measure ID
PI_HIE_1
Objective Name
Health Information Exchange
Required for Base Score?
Yes
Performance Score Weight
Up to 20%
Support Electronic Referral Loops By Sending Health Information Exclusion
Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.
Measure ID
PI_LVOTC_1
Objective Name
Health Information Exchange
Required for Base Score?
No
Performance Score Weight
0
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.
Measure ID
PI_PHCDRR_2
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
Yes
Performance Score Weight
None
Syndromic Surveillance Reporting Exclusion
Any MIPS eligible clinician who 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.
Measure ID
PI_PHCDRR_2_EX_2
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Syndromic Surveillance Reporting Exclusion
Any MIPS eligible clinician who is not in a category of health care providers from which ambulatory syndromic surveillance data is collected by their jurisdiction’s syndromic surveillance system.
Measure ID
PI_PHCDRR_2_EX_1
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Syndromic Surveillance Reporting Exclusion
Any MIPS eligible clinician who 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.
Measure ID
PI_PHCDRR_2_EX_3
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
0
Syndromic Surveillance Reporting for Multiple Registry Engagement
Report as true if, active engagement with more than one Syndromic Surveillance registry in accordance with PI_PHCDRR_2.
Measure ID
PI_PHCDRR_2_MULTI
Objective Name
Public Health And Clinical Data Exchange
Required for Base Score?
No
Performance Score Weight
Up to 10%
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.
Measure ID
PI_EP_3
Objective Name
Electronic Prescribing
Required for Base Score?
No
Performance Score Weight
Up to 5%
