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§170.315(g)(2) Automated measure calculation

Updated on 02-07-2022
Resource Documents
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 computerized provider order entry (CPOE) measures.

Reordered required tests to mirror the Centers for Medicare & Medicaid Services (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 Advancing Care Information (ACI) Measure 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 related to 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’s authorized representative rather than the Eligible Clinician (EC) per the Quality Payment Program Calendar Year (CY) 2018 Final Rule (82 FR 53568).

02-01-2018
1.7

Made the following changes based on the CMS policy changes per the CY 2019 Hospital Inpatient Prospective Payment System (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
1.8

Added text noting that the Promoting Interoperability measure for Required Tests 3, 4, 5, 6, 8, and 9 are only applicable in 2018.  Added text noting the Promoting Interoperability measure for Required Tests 13, 14, and 15 are only applicable starting in 2019.

Modified the name of the ACI Transition and ACI to Promoting Interoperability Transition and Promoting Interoperability.

02-28-2019
1.9

Updated Required Test 15 to remove the draft status for eligible hospitals/critical access hospitals (EH/CAH).

04-26-2019
2.0

Per the CY2020 IPPS Final Rule, updated Required Test 13 to remove the EH/CAH measures and the Required Test 14 measure to note it is only applicable in 2019.  Per the CY2019 Physician Fee Schedule (PFS) Final Rule, added the EC measures for Required Test 13, 14, and 15. 

09-30-2019
2.1

Per the CY2020 PFS Final Rule, removed Required Test 13 for ECs and updated Required Test 14 to note it is only applicable in 2019 for ECs.

11-04-2019
2.2

Updated Required Test 15 to remove the test lab verification requirement to verify the content of the care summary record. 

12-31-2019
2.3

Based on the sunsetting of the 2014 Edition in the 21st Century Cures Act Final Rule, measure descriptions and requirements related only to Modified Stage 2 and Promoting Interoperability Transition were removed.  Removed the Promoting Interoperability measure for Required Tests 3, 4, 5, 6, 8, and 9 as they were only applicable in 2018.  Made changes to the naming terminology to align with CMS program updates including modifying the measure naming convention from Stage 3 to Medicare and/or Medicaid Promoting Interoperability programs; and added the EH/CAH measure description.

06-01-2020
2.4

Added United States Core Data for Interoperability (USCDI) compliance date.

08-07-2020
2.5

Updated compliance date per the IFC, Information Blocking and the ONC Health IT Certification Program: Extension of Compliance Dates and Timeframes in Response to the COVID-19 Public Health Emergency 

11-02-2020
2.6

Due to the end of the Medicaid Promoting Interoperability Program, required tests that only supported the Medicaid Promoting Interoperability Program were removed.

02-07-2022
Regulation Text
Regulation Text

§ 170.315 (g)(2) Automated measure calculation

For each Promoting Interoperability 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

Testing
Testing Tool

Testing Components

 

Criterion Subparagraph Test Data
Test Data Set 1 – EH/CAH
Test Data Set 2 – EP/EC

Please consult the Final Rule entitled: 2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, ONC Health IT Certification Program Modifications, and the Interim Final Rule with Comment Period (IFC), Information Blocking and the ONC Health IT Certification Program: Extension of Compliance Dates and Timeframes in Response to the COVID-19 Public Health Emergency,  for a detailed description of the certification criterion with which these testing steps are associated. We also encourage developers to consult the Certification Companion Resource 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

No GAP Icon Documentation Icon Visual Inspection Icon No Test Tool Icon ONC Supplied Test Data Icon
System Under Test Test Lab Verification

Required Attestation

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

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

 

Required Attestation

Tester verifies that the attestation includes all required elements.


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

Measure Description

Medicare Promoting Interoperability Programs Measure:

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

Medicare Promoting Interoperability Programs Measure English Statements:

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

Medicare Promoting Interoperability Programs Measure Elements:

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

MIPS Promoting Interoperability Performance Category Measure:

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

MIPS Promoting Interoperability Performance Category English Statements:

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

MIPS Promoting Interoperability Performance Category Measure Elements:

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

The 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.


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

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

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

Test Data

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

Measure Description

Medicare Promoting Interoperability Programs Measure:

  1. Medicare EH/CAH: For at least one unique patient discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23): (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The provider ensures the patient’s health information is available for the patient (or patient-authorized representative) to access using any application of his or her choice that is configured to meet the technical specifications of the API in the provider’s CEHRT.

Medicare Promoting Interoperability Programs English Statements:

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

Medicare Promoting Interoperability Programs Measure Elements:

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

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

  1. EC: For at least one unique patient seen by the MIPS EC (1) the patient (or the patient authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) the MIPS EC ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of his or her choice that is configured to meet the technical specifications of the API in the MIPS EC's CEHRT.

MIPS Promoting Interoperability Performance Category English Statements:

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

MIPS Promoting Interoperability Performance Category Measure Elements:

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

 

The 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.

  1. Common Clinical Data Set until December 31, 2022, and USCDI after December 31, 2022 (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)

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

Measure Description

Medicare Promoting Interoperability Programs Measure:

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

Medicare Promoting Interoperability Programs Measure English Statements:

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

Medicare Promoting Interoperability Programs Measure Elements:

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

MIPS Promoting Interoperability Performance Category Measure:

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

MIPS Promoting Interoperability Performance Category Measure English Statements:

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

MIPS Promoting Interoperability Performance Category Measure Elements:

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

The 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.

System Under Test Test Lab Verification

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

Measure Description

Medicare Promoting Interoperability Program Measure (2019 only):

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

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

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

Medicare Promoting Interoperability Program Measure Elements (2019 only):

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

MIPS Promoting Interoperability Performance Category Measures (2019 only):

  1. For at least one unique patient for whom a Schedule II opioid was electronically prescribed by the MIPS EC using CEHRT during the performance period, if the total duration of the patient’s Schedule II opioid prescriptions is at least 30 cumulative days within a six-month look-back period, the MIPS EC seeks to identify the existence of a signed opioid treatment agreement and incorporates it into the patient’s electronic health record using CEHRT.

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

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

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

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

The tester must evaluate the self-declaration documentation for compliance against its defined requirements for the criteria.  The tester may require the health IT developer to list or reference its evidence/documentation from which the health IT developers has based its declaration of conformity.


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 it may create one report for all of the required tests for which it is seeking certification.

Measure Description

Medicare Promoting Interoperability Program Measure (Starting in 2019):

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

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

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

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

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

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

  1. For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS EC has never before encountered the patient, the MIPS EC conducts clinical information reconciliation for medication, medication allergy, and current problem list.

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

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

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

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

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.

 


Updated on 02-07-2022
Resource Documents
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 eligible professional (EP)/eligible clinician (EC) Individual, EC Group, and eligible hospital (EH)/critical access hospital (CAH) tests.

Clarified when actions must occur to increment the numerator.

10-21-2016
1.2

Added references to the Quality Payment Program (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 The Centers for Medicare & Medicaid Services (CMS) guidance.

01-04-2017
1.3

Added clarification on Health IT Module’s capability requirements on recording Taxpayer Identification Number (TIN)/ national provider identifier (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, Meaningful Use Stage 3 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 inpatient prospective payment systems (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
1.9

Modified the name of the Advancing Care Information Transition and Advancing Care Information measures to Promoting Interoperability Transition and Promoting Interoperability.  Modified the information on when actions must occur to populate the numerator for Promoting Interoperability measures starting in 2019 based on the 2019 Physician Fee Schedule final rule.

12-07-2018
2.0

Added a link to CMS FAQs on the new Medicare Promoting Interoperability opioid measures for eligible hospitals in 2019.

02-28-2019
2.1

Added a link to CMS FAQs on the new Medicare Promoting Interoperability Support Electronic Referral Loops by Receiving and Incorporating Health Information measure for eligible hospitals in 2019.

04-26-2019
2.2

Added text noting that the previously published CMS FAQs on the new opioid measures and the Support Electronic Referral Loop apply in the Promoting Interoperability performance category of the Merit-based Incentive Payment System (MIPS).   

09-30-2019
2.3

Based on the sunsetting of the 2014 Edition in the Cures Final rule explanations and clarifications related to Modified Stage 2 and ACI Transition were removed. Made changes to the naming terminology to align with CMS program updates including modifying the measure naming convention from Stage 3 to Medicare and/or Medicaid Promoting Interoperability Programs.

06-15-2020
2.4

Modified language to align with the sunset of CMS’ Medicaid program requirements.

02-07-2022
Regulation Text
Regulation Text

§ 170.315 (g)(2) Automated measure calculation

For each Promoting Interoperability 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

Testing
Testing Tool

Testing Components

 

Criterion Subparagraph Test Data
Test Data Set 1 – EH/CAH
Test Data Set 2 – EP/EC

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.
  • 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 a clarification in the Health IT Certification Program Overview 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 that 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 the Certification Program overview 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 Eligible Hospital to Eligible Professional
      • CPOE Medications (Eligible Hospital and Eligible Clinician only)
      • CPOE Laboratory (Eligible Hospital and Eligible Clinician only)
      • CPOE Radiology/Diagnostic Imaging (Eligible Hospital and Eligible Clinician only)
  • Please refer to CMS’ Promoting Interoperability Programs webpage and Quality Payment Program webpage for more resources on specific measures.
  • The test for (g)(2) does not require a live demonstration of recording data and generating reports. 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 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 Group calculation method.
  • Health IT Modules that are testing for the MIPS Promoting Interoperability performance category calculation method must test for both the Eligible Clinician Individual and Eligible Clinician Group calculation methods.
  • Health IT Modules that are testing for the Eligible Clinician Individual and Eligible Clinician Group calculation methods are required to be able to record an Eligible Clinician’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 Eligible Provider calculation method only are not required to record TIN or be able to associate a single NPI to multiple TINs.
  • For the Eligible Clinician Individual and Eligible Clinician 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 Eligible Clinician 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 Promoting Interoperability Program Eligible Hospital/Critical Access Hospital 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.
    • Starting in 2019, a MIPS Promoting Interoperability performance category measure numerator and denominator is constrained to the performance period chosen, with the exception of the "Security Risk Analysis" measure, which may occur any time during the calendar year.
  • 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(s). 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 Health IT Certification Program Overview]
  • 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 Eligible Professional, Eligible Clinician, Eligible Hospital, or CAH at the practice/organization-level for a given EHR reporting period (e.g., 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 (e.g., including controlled substances in the eRx measure or not). ONC strongly encourages 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. [see also 77 FR 54244–54245 and ONC Health IT Certification Program Overview]
  • ONC also applies 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 [see also 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 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 Health IT Certification Program Overview for further details.
  • The Support Electronic Referral Loops by Sending Health Information measure for the Medicare Promoting Interoperability Programs, and the MIPS Promoting Interoperability performance category require that the Eligible Professional/Eligible Clinician/Eligible Hospital/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 five 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.
  • The Medicare Promoting Interoperability "Provide Patients Electronic Access to Their Health Information" measure 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 (Eligible Professional) or 36 hours (Eligible Hospital/CAH). The MIPS Promoting Interoperability performance category Provide Patients Electronic Access to Their Health Information measure 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 four business days (Eligible Clinician). As such, Health IT Modules certified to only (e)(1) or certified to only (g)(8), (g)(9) or (g)(10) 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), (g)(9) or (g)(10). Health IT Modules certified for (e)(1) and (g)(8), (g)(9) or (g)(10) 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) (g)(9) or (g)(10) 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 Professionals, 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.
  • CMS has issued FAQ 22521 regarding the application of the transitive effect to certain MIPS Promoting Interoperability performance category 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.
  • CMS has issued a series of FAQs that provide additional guidance on the new Medicare Promoting Interoperability Program opioid measures for Eligible Hospitals in 2019: "Query of Prescription Drug Monitoring Program", and "Verify Opioid Treatment Agreement". The FAQs also apply in 2019 for the new opioid measures in the MIPS Promoting Interoperability performance category.    
  • CMS has issued a series of FAQs that provide additional guidance on the new Medicare Promoting Interoperability Program measure for Eligible Hospitals in 2019: "Support Electronic Referral Loops by Receiving and Incorporating Health Information". The FAQs also apply in 2019 for the "Support Electronic Referral Loops by Receiving and Incorporating Health Information" measure in the MIPS Promoting Interoperability performance category.
  • The Medicaid Promoting Interoperability Program ended January 2022, the required tests that only supported the Medicaid Promoting Interoperability Program were removed.