Overview
To prevent actions that block the exchange of health information, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program final rule require MIPS eligible clinicians to show that they haven’t knowingly and willfully limited or restricted the compatibility or interoperability of their certified electronic health record (EHR) technology (CEHRT). MIPS eligible clinicians show that they’re meeting this requirement by attesting to the Actions to Limit or Restrict Compatibility or Interoperability of CEHRT statement.
Do I Have to Attest?
If you’re a MIPS eligible clinician who reports for the MIPS Promoting Interoperability performance category, you must attest to the Actions to Limit or Restrict Compatibility or Interoperability of CEHRT statement.
If you’re reporting as a group, the Actions to Limit or Restrict Compatibility or Interoperability of CEHRT attestation statement by the group applies to all MIPS eligible clinicians within the group. Therefore, if one MIPS eligible clinician in the group fails to meet the requirements of the attestation, then the whole group would fail to meet the requirement.
What Actions Are Required?
If you want to earn a score greater than 0 for the Promoting Interoperability performance category, you must act in good faith when you implement and use your CEHRT to exchange electronic health information. This includes working with technology developers and others who built CEHRT to make sure the technology is used correctly and is connected (and enabled) to meet applicable standards and laws.
You must also ensure that your organizational policies and workflows are enabled and don’t restrict the CEHRT’s functionality in any way. For example, if your CEHRT gives patients access to their electronic health information or exchanges information with other MIPS eligible clinicians, your practice must use these capabilities.
We recognize that circumstances beyond a MIPS eligible clinician’s control may limit the exchange or use of electronic health information. This is why the Actions to Limit or Restrict Compatibility or Interoperability of CEHRT attestation statement focuses on whether you act in good faith to exchange electronic health information and your situation.
This focus considers a MIPS eligible clinician’s individual circumstances, such as:
- Your practice or organization size
- How much technology you have
- What your CEHRT can do
The attestation doesn’t:
- Assume how much you know about technology
- Hold you responsible for outcomes you cannot reasonably influence or control
What Am I Attesting to?
The Actions to Limit or Restrict Compatibility or Interoperability of CEHRT attestation statement is based on section 106(b)(2)(A) of MACRA about how MIPS eligible clinicians implement and use CEHRT. The statement requires MIPS eligible clinicians to demonstrate that they didn’t knowingly and willfully take action to limit or restrict the compatibility or interoperability of CEHRT.
| Actions to Limit or Restrict Compatibility or Interoperability of CEHRT Attestation Statement: |
|---|
| The MIPS eligible clinician or group must attest to CMS that he or she didn’t knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of CEHRT. |
When you attest to the statement, you’re confirming that you’ve acted in good faith to:
- Support the appropriate exchange of electronic health information
- Not knowingly and willfully limit or restrict the compatibility or interoperability of the CEHRT
Examples of actions that may restrict compatibility or interoperability include:
- Implementing or configuring CEHRT so access to certain types of data elements or to the “structure” of the data is limited
- Implementing CEHRT in ways that limit the people or entities that can access and exchange information, or the types of technologies they can use
We don’t expect you to have any special technical skills or to personally deal with the technical details of implementing your health information technology (IT). However, we do expect that you take reasonable steps to ensure that you can attest that you meet the conditions described in the statement. To be clear, you should inform health IT developers, implementers, and others who are responsible for implementing and configuring your CEHRT of the requirements.
Also, you should get adequate assurances from them that your CEHRT was connected:
- To meet the standards and laws that apply
- In a way that enables you to show you haven’t knowingly and willfully restricted its compatibility or interoperability
Do I have to Show Any Documentation to Attest?
You don’t have to give us any documentation to show you have acted in good faith to:
- Implement and use your CEHRT to support the appropriate exchange of electronic health information
- Not block information
What are the Other Promoting Interoperability Requirements?
In addition to the Actions to Limit or Restrict Compatibility or Interoperability of CEHRT Attestation, you must meet these requirements to earn a score greater than 0 in the Promoting Interoperability performance category:
- Use 2015 Edition Cures Update CEHRT
- Provide your EHR’s CMS identification code from the Certified Health IT Product List (CHPL)
- Submit performance data for a minimum of a continuous 90-day performance period
- Meet all of the required measures or qualify and claim exclusions
- Submit a “yes” that you’ve completed the Security Risk Analysis measure during the calendar year in which the performance period occurs
- Attest to work in good faith with the Office of the National Coordinator for Health Information Technology (ONC), if you get a request from ONC to assist in its review of potential non-conformities in health information technology
You can also choose to attest to work in good faith with an ONC-ACB surveillance of your health information technology if it is certified under the ONC Health IT Certification Program. You have this option if you get a request for surveillance.
Where Can You Go for Help?
- Contact the Quality Payment Program Service Center by email at QPP@cms.hhs.gov, create a QPP Service Center ticket, or by phone at 1-866-288-8292 (Monday through Friday 8 a.m. – 8 p.m. ET). To receive assistance more quickly, please consider calling during non-peak hours—before 10 a.m. and after 2 p.m. ET.
- Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.
- Visit the Quality Payment Program website for other help and support information, to learn more about MIPS, and to check out the resources available in the Quality Payment Program Resource Library.
Additional Resources
The Quality Payment Program Resource Library houses fact sheets, specialty guides, technical guides, user guides, helpful videos, and more.
| Resource | Description |
|---|---|
| 2023 MIPS Promoting Interoperability Performance Category Quick Start Guide | A high-level overview and practical information about data collection and submission for the 2023 MIPS Promoting Interoperability performance category. |
| 2023 MIPS Promoting Interoperability User Guide (available in the Quality Payment Program Resource Library in Spring 2023) | A guide to help clinicians participating in the MIPS Promoting Interoperability performance category during the 2023 performance period. |
| 2023 MIPS Promoting Interoperability Measure Specifications | Provides a detailed overview of the requirements for the 2023 Promoting Interoperability performance category objectives and measures. |