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§170.315(g)(2) Automated measure calculation

Version 1.7 Updated on 08-17-2018
Revision History
Version # Description of Change Version Date
1.0

Final Test Procedure

10-18-2016
1.1

Modified test procedure instructions to indicate self-testing and submission of reports.

Added gap criteria option for CPOE measures.

Reordered required tests to mirror the CMS measure numbers.

12-30-2016
1.2

Removed (g)(7) from the first table. Modified the first table to link Required Test 9 to the (b)(2) criterion.

Clarified in the global test requirements that health IT developers are not required to use more than one measure for testing.

Added Inpatient CPOE measure statements.

01-27-2017
1.3

Modified language on which systems need to test for each calculation method.

Modified language to clarify that health IT developers are not required to test 2a, 2b, and 2c and 4a, 4b, and 4c.

03-06-2017
1.4

Modified the numerator for Required Test 3 ACI English Statement to reflect that action must occur during the performance period.

05-26-2017
1.5

Modified language on the options systems have for testing the different calculation methods.

Added an attestation requirement around documentation provided to end users around systems ability to calculate the different methods.

08-25-2017
1.6

Added "Denominator" in front of the second definition under the ACI Measure English Statement for Required Test 6.

Clarified the View, Download, Transmit Measure for ACI to describe the action as being taken by the patient or the patient authorized representative rather than the Eligible Clinician per the QPP CY 2018 final rule (82 FR 53568).

02-01-2018
1.7

Made the following changes based on CMS policy changes per the CY2019 IPPS Final Rule: Added Required Tests 13, 14, and 15. Updated the measure thresholds for the Stage 3 measure for Required Test 1, 2a, 2b, 2c, and 7 and the name for Required Test 2a, 2b, 2c, and 7. Modified the name of the EHR Incentive Program to the Promoting Interoperability Program.

Added clarification that both the EC Individual and EC Group methods must be tested by a Health IT Module supporting the ACI Transition and/or ACI calculation method.

Modified the timely access requirement for the ACI Patient Access measure based on a CMS policy change per the QPP CY 2018 final rule (82 FR 53568).

08-17-2018
Regulation Text
Regulation Text

§170.315 (g)(2) Automated measure calculation

For each EHR Incentive Programs percentage-based measure that is supported by a capability included in a technology, record the numerator and denominator and create a report including the numerator, denominator, and resulting percentage associated with each applicable measure.

Standard(s) Referenced

None

Please consult the Final Rule entitled: 2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications for a detailed description of the certification criterion with which these testing steps are associated. We also encourage developers to consult the Certification Companion Guide in tandem with the test procedure as they provide clarifications that may be useful for product development and testing.

Note: The order in which the test steps are listed reflects the sequence of the certification criterion and does not necessarily prescribe the order in which the test should take place.

 

Testing components

GAP Icon Documentation Icon Visual Inspection Icon No Test Tool Icon ONC Supplied Test Data Icon

 

Gap Eligibility

Three measures are eligible for gap certification: 1) Required Test 10 – CPOE Medications, Modified Stage 2 Objective 3 Measure 1 and Stage 3 Objective 4 Measure 1; 2) Required Test 11 – CPOE Laboratory, Modified Stage 2 Objective 3 Measure 2 and Stage 3 Objective 4 Measure 2; and 3) Required Test 11 – CPOE Radiology/Diagnostic Imaging, Modified Stage 2 Objective 3 Measure 3 and Stage 3 Objective 4 Measure 3.

 

Required Tests

The table that provides a description of the Modified Stage 2 2015 - 2017 and Stage 3 Medicare and Medicaid Promoting Interoperability (formerly Electronic Health Record (EHR) Incentive Program) and the ACI Modified Stage 2 and ACI objectives supported by the measure calculation (§ 170.315(g)(2)) certification criteria is located in the Master Table of Related and Required Criteria. That document can be found under the 2015 Edition Test Method Resources section on the left hand side of the screen for any criterion under the Topics Navigation menu.

 

Organization

The tests are organized as follows:

  • The Global Required Test section addresses required capabilities across any or all modules that can be demonstrated once for each module, combination of modules, or complete set of modules of the Health IT Module being tested.
  • Required Tests 1 through 15 are measure-specific sections that address required capabilities for each measure.

Health IT Modules that are ambulatory systems only must use the ambulatory test data and test at least one of the four calculation methods: 1) Medicaid Promoting Interoperability Program Modified Stage 2; 2) ACI Transition (TIN/NPI); 3) Medicaid Promoting Interoperability Program Stage 3; or 4) ACI (TIN/NPI). Health IT Modules that are inpatient systems only must use the eligible hospital test data and, if the inpatient system is used in the ambulatory setting, the ambulatory test and test at least one of four calculation methods: 1) Modified Stage 2; 2) ACI Transition (TIN/NPI); 3) Medicaid Promoting Interoperability Program Stage 3; or 4) ACI (TIN/NPI). Health IT Modules that are both ambulatory and inpatient systems must use the eligible hospital test data and the ambulatory test and test at least one of four calculation methods: 1) Modified Stage 2; 2) ACI Transition (TIN/NPI); 3) Stage 3; or 4) ACI (TIN/NPI). Health IT Modules that test to the ACI measures are deemed as meeting the testing requirements for the relevant Stage 3 measures. Health IT Modules that test to the ACI Transition measures are deemed as meeting the testing requirements for the relevant Modified Stage 2 measures. Health IT Modules that test to the Stage 2 measures and demonstrate the capability to filter for NPI-TIN are deemed as meeting the testing requirements for the ACI Transition measures. Health IT Modules that test for the ACI Transition and/or ACI calculation methods(s) must test for both the EC individual and EC Group calculation methods.


For the Global Required Test

Within the global section, the test procedure addresses the capability of the Health IT Module to create reports for measures for a specified reporting period. For Inpatient settings, this test procedure addresses the capability for the Health IT Module to allow eligible hospitals and critical access hospitals to calculate emergency department (ED) admissions using one of two methods (observation services method vs. all ED visits method). Note that this calculation method is only applicable to the Modified Stage 2 Patient Education measure. The test procedure also addresses the capability for the Health IT Module to exclude patients or activities that occur outside of the reporting/performance period or calendar year (as applicable).

  • Record – evaluates the capability to electronically record the numerator and denominator and resulting percentage for each objective with a percentage-based measure.
    • The health IT developer identifies a measure that will be used for the Global Required Test. For testing the Inpatient calculation methods, the health IT developer must test the Modified Stage 2 Patient Education measure. If the health IT developer does not intend to be certified for the Modified Stage 2 Patient Education measure, they do not need to demonstrate that they can calculate the Inpatient calculation methods. Additionally, the health IT developer may identify a different measure for testing the reporting period and timing of activities if they do not wish to test all of the Global Required Tests against the Modified Stage 2 Patient Education measure.
    • The health IT developer records all numerator and denominator measure elements using the set of test patients located in the Required Global Test tab in the corresponding test data, using the method(s) by which the Health IT Module records the numerator and denominator for the chosen measure.

Within each of the reports in the Global Required Test, the test procedure addresses the capabilities to report the chosen measure. A single set of test patients has been created for use in the Global Required Test. Health IT developers are required to use the test patients as they are listed in the Required Global Test tab in the corresponding test data and may not modify patient names.

  • Report – evaluates the capability to create a report that includes the numerator and denominator and resulting percentage for § 170.315(g)(2) associated with the chosen percentage-based measure.
    • The user enters all of the test patients from the Required Global Test tab in the Test Data, as described above in Record.
    • The health IT developer creates a report that includes the numerator and denominator and resulting percentage for the chosen measure based on the supplied test data from the Required Global Test tab.
    • The health IT developer provides the report to the tester. The report must include the numerator, denominator, and resulting percentage, as well as a list of the patients who are included in the numerator and denominator of the chosen measure.
    • The tester reviews the report and verifies that the numerator and denominator and resulting percentage produced are accurate and complete and represent the expected values, based on the supplied test data, and reflecting the Information Types found in System Under Test of the Global Required Test. The tester uses the English Statements described in the Test Guide for the Global Required Test.


For Measure Specific Sections

Within each of the measure-specific sections, the test procedure addresses the capability to record the numerator and denominator and resulting percentage for § 170.315(g)(2) for each measure for Modified Stage 2 and Stage 3 of Promoting Interoperability and the ACI Transition measures and the ACI measures:

  • Record – evaluates the capability to electronically record the numerator and denominator and resulting percentage for each objective with a percentage-based measure.
    • The health IT developer records all numerator and denominator measure elements for the method(s) by which the Health IT Module records the numerator and denominator for each measure.

Within each of the measure-specific sections, the test procedure addresses the capabilities to report each measure for Modified Stage 2 and Stage 3 of Promoting Interoperability and the Transition ACI measures and the ACI measures. A single set of test patients has been created that occur across all required tests. The health IT developer is required to use all test patients in each scenario. The health IT developer must use the test patients that are in the test data and may not change their names, birthdays, or gender.

  • Report – evaluates the capability to create a report that includes the numerator and denominator associated with each percentage-based measure.
    • The health IT developer enters the test patients for Scenario 1 and the corresponding test data for each required test for which they are presenting for testing.
    • Using the functions of the Health IT Module, the health IT developer creates a report that includes the numerator and denominator and resulting percentage for each measure based on the supplied test data from Test Data Scenario 1 (baseline measure report) across all required tests. The report must also include the list of patients included in the numerator and denominator.
    • The health IT developer marks the report as Scenario 1.
    • The health IT developer enters all of the test patients in Scenario 2 and the corresponding test data for each required test.
    • Using the functions of the Health IT Module, the health IT developer creates a report that includes the numerator and denominator and resulting percentage for each measure based on the supplied test data from Test Data Scenario 2 (populate numerator) across all required tests. The report must also include the list of patients included in the numerator and denominator.
    • The health IT developer marks the report as Scenario 2.
    • The health IT developer enters all of the test patients in Scenario 3 and the corresponding test data for each required test.
    • Using the functions of the Health IT Module, the health IT developer creates a report that includes the numerator and denominator and resulting percentage for each measure based on the supplied test data from Test Data Scenario 3 (populate numerator and denominator) across all required tests. The report must also include the list of patients included in the numerator and denominator.
    • The health IT developer marks the report as Scenario 3.
    • The health IT developer enters all of the test patients in Scenario 4 and the corresponding test data for each required test.
    • Using the functions of the Health IT Module, the health IT developer creates a report that includes the numerator and denominator and resulting percentage for each measure based on the supplied test data from Test Data Scenario 4 (populate denominator) across all required tests. The report must also include the list of patients included in the numerator and denominator.
    • The health IT developer marks the report as Scenario 4.
    • The health IT developer enters all of the test patients in Scenario 5 and the corresponding test data for each required test.
    • Using the functions of the Health IT Module, the health IT developer creates a report that includes the numerator and denominator and resulting percentage for each measure based on the supplied test data from Test Data Scenario 5 (do not populate numerator or denominator) across all required tests. The report must also include the list of patients included in the numerator and denominator.
    • The health IT developer marks the report as Scenario 5.
    • The health IT developer submits all five reports to the tester for review.
    • The tester verifies that the increments in the numerator and denominator produced in the delta report are accurate and complete and represent the expected increments in comparison to the baseline measure report, based on the ONC supplied test data. The tester uses the English Statements described in the Test Guide for each measure. The tester verifies that the correct patients are included in the numerator and denominator for each measure.

The test data for § 170.315(g)(2) are previously supplied. ONC supplies Test Cases to be used during the test, and the health IT developer supplies information as directed in the test data. The measure specific test data is organized into a single set of 11 test cases or less, depending on the measure, which are used across all required tests. As such, each test case appears in the same scenario in each required test, though the numerator and denominator may not increment the same across each required test. All test cases must be used.

Each measure-specific Test Description provides a Measure Element list and English Statements for each measure. The English Statements derive from the CMS Modified Stage 2 2015 – 2017 and Stage 3 final rule definitions of a measure’s numerators and the Quality Performance Program final rule definitions of an ACI measure’s numerators. The Measure Element list deconstructs the English Statements to provide the discrete measure elements for recording the numerator and denominator.

System Under Test Test Lab Verification

Required Attestation

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

  • For ambulatory only systems or inpatient/ambulatory systems, identify and acknowledge the Health IT Module is not certified or deemed to (g)(2) for all four calculation methods 1) Medicaid Promoting Interoperability Program Modified Stage 2; 2) ACI Transition (TIN/NPI); 3) Medicaid Promoting Interoperability Program Stage 3; or 4) ACI (TIN/NPI).

Required Attestation

Tester verifies that the attestation includes all required elements.


Paragraph (g)(2) Required Global Test

System Under Test Test Lab Verification
  1. The health IT developer, using the identified Health IT Module functions and the supplied Test Data Scenario(s), is able to record values and create reports for the following reporting periods (at a minimum):
    1. Eligible Professional Reports and/or Eligible Hospital/Critical Access Hospital Reports: Any 90 consecutive days within a calendar year, including 90 day periods that span across more than 3 months; calendar year quarters (first, second, third, fourth); and calendar year.
  2. The health IT developer chooses one or more measures to test the required global test.
  3. The health IT developer enters all six test patients from the Required Global Test section of supplied test data. The health IT developer creates a report that includes the numerator and denominator for a chosen measure based on the test data. The report must also include the list of patients included in the numerator and denominator. The health IT developer marks the report as Global Required Test.
  4. (Inpatient Only) The user creates a report using both methods for inpatient admission:
    1. Observation Services Method
    2. All emergency department (ED) Visits Method

The Required Global test designates each test patient by one of the following patient and encounter information types:

Information Types

  1. Direct admission to inpatient department.
  2. Admitted to the ED and then admitted to the inpatient department.
  3. Admitted to the ED and discharged from the ED.
  4. Admitted to the ED and received observation services and then admitted to the inpatient department.
  5. Admitted to the inpatient department upon receiving observation services in the outpatient department of the hospital.

 

  1. The health IT developer submits the report(s) to the tester.
  1. The tester verifies that the Health IT Module is able to accurately adjust the reporting period types and that the numerator, denominator, and percentage information is accurate and complete for each reporting period and Promoting Interoperability stage.
  2. The tester reviews the report marked Global Required Test and verifies that the numerators, denominators, and percentages recorded, as applicable to § 170.315(g)(2), are accurate and complete, based on the measure elements described in the Test. The tester must also verify that the correct test patients are included in the numerator and denominator.
  3. (Inpatient only) The tester verifies the following:
    1. That calculation of the Observation Services Method is accurate and includes test patients with types A, B, D and E listed in Step 4 of System Under Test.
    2. That calculation of the All ED Visits Method is accurate and includes test patients with type A, B, D, C, D, and E listed in Step 4 of System Under Test.

Required Test 1 - ePrescribing

Modified Stage 2 Objective 4 and Stage 3 Objective 2

ACI Transition Objective 2 Measure 1 and ACI Objective 2 Measure 1

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. Any prescriptions written by the 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

Modified Stage 2 Measure:

  1. Eligible Professional (EP): More than 50 percent of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using Certified Health IT.
  2. Eligible Hospital/Critical Access Hospital (EH/CAH): More than 10 percent of hospital discharge medication orders for permissible prescriptions (for new and changed prescriptions) are queried for a drug formulary and transmitted electronically using Certified Health IT.

Modified Stage 2 Measure English Statements:

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

Modified Stage 2 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.

Stage 3 Measure:

  1. Eligible Professional (EP): More than 60 percent of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT.
  2. Eligible Hospital/Critical Access Hospital (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.

Stage 3 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.

Stage 3 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.

ACI Transition Measure:

  1. Eligible Clinician (EC): At least one permissible prescription written by the MIPS EC is queried for a drug formulary and transmitted electronically using certified EHR technology.

ACI Transition 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 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.

ACI Transition Measure Elements:

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

ACI Measure:

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

ACI 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.

ACI 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 tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 1 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 2a, b, or c – Provider to Patient Exchange (formerly Patient Electronic Access)

Modified Stage 2 Objective 8 Measure 1 and Stage 3 Objective 5 Measure 1

ACI Transition Objective 3 Measure 1 and ACI Objective 3 Measure 1

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. The act of giving a patient timely online access to his or her health information will populate the numerator if:

Modified Stage 2: the information is made available within 4 business days after the information is made available to the EP or within 36 hours of discharge from the EH/CAH, for patients seen by the EP or discharged from the inpatient or emergency department (POS 21 or 23) of the EH/CAH during the reporting period.

Stage 3: 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.

ACI Transition: the information is made available within 4 business days after the information is made available to the EC for patients seen by the EC during the performance period.

ACI: the information is made available to the patient within 4 business days of its availability to the EC.

Test Data

  • Health IT Modules that are certified to § 170.315 (e)(1) and (g)(8) or (g)(9) must use test data in tab RT 2a Provider Patient Exchange (EH/CAH) or RT 2a Patient Electronic Access (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) or RT 2a Patient Electronic Access (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) or RT 2a Patient Electronic Access (EP/EC) and will only be tested for the Stage 3 and ACI measures.

Measure Description

Modified Stage 2 Measure:

  1. Eligible Professional (EP): More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely access to view online, download, and transmit to a third party their health information subject to the EP's discretion to withhold certain information.
  2. Eligible Hospital/Critical Access Hospital (EH/CAH): More than 50 percent of all unique patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH are provided timely access to view online, download, and transmit to a third party their health information.

Modified Stage 2 Measure English Statements:

  1. Ambulatory:
    • Numerator: The number of patients in the denominator who have access to view online, download, and transmit their health information within 4 business days after the information is available to the EP.
    • Denominator: Number of unique patients seen by the EP during the EHR reporting period.
  2. Inpatient:
    • Numerator: The number of patients in the denominator who have access to view, download, and transmit their health information within 36 hours after the information is available to the eligible hospital or CAH.
    • Denominator: Number of unique patients discharged from an eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Modified Stage 2 Measure Elements:

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

Stage 3 Measure:

  1. Eligible Professional (EP): For more than 80 percent of all unique patients seen by the EP: (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 their choice that is configured to meet the technical specifications of the API in the provider’s CEHRT.
  2. Eligible Hospital/Critical Access Hospital (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 their choice that is configured to meet the technical specifications of the API in the provider’s CEHRT.

Stage 3 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.

Stage 3 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.

ACI Transition Measure:

  1. At least one patient seen by the MIPS EC during the performance period is provided timely access to view online, download, and transmit to a third party their health information subject to the MIPS EC's discretion to withhold certain information.

ACI Transition English Statements:

  1. 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.
  2. Denominator: The number of unique patients seen by the MIPS EC during the performance period.

ACI Transition Measure Elements:

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

ACI 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 their choice that is configured to meet the technical specifications of the API in the MIPS EC's CEHRT.

ACI 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.

ACI 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 tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 2a, 2b, or 2c and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5. The tester verifies that all of the required information below is made available to patients.

Modified Stage 2 Ambulatory Setting Only

  1. Patient name
  2. Provider’s name and office contact information
  3. Current and past problem list
  4. Procedures
  5. Laboratory test results
  6. Current medication list and medication history
  7. Current medication allergy list and medication allergy history
  8. Vital signs (height, weight, blood pressure, BMI, growth charts)
  9. Smoking status
  10. Demographic information (preferred language, sex, race, ethnicity, date of birth)
  11. Care plan field(s), including goals and instructions
  12. Any known care team members including the primary care provider (PCP) of record

Modified Stage 2 Inpatient Setting Only

  1. Patient name
  2. Admit and discharge date and location
  3. Reason for hospitalization
  4. Care team including the attending of record as well as other providers of care
  5. Procedures performed during admission
  6. Current and past problem list
  7. Current medication list and medication history
  8. Current medication allergy list and medication allergy history
  9. Vital signs at discharge
  10. Laboratory test results (available at time of discharge)
  11. Summary of care record for transitions of care or referrals to another provider
  12. Care plan field(s), including goals and instructions
  13. Discharge instructions for patient
  14. Demographics maintained by hospital (sex, race, ethnicity, date of birth, preferred language)
  15. Smoking status

Stage 3

  1. Common Clinical Data Set (which should be in their English representation)
  2. Provider’s name and office contact information (ambulatory setting only)
  3. Admission and discharge dates and locations; discharge instructions; and reason(s) for hospitalization (inpatient setting only)
  4. Laboratory test report(s)
  5. Diagnostic image report(s)

Required Test 3 – Patient Education

Modified Stage 2 Objective 6 and Stage 3 Objective 5 Measure 2

ACI Transition Objective 4 Measure 1 and ACI Objective 3 Measure 2

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. For all measures, for the Health IT Module to record the numerator, the provider must provide patient-specific resources identified by the Health IT Module no earlier than the first day of the calendar year of the reporting/performance period (for a 90-day reporting period only), during the reporting/performance period (for a 90-day and full calendar year reporting period), or no later than the last day of the calendar year of the reporting period to populate and record the numerator (for a 90-day and full calendar year reporting period).

Measure Description

Modified Stage 2 Measure:

  1. Eligible Professional (EP): Patient-specific education resources identified by Certified Health IT Module (CEHRT) are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the reporting period.
  2. Eligible Hospital/Critical Access Hospital (EH/CAH): More than 10 percent of all unique patients admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) are provided patient-specific education resources identified by Certified Health IT Module.

Modified Stage 2 Measure English Statements:

  1. Ambulatory:
    • Numerator: The number of patients in the denominator who were provided patient-specific education resources identified by the EHR technology.
    • Denominator: Number of unique patients with office visits seen by the EP during the EHR reporting period.
  2. Inpatient:
    • Numerator: Number of patients in the denominator who are subsequently provided patient-specific education resources identified by CEHRT.
    • Denominator: Number of unique patients admitted to the eligible hospital or CAH inpatient or emergency departments (POS 21 or 23) during the EHR reporting period.

Modified Stage 2 Measure Elements:

  1. Ambulatory:
    • Numerator: Provision of patient specific education resource(s) identified by the CEHRT.
    • Denominator: Number of patients with visits to the EP.
  2. Inpatient:
    • Numerator: Provision of patient specific education resource(s) identified by the CEHRT.
    • Denominator: Number of patient’s admitted to the EH or CAH.

Stage 3 Measure:

  1. Eligible Provider: The EP must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to more than 35 percent of unique patients seen by the EP during the EHR reporting period.
  2. Eligible Hospital/CAH (EH/CAH): The eligible hospital or CAH must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to more than 10 percent of unique patients discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Stage 3 Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of patients in the denominator who were provided electronic access to patient-specific educational resources using clinically relevant information identified from CEHRT during the EHR reporting period.
    • Denominator: The number of unique patients seen by the EP or 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.

Stage 3 Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Provision of electronic access to patient specific education resource(s) identified by the CEHRT.
    • Denominator:
      • Number of patients seen by the EP.
      • Number of patients discharged from the EH or CAH.

ACI Transition Measure:

  1. The MIPS EC must use clinically relevant information from certified EHR technology to identify patient-specific educational resources and provide access to those materials to at least one unique patient seen by the MIPS EC.

ACI Transition English Statements:

  1. Numerator: The number of patients in the denominator who were provided access to patient-specific educational resources using clinically relevant information identified from certified EHR technology during the performance period.
  2. Denominator: The number of unique patients seen by the MIPS EC during the performance period.

ACI Transition Measure Elements:

  1. Numerator: Provision of patient specific education resource(s) identified by the CEHRT.
  2. Denominator: Number of patients seen by the EC.

ACI Measure:

  1. The MIPS EC must use clinically relevant information from certified EHR technology to identify patient-specific educational resources and provide electronic access to those materials to at least one unique patient seen by the MIPS eligible clinician.

ACI English Statements:

  1. Numerator: The number of patients in the denominator who were provided electronic access to patient-specific educational resources using clinically relevant information identified from certified EHR technology during the performance period.
  2. Denominator: The number of unique patients seen by the MIPS EC during the performance period.

ACI Measure Elements:

  1. Numerator: Provision of electronic access to patient-specific education resource(s) identified by the CEHRT.
  2. Denominator: Number of patients seen by the EC.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 3 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 4a, b, or c – View, Download, Transmit

Modified Stage 2 Objective 8 Measure 2 and Stage 3 Objective 6 Measure 1

ACI Transition Objective 3 Measure 2 and ACI Objective 4 Measure 1

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. For the Health IT Module to record the numerator, the patient must view, download, or transmit their health information no earlier than the first day of the calendar year of the reporting/performance period (for a 90-day reporting period only), during the reporting/performance period (for a 90-day and full calendar year reporting period), or no later than the last day of the calendar year of the reporting period to populate and record the numerator (for a 90-day and full calendar year reporting period).

Test Data

  • Health IT Modules that are certified to § 170.315 (e)(1) and (g)(8) or (g)(9) must use test data in tab RT 4a VDT.
  • Health IT Modules that are certified to § 170.315 (e)(1) only must use test data in tab RT 4b VDT.
  • Health IT Modules that are certified to § 170.315 (g)(8) or (g)(9) must use test data in tab RT 4c VDT, and will only be tested for the Stage 3 and ACI measures.

Measure Description

Modified Stage 2 Measures:

  1. Eligible Professional (EP): For an EHR reporting period in 2017, more than 5 percent of unique patients seen by the EP during the EHR reporting period (or his or her authorized representatives) view, download, or transmit to a third party their health information during the reporting period.
  2. Eligible Hospital/Critical Access Hospital (EH/CAH): For an EHR reporting period in 2017, at least one unique patient discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH (or patient-authorized representative) view, download, or transmit to a third party their health information during the reporting period.

Modified Stage 2 Measure English Statements:

  1. Ambulatory:
    • Numerator: The number of patients (or patient-authorized representative) in the denominator who view, download, or transmit to a third party their health information.
    • Denominator: Number of unique patients seen by the EP during the EHR reporting period.
  2. Inpatient:
    • Numerator: The number of patients (or patient-authorized representative) in the denominator who view, download, or transmit to a third party their health information during the reporting period.
    • Denominator: Number of unique patients discharged from the inpatient or emergency department (POS 21 or 23) of the eligible hospital or CAH during the EHR reporting period.

Modified Stage 2 Measure Elements:

  1. Ambulatory:
    • Numerator: Patient/authorized representative views, downloads, or transmits their information.
    • Denominator: Number of patients seen by the EP.
  2. Inpatient:
    • Numerator: Patient/authorized representative views, downloads, or transmits their information.
    • Denominator: Number of patients discharged from the EH or CAH.

Stage 3 Measure:

  1. Eligible Provider (EP): During the EHR reporting period, more than 10 percent of all unique patients (or their authorized representatives) seen by the EP actively engage with the electronic health record made accessible by the provider and either: (1) view, download, or transmit to a third party their health information; or (2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the provider's CEHRT; or (3) a combination of (1) and (2).
  2. Eligible Hospital/Critical Access Hospital (EH/CAH): During the EHR reporting period, at least one unique patient (or their authorized representatives) discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) actively engage with the electronic health record made accessible by the provider and either: (1) view, download, or transmit to a third party their health information; or (2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the provider's CEHRT; or (3) a combination of (1) and (2).

Stage 3 Measure English Statements:

  1. Ambulatory:
    • Numerator: The number of unique patients (or their authorized representatives) in the denominator who have viewed online, downloaded, or transmitted to a third party the patient's health information during the EHR reporting period and the number of unique patients (or their authorized representatives) in the denominator who have accessed their health information through the use of an API during the EHR reporting period.
    • Denominator: Number of unique patients seen by the EP during the EHR reporting period.
  2. Inpatient:
    • Numerator: The number of unique patients (or their authorized representatives) in the denominator who have viewed online, downloaded, or transmitted to a third party the patient's health information during the EHR reporting period and the number of unique patients (or their authorized representatives) in the denominator who have accessed their health information through the use of an API during the EHR reporting period.
    • Denominator: Number of unique patients discharged from an eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Stage 3 Measure Elements:

  1. Ambulatory:
    • Numerator:
      • Patient (or authorized representative) views, downloads, or transmits their information;
      • Patient (or authorized representative) accesses their information via API.
    • Denominator: Number of patients seen by the EP.
  2. Inpatient:
    • Numerator:
      • Patient (or authorized representative) views, downloads, or transmits their information;
      • Patient (or authorized representative) accesses their information via API.
    • Denominator: Number of patients discharged from the EH or CAH.

ACI Transition Measure:

  1. At least one patient seen by the MIPS EC during the performance period (or patient-authorized representative) views, downloads, or transmits their health information to a third party during the performance period.

ACI Transition English Statements:

  1. Numerator: The number of unique patients in the denominator (or their authorized representatives) who have viewed online, downloaded, or transmitted to a third party the patient’s health information during the performance period.
  2. Denominator: Number of unique patients seen by the MIPS EC during the performance period.

ACI Transition Measure Elements:

  1. Numerator: Patient views, downloads, or transmits their information.
  2. Denominator: Number of patients seen by the EC.

ACI Measure:

  1. During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS EC actively engages with the EHR made accessible by the MIPS EC by either: (1) viewing, downloading, or transmitting to a third party their health information; or (2) accessing their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician's certified EHR technology; or (3) a combination of (1) and (2).

ACI English Statements:

  1. Numerator: The number of unique patients (or their authorized representatives) who have viewed online, downloaded, or transmitted to a third party the patient’s health information during the performance period and the number of unique patients (or their authorized representatives) who have accessed their health information through the use of an API during the performance period.
  2. Denominator: Number of unique patients seen by the MIPS EC during the performance period.

ACI Measure Elements:

  1. Numerator:
    • Patient views, transmits, or downloads their information;
    • Patient accesses their information via an API.
  2. Denominator: Number of patients seen by the EC.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 4a, 4b, or 4c and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.

The tester verifies that the Health IT Module functions makes the following information available:

Modified Stage 2 Ambulatory Setting Only

  1. Patient name
  2. Provider’s name and office contact information
  3. Current and past problem list
  4. Procedures
  5. Laboratory test results
  6. Current medication list and medication history
  7. Current medication allergy list and medication allergy history
  8. Vital signs (height, weight, blood pressure, BMI, growth charts)
  9. Smoking status
  10. Demographic information (preferred language, sex, race, ethnicity, date of birth)
  11. Care plan field(s), including goals and instructions
  12. Any known care team members including the primary care provider (PCP) of record

Modified Stage 2 Inpatient Setting Only

  1. Patient name
  2. Admit and discharge date and location
  3. Reason for hospitalization
  4. Care team including the attending of record as well as other providers of care
  5. Procedures performed during admission
  6. Current and past problem list
  7. Current medication list and medication history
  8. Current medication allergy list and medication allergy history
  9. Vital signs at discharge
  10. Laboratory test results (available at time of discharge)
  11. Summary of care record for transitions of care or referrals to another provider
  12. Care plan field(s), including goals and instructions.
  13. Discharge instructions for patient
  14. Demographics maintained by hospital (sex, race, ethnicity, date of birth, preferred language)
  15. Smoking status

Stage 3

  1. Common Clinical Data Set (which should be in their English representation)
  2. Provider’s name and office contact information (ambulatory setting only)
  3. Admission and discharge dates and locations; discharge instructions; and reason(s) for hospitalization (inpatient setting only)
  4. Laboratory test report(s)
  5. Diagnostic image report(s)

Required Test 5 – Secure Messaging

Modified Stage 2 Objective 9 and Stage 3 Objective 6 Measure 2

ACI Transition Objective 5 Measure 1 and ACI Objective 4 Measure 2

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. The Health IT Module will populate the numerator when the provider sends a secure message no earlier than the first day of the calendar year of the reporting/performance period (for a 90-day reporting period only), during the reporting/ performance period (for a 90-day and full calendar year reporting period), or no later than the last day of the calendar year of the reporting period to populate and record the numerator (for a 90-day and full calendar year reporting period).

Measure Description

Modified Stage 2 Measure:

  1. Eligible Professional (EP): For an EHR reporting period in 2017, for more than 5 percent of unique patients seen by the EP during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative) during the EHR reporting period. For an EHR reporting period in 2016, the threshold for this measure is at least one message sent.
  2. Eligible Hospital/Critical Access Hospital (EH/CAH): None.

Modified Stage 2 Measure English Statements:

  1. Ambulatory:
    • Numerator: The number of patients in the denominator for whom a secure electronic message is sent to the patient (or patient-authorized representative), or in response to a secure message sent by the patient (or patient-authorized representative).
    • Denominator: Number of unique patients seen by the EP during the EHR reporting period.
  2. Inpatient: None.

Modified Stage 2 Measure Elements:

  1. Ambulatory:
    • Numerator:
      • EP Replies to Secure Electronic Message from Patient or Patient Representative;
      • EP Sends Secure Electronic Message to Patient or Patient Representative.
    • Denominator: Number of patients seen by the EP.

Stage 3 Measure:

  1. Eligible Professional (EP): For more than 25 percent of all unique patients seen by the EP during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient or their authorized representative. For an EHR reporting period in 2016, the threshold for this measure is at least one message sent rather than 25 percent. For an EHR reporting period in 2017, the threshold for this measure is 5 percent rather than 25 percent.
  2. Eligible Hospital/Critical Access Hospital (EH/CAH): For more than 5 percent of all unique patients discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient or their authorized representative. For an EHR reporting period in 2016, the threshold for this measure is at least one message sent rather than 25 percent.

Stage 3 Measure English Statements:

  1. Numerator: The number of patients in the denominator for whom a secure electronic message is sent to the patient (or patient-authorized representative) or in response to a secure message sent by the patient (or patient-authorized representative), during the EHR reporting period.
  2. Denominator: Number of unique patients seen by the EP or discharged from the EH or CAH inpatient or emergency department during the reporting period.

Stage 3 Measure Elements:

  1. Numerator:
    • EP/EH Replies to Secure Electronic Message from Patient or Patient Representative;
    • EP/EH Sends Secure Electronic Message to Patient or Patient Representative;
    • EP/EH Sends Secure Message to Provider Including Patient or Patient Representative.
  2. Denominator: Number of unique patients seen by the EP or discharged from the EH or CAH.

ACI Transition Measure:

  1. For at least one patient seen by the MIPS EC during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or patient-authorized representative) during the performance period.

ACI Transition Measure English Statements:

  1. Numerator: The number of patients in the denominator for whom a secure electronic message is sent to the patient (or patient-authorized representative) or in response to a secure message sent by the patient (or patient-authorized representative), during the performance period.
  2. Denominator: Number of unique patients seen by the MIPS EC during the performance period.

ACI Transition Measure Elements:

  1. Numerator:
    • EC Replies to Secure Electronic Message from Patient or Patient Representative;
    • EC Sends Secure Electronic Message to Patient or Patient Representative.
  2. Denominator: Number of patients seen by the EC.

ACI Measure:

  1. For at least one unique patient seen by the MIPS EC during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or patient-authorized representative) during the performance period.

ACI Measure English Statements:

  1. Numerator: The number of patients in the denominator for whom a secure electronic message is sent to the patient (or patient-authorized representative) or in response to a secure message sent by the patient (or patient-authorized representative), during the performance period.
  2. Denominator: Number of unique patients seen by the MIPS EC during the performance period.

ACI Measure Elements:

  1. Numerator:
    • EC replies to secure electronic message from patient or patient representative;
    • EC sends secure electronic message to patient or patient representative;
    • EC sends secure message to provider including patient or patient representative.
  2. Denominator: Number of patients seen by the EC.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 5 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 6 – Patient Generated Health Data

Stage 3 Objective 6 Measure 3

ACI Objective 4 Measure 3

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. The Health IT Module will populate the numerator when patient generated data, or data from a non-clinical setting are incorporated during the reporting/performance period.

Measure Description

Stage 3 Measure:

  1. Eligible Professional/Eligible Hospital/Critical Access Hospital (EP/EH/CAH): Patient generated health data or data from a nonclinical setting is incorporated into the CEHRT for more than 5 percent of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Stage 3 Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of patients in the denominator for whom data from non-clinical settings, which may include patient-generated health data, is captured through the CEHRT into the patient record during the EHR reporting period.
    • Denominator: Number of unique patients seen by the EP or 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.

Stage 3 Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator:
      • Patients with non-clinical data incorporated into the record;
      • Patients with patient-generated health data incorporated into the record.
    • Denominator: Number of patients seen by the EP.

ACI Measure:

  1. Patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for at least one unique patient seen by the MIPS EC during the performance period.

ACI Measure English Statements:

  1. Numerator: The number of patients in the denominator for whom data from non-clinical settings, which may include patient-generated health data, is captured through the certified EHR technology into the patient record during the performance period.
  2. Denominator: Number of unique patients seen by the MIPS EC during the performance period.

ACI Measure Elements:

  1. Numerator:
    • Patients with non-clinical data incorporated into the record;
    • Patients with patient-generated health data incorporated into the record.
  2. Denominator: Number of patients seen by the EC.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 6 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 7 – Support Electronic Referral Loops by Sending Health Information (formerly Transitions of Care)

Modified Stage 2 Objective 5 and Stage 3 Objective 7 Measure 1

ACI Transition Objective 6 Measure 1 and ACI Objective 5 Measure 1

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are 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

Modified Stage 2 Measure:

  1. Eligible Professional/Eligible Hospital/Critical Access Hospital (EP/EH/CAH): The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care must – (1) use CEHRT to create a summary of care record; and (2) electronically transmit such summary to a receiving provider for more than 10 percent of transitions of care and referrals.

Modified Stage 2 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 eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) was the transferring or referring provider.

Modified Stage 2 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 and referrals for which the EP, EH or CAH was the transferring of referring provider.

Stage 3 Measure:

  1. Eligible Professional (EP): For more than 50% of transitions of care and referrals, the EP 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.
  2. Eligible Hospital/Critical Access Hospital (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.

Stage 3 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 certified EHR technology and exchanged electronically.
    • Denominator: Number of transitions of care and referrals during the EHR reporting period for which the EP or eligible hospital or CAH inpatient or emergency department (POS 21 or 23) was the transferring or referring provider.

Stage 3 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.

ACI Transition Measure:

  1. The MIPS EC that transitions or refers their patient to another setting of care or health care provider: (1) uses certified EHR technology to create a summary of care record; and (2) electronically transmits such summary to a receiving health care provider for at least one transition of care or referral.

ACI Transition 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 EP was the transferring or referring health care provider.

ACI Transition 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.

ACI 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.

ACI 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.

ACI 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 tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 7 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.

The tester shall verify that at a minimum, the following fields (listed below) in the summary of care record contain all of the information (or an indication of none) prior to numerator population. If a summary of care record does not contain all of the information (or an indication of none), the numerator should not be populated for both Ambulatory & Inpatient Settings:

  1. Current problem list;
  2. Current medication list;
  3. Current medication allergy list.

Required Test 8 Receive and Incorporate

Stage 3 Objective 7 Measure 2

ACI Objective 5 Measure 2

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. The Health IT Module will populate the numerator when the provider receives and incorporates a 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

Stage 3 Measure:

  1. Eligible Professional (EP): For more than 40 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP incorporates into the patient's EHR an electronic summary of care document.
  2. Eligible Hospital/Critical Access Hospital (EH/CAH): For more than 10 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the eligible hospital or CAH incorporates into the patient's EHR an electronic summary of care document.

Stage 3 Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: Number of patient encounters in the denominator where an electronic summary of care record received is incorporated by the provider into the certified EHR technology.
    • Denominator: Number of patient encounters during the EHR reporting period for which an EP, eligible hospital, or CAH was the receiving party of a transition or referral or has never before encountered the patient and for which an electronic summary of care record is available.

Stage 3 Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Summary of care record
      • Requested and available;
      • Received through query or request;
      • Incorporated into the record.
    • Denominator:
      • Number of patient encounters where the EP, EH or CAH was the receiving party of a transition or referral;
      • Number of patient encounters where the EP, EH, or CAH has never before encountered the patient;
      • Electronic summary of care record is available.

ACI Measure:

  1. For at least one transition of care or referral received or patient encounter in which the MIPS EC has never before encountered the patient, the MIPS EC receives or retrieves and incorporates into the patient's record and electronic summary of care document.

ACI Measure English Statements:

  1. Numerator: The number of transitions of care or referrals in the denominator where an electronic summary of care record received is incorporated by the provider into the certified EHR technology.
  2. Denominator: Number of transitions of care or referrals during the performance period for which the MIPS EC was the recipient of the transition or referral or had never before encountered the patient.

ACI Measure Elements:

  1. Numerator: Summary of care record
    • Requested and available;
    • Received through query or request;
    • Incorporated into the record.
  2. Denominator:
    • Number of patient encounters where the EC was the receiving party of a transition or referral;
    • Number of patient encounters where the EC has never before encountered the patient;
    • Electronic summary of care record is available.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 8 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 9 – Medication/Clinical Information Reconciliation

Modified Stage 2 Objective 7 and Stage 3 Objective 7 Measure 3

ACI Transition Objective 7 Measure 1 and ACI Objective 5 Measure 3

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. Medication reconciliation will populate the numerator if it is performed for a transition of care that is received during the reporting/performance period. The Health IT Module will populate the numerator if the provider performs reconciliation no earlier than the first day of the calendar year of the reporting/performance period (for a 90-day reporting period only), during the reporting/performance period (for a 90-day and full calendar year reporting period), or no later than the end of the calendar year of the reporting/performance period (for a 90-day reporting period only).

Measure Description

Modified Stage 2 Measures:

  1. Eligible Professional (EP): The EP performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP during the reporting period.
  2. Eligible Hospital/Critical Access Hospital (EH/CAH): The eligible hospital or CAH performs medication reconciliation for more than 50 percent of transitions of care in which the patient is admitted to the eligible hospital’s or CAH’s Inpatient or emergency department (POS 21 or 23) during the reporting period.

Modified Stage 2 Measure English Statements:

  1. Ambulatory:
    • Numerator: The number of transitions of care in the denominator where medication reconciliation was performed.
    • Denominator: Number of transitions of care during the EHR reporting period for which the EP was the receiving party of the transition.
  2. Inpatient:
    • Numerator: The number of transitions of care in the denominator where medication reconciliation was performed.
    • Denominator: Number of transitions of care during the EHR reporting period for which the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) was the receiving party of the transition.

Modified Stage 2 Measure Elements:

  1. Ambulatory:
    • Numerator: Indication that medication reconciliation occurred.
    • Denominator:
      • Provision of summary of care record of any type for an existing patient;
      • Number of transitions of care for which the EP was the receiving party;
      • Number of patients the EP has not previously encountered.
  2. Inpatient:
    • Numerator: Indication that medication reconciliation occurred.
    • Denominator:
      • Number of transitions of care for which the EH or CAH was the receiving party;
      • Number of patients the provider has not previously encountered.

Stage 3 Measure:

  1. Eligible Professional (EP): For more than 80 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP performs a clinical information reconciliation. The provider must implement clinical information reconciliation for the following three clinical information sets: (a) Review of the patient's medication, including the name, dosage, frequency, and route of each medication; (b) Review of the patient's known medication allergies; and (c) Review of the patient's current and active diagnoses.
  2. Eligible Hospital/Critical Access Hospital (EH/CAH): For more than 50 percent of transitions or referrals received and patient encounters in which the EH/CAH has never before encountered the patient, the EH/CAH performs a clinical information reconciliation. The provider must implement clinical information reconciliation for the following three clinical information sets: (a) Review of the patient's medication, including the name, dosage, frequency, and route of each medication; (b) Review of the patient's known medication allergies; and (c) Current Problem list. Review of the patient's current and active diagnoses.

Stage 3 Measure English Statements:

  1. Ambulatory:
    • Numerator: The number of transitions of care or referrals in the denominator where the following three clinical information reconciliations were performed: Medication list, medication allergy list, and current problem list.
    • Denominator: Number of transitions of care or referrals during the EHR reporting period for which the EP was the recipient of the transition or referral or has never before encountered the patient.
  2. Inpatient:
    • Numerator: The number of transitions of care or referrals in the denominator where the following three clinical information reconciliations were performed: Medication list, medication allergy list, and current problem list.
    • Denominator: Number of transitions of care or referrals during the EHR reporting period for which the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) was the recipient of the transition or referral or has never before encountered the patient.

Stage 3 Measure Elements:

  1. Ambulatory:
    • Numerator: Indication that medication, medication allergy, and problem list reconciliation occurred.
    • Denominator:
      • Provision of summary of care record of any type for an existing patient;
      • Number of transitions of care or referrals for which the EP was the recipient;
      • Number of patients the EP has not previously encountered.
  2. Inpatient:
    • Numerator: Indication that medication, medication allergy, and problem list reconciliation occurred.
    • Denominator:
      • Number of transitions of care or referrals for which the EH or CAH was the recipient;
      • Number of patients the provider has not previously encountered.

ACI Transition Measure:

  1. The MIPS EC performs medication reconciliation for at least one transition of care in which the patient is transitioned into the care of the MIPS EC.

ACI Transition Measure English Statements:

  1. Numerator: The number of transitions of care or referrals in the denominator where medication reconciliation was performed.
  2. Denominator: Number of transitions of care or referrals during the performance period for which the MIPS EC was the recipient of the transition or referral or has never been encountered by the patient.

ACI Transition Measure Elements:

  1. Numerator: Indication that medication reconciliation occurred.
  2. Denominator:
    • Provision of summary of care record of any type for an existing patient;
    • Number of transitions of care for which the EC was the receiving party;
    • Number of patients the EC has not previously encountered.

ACI Measure:

  1. For at least one transition of care or referral received or patient encounter in which the MIPS EC has never before encountered the patient, the MIPS EC performs clinical information reconciliation. The clinician must implement clinical information reconciliation 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. (3) Current Problem list. Review of the patient's current and active diagnoses.

ACI Measure English Statements:

  1. Numerator: The number of transitions of care or referrals in the denominator where the following three clinical information reconciliations were performed: medication list, medication allergy list, and current problem list.
  2. Denominator: Number of transitions of care or referrals during the performance period for which the MIPS EC was the recipient of the transition or referral or has never before encountered the patient.

ACI Measure Elements:

  1. Numerator: Indication that medication, medication allergy, and problem list reconciliation occurred.
  2. Denominator:
    • Provision of summary of care record of any type for an existing patient;
    • Number of transitions of care for which the EC was the receiving party;
    • Number of patients the EC has not previously encountered.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 9 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 10 – CPOE Medications

Modified Stage 2 Objective 3 Measure 1 and Stage 3 Objective 4 Measure 1

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. The Health IT Module will populate the numerator when medication orders are ordered using CPOE.

The CPOE measure is only applicable to EPs participating in the Medicaid Promoting Interoperability Program and EHs/CAHs participating in the Medicaid Promoting Interoperability Program only. EHs/CAHs who are participating in both the Medicaid and Medicare Promoting Interoperability Programs or just the Medicare Promoting Interoperability Program are exempt from this measure. 

Measure Description

Modified Stage 2 Measure:

  1. Eligible Professional/Eligible Hospital/Critical Access Hospital (EP/EH/CAH): More than 60 percent of medication orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.

Modified Stage 2 Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of medication orders in the denominator recorded using CPOE.
    • Denominator: Number of medication orders created by the EP or authorized providers in the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Modified Stage 2 Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Medication order recorded using CPOE.
    • Denominator: Number of medication orders.

Stage 3 Measure:

  1. Eligible Professional/Eligible Hospital/Critical Access Hospital (EP/EH/CAH): More than 60 percent of medication orders created by the EP or authorized providers of the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.

Stage 3 Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of medication orders in the denominator recorded using CPOE.
    • Denominator: Number of medication orders created by the EP or authorized providers in the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Stage 3 Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Medication order recorded using CPOE.
    • Denominator: Number of medication orders.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 10 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 11 – CPOE Laboratory

Modified Stage 2 Objective 3 Measure 2 and Stage 3 Objective 4 Measure 2

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. The Health IT Module will populate the numerator when laboratory orders are ordered using CPOE.

The CPOE measure is only applicable to EPs participating in the Medicaid Promoting Interoperability Program and EHs/CAHs participating in the Medicaid Promoting Interoperability Program only. EHs/CAHs who are participating in both the Medicaid and Medicare Promoting Interoperability Programs or just the Medicare Promoting Interoperability Program are exempt from this measure. 

Measure Description

Modified Stage 2 Measure:

  1. Eligible Professional/Eligible Hospital/Critical Access Hospital (EP/EH/CAH): More than 30 percent of laboratory orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.

Modified Stage 2 Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of laboratory orders in the denominator recorded using CPOE.
    • Denominator: Number of laboratory orders created by the EP or authorized providers in the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Modified Stage 2 Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Laboratory order recorded using CPOE.
    • Denominator: Number of laboratory orders.

Stage 3 Measure:

  1. Eligible Professional/Eligible Hospital/Critical Access Hospital (EP/EH/CAH): More than 60 percent of laboratory orders created by the EP or authorized providers of the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.

Stage 3 Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of laboratory orders in the denominator recorded using CPOE.
    • Denominator: Number of laboratory orders created by the EP or authorized providers in the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Stage 3 Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Laboratory order recorded using CPOE.
    • Denominator: Number of laboratory orders.

 

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 11 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 12 – CPOE Radiology/Diagnostic Imaging

Modified Stage 2 Objective 3 Measure 3 and Stage 3 Objective 4 Measure 3

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification. The Health IT Module will populate the numerator when Radiology orders (Modified Stage 2) or Diagnostic Imaging orders (Stage 3) are ordered using CPOE.

The CPOE measure is only applicable to EPs participating in the Medicaid Promoting Interoperability Program and EHs/CAHs participating in the Medicaid Promoting Interoperability Program only. EHs/CAHs who are participating in both the Medicaid and Medicare Promoting Interoperability Programs or just the Medicare Promoting Interoperability Program are exempt from this measure. 

Measure Description

Modified Stage 2 Measure:

  1. Eligible Professional/Eligible Hospital/Critical Access Hospital (EP/EH/CAH): More than 30 percent of radiology orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.

Modified Stage 2 Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of radiology orders in the denominator recorded using CPOE.
    • Denominator: Number of radiology orders created by the EP or authorized providers in the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Modified Stage 2 Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Radiology order recorded using CPOE.
    • Denominator: Number of radiology orders. 

Stage 3 Measure:

  1. Eligible Professional/Eligible Hospital/Critical Access Hospital (EP/EH/CAH): More than 60 percent of diagnostic imaging orders created by the EP or authorized providers of the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.

Stage 3 Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of orders in the denominator recorded using CPOE.
    • Denominator: Number of diagnostic imaging orders created by the EP or authorized providers in the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Stage 3 Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Diagnostic Imaging order recorded using CPOE.
    • Denominator: Number of diagnostic imaging orders.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 12 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 13 – Query of Prescription Drug Monitoring Program (PDMP)

Stage 3

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification.

Measure Description

Stage 3 Measure:

  1. Eligible Hospital/Critical Access Hospital (EH/CAH): For at least one Schedule II opioid electronically prescribed using CEHRT during the EHR reporting period, the eligible hospital or CAH 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.

Stage 3 Measure English Statements:

  1. Inpatient:
    • Numerator: The number of Schedule II opioid prescriptions in the denominator for which data from CEHRT is used to conduct a query of a PDMP for prescription drug history, except where prohibited and in accordance with applicable law.
    • Denominator: Number of Schedule II opioids electronically prescribed using CEHRT by the eligible hospital or CAH during the EHR reporting period.

Stage 3 Measure Elements:

  1. Inpatient:
    • Numerator:
      • Number of Schedule II opioids electronically prescribed using CEHRT;
      • Number of queries of a PDMP for prescription drug history using data from CEHRT.
  2. Denominator: Number of Schedule II opioids electronically prescribed.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 13 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 14 – Verify Opioid Treatment Agreement

Stage 3

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification.

Measure Description

Stage 3 Measure:

  1. Eligible Hospital/Critical Access Hospital (EH/CAH): For at least one unique patient for whom a Schedule II opioid was electronically prescribed by the eligible hospital 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 6-month look-back period, the eligible hospital or CAH seeks to identify the existence of a signed opioid treatment agreement and incorporates it into CEHRT.

Stage 3 Measure English Statements:

  1. Inpatient:
    • Numerator: The number of unique patients in the denominator for whom the eligible hospital 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 eligible hospital 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 6-month look-back period.

Stage 3 Measure Elements:

  1. Inpatient:
    • Numerator: Number of unique patients the eligible hospital 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.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 14 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.


Required Test 15 – Support Electronic Referral Loops by Receiving and Incorporating Health Information

Stage 3

System Under Test Test Lab Verification

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 they may create one report for all of the required tests for which they are seeking certification.

Measure Description

Stage 3 Measure:

  1. Eligible Hospital/Critical Access Hospital (EH/CAH): For at least one electronic summary of care record received for patient encounters during the EHR reporting period for which an eligible hospital 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 eligible hospital or CAH has never before encountered the patient, the eligible hospital or CAH conducts clinical information reconciliation for medication, mediation allergy, and current problem list.

Stage 3 Measure English Statements:

  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 eligible hospital 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 eligible hospital or CAH has never before encountered the patient.

Stage 3 Measure Elements:

  1. Inpatient:
    • Numerator: Summary of care record
      • Indication that clinical reconciliation of medications, medications allergy, and current problem list occurred.
    • Denominator:
      • Number of patient encounters where the eligible hospital or CAH was the receiving party of a transition or referral;
      • Number of patient encounters where the eligible hospital or CAH has never before encountered the patient;
      • Electronic summary of care received.

The tester verifies that each report, including the numerator, denominator, and resulting percentages, are created correctly and without omission and include sufficient detail to match the patients or actions in the numerator report to the measure’s denominator limitations. The tester ensures that the correct patients are included in the numerator and denominator. The tester will use the information provided in required Test 15 and use ONC Test Data Scenario(s) 1, 2, 3, 4, and 5.

The tester shall verify that at a minimum, the following fields (listed below) in the summary of care record contain all of the information (or an indication of none) prior to numerator population. If a summary of care record does not contain all of the information (or an indication of none), the numerator should not be populated for the Inpatient Setting:

  1. Current problem list;
  2. Current medication list; and
  3. Current medication allergy list.

Version 1.8 Updated on 08-17-2018
Revision History
Version # Description of Change Version Date
1.0

Initial Publication

02-05-2016
1.1

Added clarification on which Health IT Modules must test to the EP/EC Individual, EC Group, and EH/CAH tests.

Clarified when actions must occur to increment the numerator.

Clarified how Health IT Modules must test for Required Test 2, and the documentation that they must submit.

10-21-2016
1.2

Added references to the QPP.

Added clarification on deduplication of patients and the transitive effect for the numerator on the EC Individual and Group calculation methods.

Added information about the self-testing option.

Modified the information on when actions must occur to populate the numerator based on recent CMS guidance.

01-04-2017
1.3

Added clarification on Health IT Module’s capability requirements on recording TIN/NPI combinations.

Added clarification on confirmation of receipt of a C-CDA by a receiving provider prior to incrementing the numerator.

Added links to measure-specific guidance.

03-17-2017
1.4

Added clarification for patient education materials, MU3 Objective 5 automated measure calculation eligibility.

07-07-2017
1.5

Provided additional clarification for the patient-specific education measure regarding provider ability to configure systems based on patient information.

08-25-2017
1.6

Added clarification on numerator inclusion for the patient-specific education measure, which provides certification guidance for the use of automation in the provision of patient-specific education materials.

09-29-2017
1.7

Added clarification about flexibility for testing this criterion and developer expectations for measures to which the transitive effect applies when the Health IT Module is unable to differentiate actions at the TIN/NPI level. 

02-01-2018
1.8

Added clarification that both the EC Individual and EC Group calculation methods must be tested by a Health IT Module supporting the ACI and/or the ACI Transition calculation method(s). Modified the timely access requirement for the ACI Patient Access measure based on a CMS policy change per the QPP CY 2018 final rule (82 FR 53568).

Modified the information on when actions must occur to populate the numerator for Stage 3 measures starting in 2019 based on 2019 IPPS Final Rule. Modified the name of the EHR Incentive Program to the Promoting Interoperability Program. Updated the Measure-Specific Guidance from CMS.

08-17-2018
Regulation Text
Regulation Text

§170.315 (g)(2) Automated measure calculation

For each EHR Incentive Programs percentage-based measure that is supported by a capability included in a technology, record the numerator and denominator and create a report including the numerator, denominator, and resulting percentage associated with each applicable measure.

Standard(s) Referenced

None

Certification Companion Guide: Automated measure calculation

This Certification Companion Guide (CCG) is an informative document designed to assist with health IT product development. The CCG is not a substitute for the 2015 Edition final regulation. It extracts key portions of the rule’s preamble and includes subsequent clarifying interpretations. To access the full context of regulatory intent please consult the 2015 Edition final rule or other included regulatory reference. The CCG is for public use and should not be sold or redistributed.
 

 

Certification Requirements

This certification criterion was adopted at § 170.315(g)(2). Quality management system (§ 170.315(g)(4)) and accessibility-centered design (§ 170.315(g)(5)) need to be certified as part of the overall scope of the certificate issued to the product.

  • When a single quality management system (QMS) is used, the QMS only needs to be identified once. Otherwise, the QMS’ need to be identified for every capability to which it was applied.
  • When a single accessibility-centered design standard is used, the standard only needs to be identified once. Otherwise, the accessibility-centered design standards need to be identified for every capability to which they were applied; or, alternatively the developer must state that no accessibility-centered design was used.

 

Measure-Specific Guidance from CMS

Technical Explanations and Clarifications

 

Applies to entire criterion

Technical outcome – A user can create a report that includes the numerator, denominator, and resulting percentage for each applicable percentage-based Promoting Interoperability Programs measure supported.

Clarifications:

  • There is no standard required for this certification criterion.
  • The gap certification eligibility of this criterion at § 170.315(g)(2) depends on any modifications to the certification criteria to which this criterion applies and relevant Stage 3 Promoting Interoperability objectives and measures.
  • ONC administers the ONC Health IT Certification Program; CMS administers the Promoting Interoperability and Quality Payment Programs. Questions regarding requirements for the Promoting Interoperability and Quality Payment Programs should be directed to CMS.
  • ONC has issued an FAQ (#50) on testing and certification for the 2014 Edition automated numerator recording (§ 170.314(g)(1)) and automated measure calculation (§ 170.314(g)(2)) certification criteria for measures which are no longer included in the Promoting Interoperability criteria based for EHR reporting periods in 2015-2017 based on updates included in the CMS final rule. [see also 80 FR 62761, 80 FR 62785, 80 FR 62875] Although this FAQ references the 2014 Edition certification criteria for automated numerator recording and automated measure calculation, the policy applies to testing and certification for the 2015 Edition automated numerator recording (§ 170.315(g)(1)) and automated measure calculation (§ 170.315(g)(2)) certification criteria if the Health IT Module will be used to report on measures in 2016 and 2017.
    • The following measures are no longer applicable for CMS Promoting Interoperability Programs:
      • Demographics
      • Vital signs
      • Smoking status
      • Clinical summaries
      • Incorporate lab results
      • Patient reminders
      • Electronic notes
      • Imaging
      • Family health history
      • Problem list
      • Medication list
      • Medication allergy list
      • Advance directives
      • Electronic medication administration record (eMAR)
      • Send labs from EH to EP
      • CPOE Medications (EH and EC only)
      • CPOE Laboratory (EH and EC only)
      • CPOE Radiology/Diagnostic Imaging (EH and EC only)
  • Please refer to CMS’ Promoting Interoperability Programs webpage and Quality Payment Program webpage for more resources on specific measures.
  • Three measures are eligible for gap certification: 1) Required Test 10 – CPOE Medications, Modified Stage 2 Objective 3 Measure 1 and Stage 3 Objective 4 Measure 1; 2) Required Test 11 – CPOE Laboratory, Modified Stage 2 Objective 3 Measure 2 and Stage 3 Objective 4 Measure 2; and 3) Required Test 11 – CPOE Radiology/Diagnostic Imaging, Modified Stage 2 Objective 3 Measure 3 and Stage 3 Objective 4 Measure 3.
  • The test for (g)(2) does not require a live demonstration of recording data and generating reports. Health IT developers may self-test their Health IT Modules(s) and submit the resulting reports to the ONC-ATL to verify compliance with the criterion. The test procedure specifies what reports must be submitted for the Global Required Test and each Required Test, as well as what the tester must verify within each report.
  • Health IT Modules are required to de-duplicate test patients when aggregating together data for the Eligible Clinician (EC) Group calculation method.
  • Health IT Modules that are testing for the Advancing Care Information (ACI) and/or ACI Transition calculation method(s) must test for both the EC Individual and EC Group calculation methods.
  • Health IT Modules that are testing for the EC Individual and EC Group calculation methods are required to be able to record an EC’s TIN. Further, they are also required to be able to associate a single NPI with multiple TINs within a single instance, database, etc. of the Health IT Module. Health IT Modules that are testing for the Individual EP calculation method only are not required to record TIN or be able to associate a single NPI to multiple TINs.
  • For the EC Individual and Group calculation methods, actions that accrue to the numerator have a transitive effect across all of the TINs that an individual NPI is included in. For example, if an EC provides patient education materials to a patient under TIN A, they will receive credit in the numerator for TIN B as long as the same NPI is used in both TINs and the same Health IT Module (i.e. same database, instance, etc.) is used. The test data reflects this transitive effect.
  • The capability for technology to populate the numerator before, during, and after the reporting/performance period depends on the numerator and denominator statements for the Promoting Interoperability measure. Developers should refer to the numerator and denominator statements in the measure specification sheets provided by CMS’ Promoting Interoperability Programs webpage to determine the reporting/performance period technology needs to support. Regardless of whether an action must occur during the reporting/performance period or can occur outside of the reporting/performance period, all actions must occur during the calendar year of the reporting/performance period.
    • Starting in 2019, CMS has clarified that the numerator for the Medicare Stage 3 EH/CAH measures is constrained to the EHR reporting period. The numerator action therefore must take place during the reporting period. Actions occurring outside of the reporting period, including after the calendar year will not count in the numerator.
    • For a reporting period in CY 2018, a Medicare Stage 3 EH/CAH Measure numerator action may continue to be calculated using a system that does not constrain the numerator to the EHR reporting period to allow time to transition to the new approach beginning in CY 2019
    • For the Modified Stage 2 measures, CMS clarified that a numerator is not constrained to an EHR reporting period when the EHR reporting period is less than one year. The numerator action may reasonably fall outside the EHR reporting period timeframe but must take place no earlier than the start of the calendar year and no later than the end of the calendar year in order for the patients to be counted in the numerator. As such, actions occurring after the end of the reporting period's calendar year will not count in the numerator.
    • For a performance period in CY 2018, an ACI Measure numerator is not constrained to the EHR reporting period unless expressly stated in the numerator statement for a given ACI measure, and the numerator action may reasonably fall outside the EHR reporting period timeframe but must take place no earlier than the start of the calendar year and no later than the end of the calendar year in order for the patients to be counted in the numerator. As such, actions occurring after the end of the reporting period's calendar year will not count in the numerator.
  • Although being put on observation in the outpatient department (POS 22) by itself would not qualify a patient towards counting in the denominator for the ED Visits method, please note that the first part of Scenario E in IN170.314(g)(2) – 3.03 specifies an admission to the inpatient department (POS 21) after being placed on observation in POS 22. The admission as an inpatient is what qualifies the patient for the denominator of the All ED Visits method in this scenario. Patients who are admitted as inpatients, regardless of whether they may have been admitted previously, should be included in the denominator for both eligible hospital denominator methods.
  • It is possible for the action of “record” in this certification criterion to be implemented in different ways. For example, “record” could comprise the ability of a centralized analytics Health IT Module to accept or retrieve raw data from another Health IT Module or Health IT Modules. Other possible methods could include a Health IT Module that accepts or retrieves raw data, analyzes the data, and then generates a report based on the analysis; a Health IT Module that separately tracks each capability with a percentage-based Promoting Interoperability measure and later aggregates the numbers and generates a report; or an integrated bundle of Health IT Modules in which each of the Health IT Modules that is part of the bundle categorizes relevant data, identifies the numerator and denominator and calculates, when requested, the percentage associated with the applicable Promoting Interoperability Programs measure. In each of these examples, the action of “record” means to obtain the information necessary to generate the relevant numerator and denominator. [see also FAQ #20]
  • What is required for certification for this criterion depends on the type of flexibility identified by CMS.
    • In some cases, CMS identifies certain measurement flexibilities that are limited to “either/or” options. In these cases, technology presented for certification must be able to calculate the percentage based on both identified options.
    • In cases where CMS has identified measurement flexibilities that are open-ended and dependent on a unique decision by an EP, EC, eligible hospital, or CAH at the practice/organization-level for a given EHR reporting period (such as: calculating hospital admissions based on the observation services method or the all ED method and excluding certain orders from the CPOE measure because they are protocol/standing orders), then the technology presented for certification is not required to support every possible method of calculation in order to meet this certification criterion. Rather, the technology must support at least one calculation method for a certification criterion, as long as the technology supports all distinct options for measurement (such as including controlled substances in the eRx measure or not). We strongly encourage technology developers to work with their clients and to incorporate as many of these practice/organization-level open-ended flexibilities in the technology as appropriate to make the Promoting Interoperability measures as relevant as possible to their clients’ scopes of practice. [77 FR 54244–54245 and ONC FAQ #32]
  • Capabilities to perform automated measure calculation are split into two sections. (1) The ability to address required capabilities across any Health IT Module included for testing (global) and (2) the ability to perform required capabilities specified by specific measures listed above (measure specific).
    • Global requirements include the ability for the module to create reports for measures for a specific reporting period. In the inpatient care setting only, the ability to allow eligible hospitals and critical access hospitals to calculate emergency department admissions using one of two methods (observation services method or all ED visits methods) must be made available. Note that only one required tests allows EHs and CAHs to calculate measures by one of these methods. CMS FAQ 10126 provides additional details on each method. Global requirements also include the ability for the module to correctly include or exclude actions that occur inside or outside of the reporting/performance period or calendar year.
    • Measure specific requirements address the capability of the technology to electronically record the numerator and denominator and resulting percentage for each Promoting Interoperability/ACI objective with a percentage-based measure and the capability to create a report that includes the numerator, denominator and resulting percentage recorded that is associated with each percentage-based Promoting Interoperability (ACI) measure.
  • We also apply to this 2015 Edition “automated measure calculation” criterion the clarification and guidance included for certification to the 2014 Edition “automated measure calculation” criterion in the 2014 Edition Release 2 rulemaking [79 FR 10920 and 54445].
    • A Health IT Module may be certified to only the ‘‘automated measure calculation’’ certification criterion (§ 170.315(g)(2)) in situations where the Health IT Module does not include a capability that supports a Promoting Interoperability Program/ACI percentage-based measure, but can meet the requirements of the ‘‘automated measure calculation’’ certification criterion.
    • An example of this would be an ‘‘analytics’’ Health IT Module where data is fed from other health IT, and the Health IT Module can record the requisite numerators, denominators and create the necessary percentage report as specified in the ‘‘automated measure calculation’’ certification criterion.
  • ONC-ACBs can certify a Health IT Module to either § 170.315(g)(1) or (g)(2) per FAQ #28. ONC-ACBs should refer to the scenarios outlined in FAQ #28 for further details.
  • Modified Stage 2 Objective 5 Measure 1, Stage 3 Objective 7 Measure 1, ACI Transition Objective 6 Measure 1, and ACI Objective 5 Measure 1 require that the EP/EC/EH/CAH confirm receipt of the summary of care by the referred to provider in order to increment the numerator. The test data tests this baseline requirement by requiring that a Health IT Module demonstrate confirmation of receipt before incrementing the numerator. ONC does not require a specific method Health IT Modules should use to confirm receipt. Health IT Modules could use a number of methods, including but not limited to, the Direct Message Disposition Notification, a check box, report verifications, etc.
  • The test data used for this criterion is supplied by ONC and is organized into 5 Test Data scenarios, with a single set of 12 Test Cases. Health IT developers are required to use the ONC-supplied test data and may not modify the test case names.
  • Stage 3 CMS Objective 5 Measure 1, Patient Access requires that two conditions be met in order to increment/populate the numerator: patient data must be available to view, download, or transmit AND it must be available to an API within 48 hours (EP) or 36 hours (EH/CAH). ACI CMS Objective 3 Measure 1, Patient Access requires that two conditions be met in order to increment/populate the numerator: patient data must be available to view, download, or transmit AND it must be available to an API within 4 business days (EC). As such, Health IT Modules certified to only (e)(1) or certified to only (g)(8) or (g)(9) will be required to demonstrate that the product increments the denominator for the condition for which they are certified. For example, if the Test Case indicates that only view, download, or transmit was met, the numerator will increment for products certified to (e)(1) but will not increment for products certified to (g)(8) or (g)(9). Health IT Modules certified for (e)(1) AND (g)(8) or (g)(9) will be expected to increment the numerator as the measure specifies. Health IT Modules certified to only (e)(1) or certified to only (g)(8) or (g)(9) will be required to provide documentation during testing that demonstrates how the Health IT Module performs the calculation for its “portion” of the measure as a condition of passing testing. This documentation must also be made available with the health IT developer’s transparency statement regarding costs and limitations. Documentation should enable Eligible Providers, Eligible Clinicians, Eligible Hospitals, and Critical Access Hospitals to determine how to correctly add together the numerator and denominator from systems providing each of the capabilities.
  • EH/CAH/EP MU3 Objective 5 Measure 2, EH/CAH/EP Modified Stage 2 Objective 6, ACI Transition Objective 4, and ACI Objective 3: Patient educational material identified by the patient rather than the provider do not qualify for inclusion in the automated measure calculation. Providers may configure their health IT to automatically make available patient education materials based on patient-specific information. For numerator inclusion, the automated provision of patient-specific education materials must demonstrate that the health care provider can determine the clinical relevance of such materials, either at a clinician level, provider organization level, or both.
  • CMS has issued FAQ 22521 regarding the application of the transitive effect to certain MIPS advancing care information (ACI) measures. For the purposes of testing to this criterion, the test data is structured to differentiate actions between TIN/NPI combinations. However, Health IT Modules that are not able to differentiate actions between TIN/NPI combinations for the measures to which the transitive effect applies are not required to demonstrate this capability. ONC-ATLs may offer flexibility during testing regarding the transitive effect and focus on the outcome to ensure the correct numerator and denominator are calculated by the Health IT Module. At a minimum, developers of Health IT Modules unable to differentiate actions at the TIN/NPI level for those measures to which the transitive effect applies must provide sufficient documentation and explanation of alternate workflows to the ONC-ATL to demonstrate how actions taken by a provider relate to the numerator and denominator. Health IT developers must also provide documentation to providers on configuration and the logic for properly using the “automated measure calculation” functionality, including details on how the developer has implemented the transitive effect policy.

Regulation Text
Regulation Text

§170.315 (g)(2) Automated measure calculation

For each EHR Incentive Programs percentage-based measure that is supported by a capability included in a technology, record the numerator and denominator and create a report including the numerator, denominator, and resulting percentage associated with each applicable measure.

Criterion Subparagraph Test Data
Test Data Set 1 – EH/CAH

See the file "§170.315(g)(2) EH/CAH" below under the Attachments section.  Last updated on 08-17-2018.

Test Data Set 2 – EP/EC

See the file "§170.315(g)(2) EP/EC" below under the Attachments section.  Last updated on 08-17-2018.

Content last reviewed on September 24, 2018
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