High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides | MIPS PI Measures for 2023 Reporting

Definition of Terms

N/A

Reporting Requirements

YES/NO

To meet this measure, MIPS eligible clinicians must attest YES or NO to conducting an annual self-assessment of the High Priority Practices Guide of the SAFER Guides (
https://www.healthit.gov/topic/safety/safer-guides) the 2023 performance period.

Scoring Information

• Required for Promoting Interoperability Performance Category Score: Yes
• Score: N/A
• Eligible for Bonus Score: No

Note: In order to earn a score greater than zero for the Promoting Interoperability performance category, MIPS eligible clinicians must:

• Complete the Security Risk Analysis measure
• Review the High Priority Practices SAFER Guide¹
• Complete the ONC Direct Review attestation
• Attest to the Actions to limit or restrict compatibility or interoperability of CEHRT statement
• Submit their complete numerator and denominator or Yes/No data for all required measures
• Submit their CMS certification identification number
• Submit their level of active engagement for the Public Health and Clinical Data Exchange measures
• Failure to report at least a “1” in all required measures with a numerator or reporting a “No” for a Yes/No response measure (except for the SAFER Guides measure²) will result in a total score of 0 points for the Promoting Interoperability performance category.

Additional Information

• In 2023, MIPS eligible clinicians must use technology certified to the 2015 Edition of health IT certification criteria and updated to the 2015 Edition Cures Update to meet the CEHRT definition. (85 FR 84472)
• To learn more about the 2015 Edition Cures Update and the changes to 2015 Edition certification criteria finalized in the 21st Century Cures Act final rule (85 FR 25642), we encourage MIPS eligible clinicians to visit https://www.healthit.gov/curesrule/final-rule-policy/2015-edition-cures-....
• To check whether a health IT product has been certified to criteria updated for the 2015 Edition Cures Update, visit the Certified Health IT Product List (CHPL) at https://chpl.healthit.gov/.
• Certified functionality must be used as needed for a measure action to count in the numerator during a performance period. However, in some situations the product may be deployed during the performance period, but pending certification. In such cases, the product must be certified by the last day of the performance period.
• To complete the High Priority Practices Guide self-assessment, MIPS eligible clinicians are expected to fill out the checklist and practice worksheet at the beginning of the guide.
• Failure to report to either “Yes” or “No” for the SAFER Guide will result in no score for the Promoting Interoperability performance category, regardless of whether other measures in this category are reported.
• The SAFER Guide measure is not scored and does not contribute any points to the MIPS eligible clinician’s total score.
• The MIPS eligible clinician does not have to confirm that it has implemented “fully in all areas” each practice described in the SAFER guide, nor will the MIPS eligible clinician be scored on how many of the practices are fully implemented.
• More information about Promoting Interoperability performance category scoring is available on the QPP website.

Regulatory References

• For further discussion, please see the CY 2022 PFS final rule at 86 FR 65475 through 65477.

¹ The SAFER, or Safety Assurance Factors for EHR Resilience, Guides measure was added in the CY 2022 Physician Fee Schedule Final Rule.
² In 2023, eligible clinicians will be required to submit one “yes/no” attestation statement for completing an annual self-assessment of the High Priority Practices SAFER Guide, and the “yes” or “no” attestation response will fulfill the measure.