| Objective: | Protect Patient Health Information |
|---|---|
| Measure: | High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides |
| Measure ID: | PI_PPHI_2 |
| PDF link: | High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides |
Definition of Terms
N/A
Reporting Requirements
YES/NO
To meet this measure, MIPS eligible clinicians must attest YES to conducting an annual selfassessment using the High Priority Practices Guide of the SAFER Guides (https://www.healthit.gov/topic/safety/safer-guides) during the 2024 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
- Complete the High Priority Practices SAFER Guide measure
- Complete the ONC Direct Review attestation (optional)
- 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 will result in a total score of 0 points for the Promoting Interoperability performance category
- Submit data for a minimum of 180 consecutive days within the calendar year
Additional Information
- MIPS eligible clinicians must use technology certified to ONC Certification Criteria for Health IT necessary to meet the CEHRT definition (88 FR 79307).
- To check whether a health IT product has been certified to ONC Certification Criteria for Health IT, 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 a “Yes” for the SAFER Guide measure 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 2024 PFS final rule at 88 FR 79354 through 88 FR 79357.
- No health IT certification criteria at this time.