§170.315(g)(2) Automated measure calculation

Required Attestation

Health IT developers with Health IT Modules certified to section (g)(2) are required to attest that they have provided to other health IT developers and end-users documentation including the following as applicable:

• For ambulatory only systems or inpatient/ambulatory systems, identify and acknowledge the Health IT Module is not certified or deemed to section (g)(2) for calculation method Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category (TIN/NPI).

The health IT developer records and creates five reports, one for each scenario. Note that the health IT developer may create each report for a single required test or it may create one report for all of the required tests for which it is seeking certification. Any prescriptions written by the eligible professional (EP) in an ambulatory setting, or discharge medication orders in an inpatient setting, will populate the numerator once per prescription transmitted electronically and queried for a drug formulary for a patient who was seen/admitted during the reporting/performance period.

Measure Description

Medicare Promoting Interoperability Programs Measure:

1. Medicare EH/CAH: At least one hospital discharge medication order for permissible prescriptions (for new and changed prescriptions) is queried for a drug formulary and transmitted electronically using CEHRT.

Medicare Promoting Interoperability Programs Measure English Statements:

1. Ambulatory:
   • Numerator: The number of prescriptions in the denominator generated, queried for a drug formulary, and transmitted electronically using CEHRT.
   • Denominator: The number of prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances during the EHR reporting period; or number of prescriptions written for drugs requiring a prescription in order to be dispensed during the EHR reporting period.
2. Inpatient:
   • Numerator: The number of prescriptions in the denominator generated, queried for a drug formulary, and transmitted electronically.
   • Denominator: The number of new or changed prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances for patients discharged during the EHR reporting period.

Medicare Promoting Interoperability Programs Measure Elements:

1. Ambulatory:
   • Numerator: Prescription generated, queried for a formulary, and transmitted electronically.
   • Denominator: Prescriptions generated.
2. Inpatient:
   • Numerator: Prescription generated, queried for a formulary, and transmitted electronically.
   • Denominator: Prescriptions generated.

MIPS Promoting Interoperability Performance Category Measure:

1. EC: At least one permissible prescription written by the MIPS EC is queried for a drug formulary and transmitted electronically using CEHRT.

MIPS Promoting Interoperability Performance Category English Statements:

1. Numerator: The number of prescriptions in the denominator generated, queried for a drug formulary, and transmitted electronically using certified EHR technology.
2. Denominator: Number of prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances during the performance period; or number of prescriptions written for drugs requiring a prescription in order to be dispensed during the performance period.

MIPS Promoting Interoperability Performance Category Measure Elements:

1. Numerator: Prescription generated, queried for a formulary, and transmitted electronically.
2. Denominator: Prescriptions other than controlled substances generated; or prescriptions generated.

The health IT developer records and creates five reports, one for each scenario. Note that the health IT developer may create each report for a single required test or it may create one report for all of the required tests for which it is seeking certification. The act of giving a patient timely online access to his or her health information will populate the numerator if:

Medicare Promoting Interoperability Program: the information is made available to the patient within 48 hours of its availability to the provider for an EP or within 36 hours of its availability to the provider for an eligible hospital or CAH.

Promoting Interoperability performance category: the information is made available to the patient within four business days of its availability to the EC.

Test Data

• Health IT Modules that are certified to § 170.315 (e)(1) and (g)(8),  (g)(9) or (g)(10) must use test data in tab RT 2a Provider Patient Exchange (EH/CAH and EP/EC). Health IT Modules that are certified to § 170.315 (e)(1) only must use test data in tab RT 2b Provider Patient Exchange (EH/CAH and EP/EC).
• Health IT Modules that are certified to § 170.315 (g)(8) or (g)(9) must use test data in tab RT 2c Provider Patient Exchange (EH/CAH and EP/EC) and will only be tested for the Medicare Promoting Interoperability Programs and Promoting Interoperability performance category measures.

Measure Description

Medicare Promoting Interoperability Programs Measure:

1. Medicare EH/CAH: For at least one unique patient discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23): (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 provider ensures the patient’s health information is available for the patient (or patient-authorized representative) to access using any application of his or her choice that is configured to meet the technical specifications of the API in the provider’s CEHRT.

Medicare Promoting Interoperability Programs English Statements:

1. Ambulatory:
   • Numerator: The number of patients in the denominator (or patient-authorized representative) who are provided timely access to health information to view online, download, and transmit to a third party and to access using an application of their choice that is configured meet the technical specifications of the API in the provider's CEHRT.
   • Denominator: The number of unique patients seen by the EP during the EHR reporting period.
2. Inpatient:
   • Numerator: The number of patients in the denominator (or patient-authorized representative) who are provided timely access to health information to view online, download, and transmit to a third party and to access using an application of their choice that is configured meet the technical specifications of the API in the provider's CEHRT.
   • Denominator: The number of unique patients discharged from an eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Medicare Promoting Interoperability Programs Measure Elements:

1. Ambulatory:
   • Numerator:
     • Date and time information available to the EP;
     • Date and time information made available online to patient;
     • Date and time information made available to an API.
   • Denominator: Number of patients seen by the EP.
2. Inpatient:
   • Numerator:
     • Date and time information made available online to patient;
     • Date and time of discharge;
     • Date and time information made available to an API.
   • Denominator: Number of patients discharged from the EH or CAH.

Merit-based Incentive Payment System (MIPS) Promoting Interoperability Performance Category Measure:

1. EC: For at least one unique patient seen by the MIPS EC (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 EC ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of his or her choice that is configured to meet the technical specifications of the API in the MIPS EC's CEHRT.

MIPS Promoting Interoperability Performance Category English Statements:

1. Numerator: The number of patients in the denominator (or patient authorized representatives) who are provided timely access to health information to view online, download, and transmit to a third party and to access using an application of their choice that is configured to meet the technical specifications of the API in the MIPS EC’s certified EHR technology.
2. Denominator: The number of unique patients seen by the MIPS EC during the performance period.

MIPS Promoting Interoperability Performance Category Measure Elements:

1. Numerator:
   • Date and time information available to the EC;
   • Date and time information made available online to patient;
   • Date and time information made available to an API.
2. Denominator: Number of patients seen by the EC.

The health IT developer records and creates five reports, one for each scenario. Note that the health IT developer may create each report for a single required test or it may create one report for all of the required tests for which it is seeking certification. The Health IT Module will populate the numerator when a provider creates and transmits/exchanges a summary of care record, and confirms receipt of the transmitted/exchanged summary of care record, no earlier than the first day of the calendar year of the reporting/performance period (for a 90-day reporting/performance period only), during the reporting/performance period (for a 90-day and full calendar year reporting/performance period), or no later than the end of the calendar year (for a 90-day reporting/performance period only).

Measure Description

Medicare Promoting Interoperability Programs Measure:

1. Medicare EH/CAH: For at least one transition of care or referral the eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care: (1) creates a summary of care record using CEHRT; and (2) electronically exchanges the summary of care record.

Medicare Promoting Interoperability Programs Measure English Statements:

1. Ambulatory/Inpatient:
   • Numerator: The number of transitions of care and referrals in the denominator where a summary of care record was created using CEHRT and exchanged electronically.
   • Denominator: Number of transitions of care and referrals during the EHR reporting period for which the EP or EH or CAH inpatient or emergency department (POS 21 or 23) was the transferring or referring provider.

Medicare Promoting Interoperability Programs Measure Elements:

1. Ambulatory/Inpatient:
   • Numerator:
     • Summary of care record created and exchanged;
     • Summary of care record receipt confirmed.
   • Denominator: Number of transitions of care for which the EP, EH, or CAH was the transferring or referring provider.

MIPS Promoting Interoperability Performance Category Measure:

1. For at least one transition of care or referral, the MIPS EC that transitions or refers their patient to another setting of care or health care provider: (1) creates a summary of care record using certified EHR technology; and (2) electronically exchanges the summary of care record.

MIPS Promoting Interoperability Performance Category Measure English Statements:

1. Numerator: The number of transitions of care and referrals in the denominator where a summary of care record was created using certified EHR technology and exchanged electronically.
2. Denominator: Number of transitions of care and referrals during the performance period for which the MIPS EC was the transferring or referring clinician.

MIPS Promoting Interoperability Performance Category Measure Elements:

1. Numerator:
   • Summary of care record created and exchanged;
   • Summary of care record receipt confirmed.
2. Denominator: Number of transitions of care and referrals for which the EP, EH, or CAH was the transferring of referring provider.

The test approach for this Required Test is health IT developer self-declaration. Health IT developers are required to assess their health IT against the full scope of the product’s required capabilities, including but not limited to regulatory/conformance expectation clarifications and interpretations set forth in the applicable Certification Companion Guides and other issued guidance. If the health IT developer has determined from the outcome of its own assessment that its product meets the required capabilities of the criterion, the developer must submit its self-declaration to the ONC-ATL.

Measure Description

Medicare Promoting Interoperability Program Measure (2019 only):

1. Medicare EH/CAH: For at least one unique patient for whom a Schedule II opioid was electronically prescribed by the EH or CAH using CEHRT during the EHR reporting period, if the total duration of the patient’s Schedule II opioid prescriptions is at least 30 cumulative days within a six-month look-back period, the EH or CAH seeks to identify the existence of a signed opioid treatment agreement and incorporates it into CEHRT.

Medicare Promoting Interoperability Program Measure English Statements (2019 only):

1. Inpatient:
   • Numerator: The number of unique patients in the denominator for whom the EH or CAH seeks to identify a signed opioid treatment agreement and, if identified, incorporates the agreement in CEHRT.
   • Denominator: Number of unique patients for whom a Schedule II opioid was electronically prescribed by the EH or CAH using CEHRT during the EHR reporting period and the total duration of Schedule II opioid prescriptions is at least 30 cumulative days as identified in the patient’s medication history request and response transactions during a six-month look-back period.

Medicare Promoting Interoperability Program Measure Elements (2019 only):

1. Inpatient:
   • Numerator: Number of unique patients the EH or CAH has identified a signed opioid treatment agreement for and incorporated into CEHRT.
   • Denominator:
     • Number of unique patients for whom a Schedule II opioid was electronically prescribed;
     • Number of unique patients who have a total duration of Schedule II opioids of at least 30 cumulative days within the previous six months.

MIPS Promoting Interoperability Performance Category Measures (2019 only):

1. For at least one unique patient for whom a Schedule II opioid was electronically prescribed by the MIPS EC 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 six-month look-back period, the MIPS EC seeks to identify the existence of a signed opioid treatment agreement and incorporates it into the patient’s electronic health record using CEHRT.

MIPS Promoting Interoperability Performance Category Measures English Statement ( 2019 only):

1. Numerator: The number of unique patients in the denominator for whom the MIPS EC seeks to identify a signed opioid treatment agreement and, if identified, incorporates the agreement in CEHRT. A numerator of at least one is required to fulfill this measure.
2. Denominator: Number of unique patients for whom a Schedule II opioid was electronically prescribed by the MIPS EC using CEHRT during the performance period and the total duration of Schedule II opioid prescriptions is at least 30 cumulative days as identified in the patient’s medication history request and response transactions during a six-month look-back period.

MIPS Promoting Interoperability Performance Category Measure Elements (2019 only):

1. Numerator: Number of unique patients the EC has identified a signed opioid treatment agreement for and incorporated into CEHRT.
2. Denominator:
   • Number of unique patients for whom a Schedule II opioid was electronically prescribed;
   • Number of unique patients who have a total duration of Schedule II opioids of at least 30 cumulative days within the previous six months.

The health IT developer records and creates five reports, one for each scenario. Note that the health IT developer may create each report for a single required test or it may create one report for all of the required tests for which it is seeking certification.

Measure Description

Medicare Promoting Interoperability Program Measure (Starting in 2019):

1. Medicare EH/CAH: For at least one electronic summary of care record received for patient encounters during the EHR reporting period for which an EH or CAH was the receiving party of a transition of care or referral, or for patient encounters during the EHR reporting period in which the EH or CAH has never before encountered the patient, the EH or CAH conducts clinical information reconciliation for medication, mediation allergy, and current problem list.

Medicare Promoting Interoperability Program Measure English Statements (Starting in 2019):

1. Inpatient:
   • Numerator: The number of electronic summary of care records in the denominator for which clinical information reconciliation is completed using CEHRT for the following three clinical information sets: (1) Medication – Review of the patient's medication, including the name, dosage, frequency, and route of each medication; (2) Medication Allergy – Review of the patient's known medication allergies; and (3) Current Problem List – Review of the patient’s current and active diagnoses.
   • Denominator: Number of electronic summary of care records received using CEHRT for patient encounters during the EHR reporting period for which an EH or CAH was the receiving party of a transition of care or referral, and for patient encounters during the EHR reporting period in which the EH or CAH has never before encountered the patient.

Medicare Promoting Interoperability Program Measure Elements (Starting in 2019):

1. Inpatient:
   • Numerator:
     • The number of electronic summary of care records with an indication that clinical reconciliation of medications, medications allergy, and current problem list occurred.
   • Denominator:
     • Number of electronic care summary records received where the EH or CAH was the receiving party of a transition or referral; and
     • Number of electronic care summary records received where the EH or CAH has never before encountered the patient.

Merit-based Incentive Payment System (MIPS) Promoting Interoperability Performance Category Measures (starting in 2019):

1. 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 EC has never before encountered the patient, the MIPS EC conducts clinical information reconciliation for medication, medication allergy, and current problem list.

MIPS Promoting Interoperability Performance Category Measures English Statement (starting in 2019):

1. Numerator: The number of electronic summary of care records in the denominator for which clinical information reconciliation is completed using CEHRT for the following three clinical information sets: (1) Medication – Review of the patient's medication, including the name, dosage, frequency, and route of each medication; (2) Medication Allergy – Review of the patient's known medication allergies; and (3) Current Problem List – Review of the patient’s current and active diagnoses.
2. Denominator: Number of electronic summary of care records received using CEHRT for patient encounters during the performance period for which a MIPS EC was the receiving party of a transition of care or referral, and for patient encounters during the performance period in which the MIPS EC has never before encountered the patient.

MIPS Promoting Interoperability Performance Category Measure Elements (Starting in 2019):

1. Numerator:
   • The number of electronic summary of care records with an indication that clinical reconciliation of medications, medication allergy, and current problem list occurred.
2. Denominator:
   • Number of electronic care summary records received where the EC was the receiving party of a transition or referral; and
   • Number of electronic care summary records received where the EC has never before encountered the patient.