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§170.315(g)(1) Automated numerator recording

Version 2.4 Updated on 06-01-2020
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

Removed incorrect references to a denominator.

Added an attestation requirement around documentation provided to end users.

04-24-2017
1.5

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

Added an attestation requirement around documentation provided related to the end user’s system’s ability to calculate the different methods.

08-25-2017
1.6

Removed 2nd bullet under the Advancing Care Information (ACI) Measure English Statement of the Required Test 6 - Patient Generated Health Data section.

Removed the wording "of of" before 'the following' within the first sentence of the Required Attestation section.

Clarified the View, Download, Transmit Measure for ACI to describe the action as being taken by the patient or patient-authorized representative rather than the Eligible Clinician (EC) per the Quality Payment Program (QPP) Calendar Year (CY) 2018 Final Rule (82 FR 53568).

02-01-2018
1.7

Made the following changes based on CMS policy changes per the CY 2019 Hospital Inpatient PPS final rule (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

Removed the reference to tax identifier number and national provider identifier (TIN/NPI) in the Required Tests organization section as it is not applicable to g1. 

06-28-2019
2.1

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. 

09-29-2019
2.2

Per the CY2020 Physician Fee Schedule (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
2.3

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

 

Per the ONC Cures Act Final Rule removed the Modified Stage 2 and Advancing Care Information (ACI) Transition measures.

12-31-2019
2.4

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 Medicaid EH/CAH measure description.

06-01-2020
Regulation Text
Regulation Text

§170.315 (g)(1) Automated numerator recording

For each Promoting Interoperability Programs percentage-based measure, technology must be able to create a report or file that enables a user to review the patients or actions that would make the patient or action eligible to be included in the measure's numerator. The information in the report or file created must be of sufficient detail such that it enables a user to match those patients or actions to meet the measure's denominator limitations when necessary to generate an accurate percentage.

Standard(s) Referenced

None

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

See the file "§170.315(g)(1) EH/CAH" below under the Attachments section.  Last updated on 06-15-2020.

Test Data Set 2 – EP/EC

See the file "§170.315(g)(1) EP/EC" below under the Attachments section.  Last updated on 06-15-2020.

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. Developers are also encouraged to consult the Certification Companion Resource in tandem with the test procedure as they both 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

 

Gap Eligibility

Three measures are eligible for gap certification: 1) Required Test 10 – CPOE Medications, Medicaid Promoting Interoperability Program; 2) Required Test 11 – CPOE Laboratory, Medicaid Promoting Interoperability Program; and 3) Required Test 11 – CPOE Radiology/Diagnostic Imaging, Medicaid Promoting Interoperability Program.

 

Required Tests

The table that provides a description of the Medicare and Medicaid Promoting Interoperability (formerly Electronic Health Record (EHR) Incentive) Program and the Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category 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:

  • 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 two calculation methods: 1) Medicaid Promoting Interoperability Program or Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category (TIN/NPI). Health IT Modules that are inpatient systems only must use the EH test data and, if the inpatient system is used in the ambulatory setting, the ambulatory test and test at least one of two calculation methods: 1) Medicaid Promoting Interoperability Program 3; or 2) Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category. Health IT Modules that are both ambulatory and inpatient systems must use the EH test data and the ambulatory test and test at least one of two calculation methods: 1) Medicare and Medicaid Promoting Interoperability Programs; or 2) MIPS Promoting Interoperability performance category (TIN/NPI). Health IT Modules that test to the MIPS Promoting Interoperability performance category measures are deemed as meeting testing requirements for the relevant Medicaid Promoting Interoperability Program measures. 

 

For Measure-Specific Sections

Within each of the measure-specific sections, the test procedure addresses the capability to record the numerator for § 170.315(g)(1) for each measure for Medicare and Medicaid Promoting Interoperability Programs and the MIPS Promoting Interoperability performance category measures:

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

 

Within each of the measure-specific sections, the test procedure addresses the capabilities to report each measure for Medicare and Medicaid Promoting Interoperability Programs and MIPS Promoting Interoperability performance category 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 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 it is presenting for testing.
    • Using the functions of the Health IT Module, the health IT developer creates a report that includes the numerator 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.
    • 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 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.
    • 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 for each measure based on the supplied test data from Test Data Scenario 3 (populate numerator) across all required tests. The report must also include the list of patients included in the numerator.
    • 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 for each measure based on the supplied test data from Test Data Scenario 4 (do not populate numerator) across all required tests. The report must also include the list of patients included in the numerator.
    • The health IT developer marks the report as Scenario 4.
    • The health IT developer submits all four reports to the tester for review.
    • The tester verifies that the increments in the numerator 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 for each measure.

The test data for § 170.315(g)(1) 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 eight 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 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 Measure Element list deconstructs the English Statements to provide the discrete measure elements for recording the numerator.

System Under Test Test Lab Verification

Required Attestation

Health IT developers with Health IT Modules certified to (g)(1) are required to attest that they have provided to other health IT developers and end-users documentation, including the following as applicable:

  • Identify and acknowledge specific situations where the Health IT Module certified to (g)(1) does not have access to information that allows the module to determine if a numerator should be incremented or decremented for a measure. 
  • Identify and acknowledge that the Health IT Module does not record TIN/NPIs and that the health IT developer or end-user is responsible for calculating performance at the TIN/NPI or group TIN for Promoting Interoperability measures. 
  • For ambulatory only systems or inpatient/ambulatory systems, identify and acknowledge the Health IT Module is not certified or deemed to (g)(1) for both calculation methods 1) Medicaid Promoting Interoperability Program; or 2) Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category (TIN/NPI.

Required Attestation

Tester verifies that the attestation includes all required elements.


Required Test 1 – ePrescribing

Medicare and Medicaid Promoting Interoperability Programs

MIPS Promoting Interoperability Performance Category

System Under Test Test Lab Verification

The health IT developer records and creates two 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 and Medicaid Promoting Interoperability Programs Measure:

  1. EP: More than 60 percent of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using certified electronic health record terminology (CEHRT).
  2. 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 and Medicaid 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.
  2. Inpatient:
    • Numerator: The number of prescriptions in the denominator generated, queried for a drug formulary, and transmitted electronically.

 

Medicare and Medicaid Promoting Interoperability Programs Measure Elements:

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

 

Merit-based Incentive Payment System (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 certified EHR technology.

 

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.

 

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

  1. Numerator: Prescription generated, queried for a formulary, and transmitted electronically.

The tester verifies that each report, including the numerator, is created correctly and without omission and includes 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. The tester will use the information provided in required Test 1 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.


Required Test 2a, b, or c – Provide Patients Electronic Access to Their Health Information (formerly Patient Electronic Access)

Medicare and Medicaid Promoting Interoperability Programs

MIPS Promoting Interoperability Performance Category

System Under Test Test Lab Verification

The health IT developer records and creates two 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 and Medicaid Promoting Interoperability Programs: 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 EH 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), (g)(9) or (g)(10) must use test data in tab RT 2c Provider Patient Exchange (EH/CAH and EP/EC) and will only be tested for the Medicare and Medicaid Promoting Interoperability Programs and Promoting Interoperability performance Category measures.

 

Measure Description

 

Medicare and Medicaid Promoting Interoperability Programs Measure:

  1. Medicaid 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 his or her choice that is configured to meet the technical specifications of the API in the provider’s CEHRT.
  2. Medicaid EH/CAH: For more than 80 percent of all unique patients discharged from the EH 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.
  3. Medicare EH/CAH: For at least one unique patient discharged from the EH 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 and Medicaid Promoting Interoperability Programs English Statements:

  1. Ambulatory:
    • 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 meet the technical specifications of the API in the provider's CEHRT.
  2. Inpatient:
    • 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 meet the technical specifications of the API in the provider's CEHRT.

 

Medicare and Medicaid Promoting Interoperability Programs Measure Elements:

  1. Ambulatory:
    • Numerator:
      • Date and time information available to the EP;
      • Date and time information made available online to the patient;
      • Date and time information made available to an API.
  2. Inpatient:
    • Numerator:
      • Date and time information made available online to the patient;
      • Date and time of discharge;
      • Date and time information made available to an API.

 

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 CEHRT.

 

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 the patient;
    • Date and time information made available to an API.

The tester verifies that each report, including the numerator, is created correctly and without omission and includes 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. The tester will use the information provided in required Test 2a, 2b, or 2c and use ONC Test Data Scenario(s) 1, 2, 3, and 4. The tester verifies that all of the required information below is made available to patients.

 

  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

Medicaid Promoting Interoperability Program

System Under Test Test Lab Verification

The health IT developer records and creates two 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. 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

 

Medicaid Promoting Interoperability Program Measure:

  1. Medicaid EP: 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. Medicaid EH/CAH: The EH 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 35 percent of unique patients discharged from the EH or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

 

Medicaid Promoting Interoperability Program 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.

 

Medicaid Promoting Interoperability Program Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Provision of electronic access to patient specific education resource(s) identified by the CEHRT.

The tester verifies that each report, including the numerator, is created correctly and without omission and includes 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. The tester will use the information provided in required Test 3 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.


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

Medicaid Promoting Interoperability Program

System Under Test Test Lab Verification

The health IT developer records and creates four 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. For the Health IT Module to record the numerator, the patient must view, download, or transmit his or her 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), (g)(9) or (g)(10) 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), (g)(9), or (g)(10) must use test data in tab RT 4c VDT, and will only be tested for the Medicaid Promoting Interoperability Program measure.

 

Measure Description

 

Medicaid Promoting Interoperability Program Measure:

  1. Medicaid 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 (EHR) 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. Medicaid EH/CAH: More than 10 percent of all unique patients (or their authorized representatives) discharged from the EH or CAH inpatient or emergency department (POS 21 or 23) actively engage with the EHR 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).

 

Medicaid Promoting Interoperability Program 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.
  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.

 

 Medicaid Promoting Interoperability Program Measure Elements:

  1. Ambulatory:
    • Numerator:
      • Patient (or patient-authorized representative) views, downloads, or transmits the patient’s information;
      • Patient (or patient-authorized representative) accesses the patient’s information via API.
  1. Inpatient:
    • Numerator:
      • Patient (or patient-authorized representative) views, downloads, or transmits the patient’s information;
      • Patient (or patient-authorized representative) accesses the patient’s information via API.

The tester verifies that each report, including the numerator, is created correctly and without omission and includes 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. The tester will use the information provided in required Test 4a, 4b, or 4c and use ONC Test Data Scenario(s) 1, 2, 3, and 4.

 

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

 

  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

Medicaid Promoting Interoperability Program

System Under Test Test Lab Verification

The health IT developer records and creates four 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 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

 

Medicaid Promoting Interoperability Program Measure:

  1. Medicaid 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 his or her authorized representative.
  2. Medicaid EH/CAH: More than 25 percent of all unique patients discharged from the EH 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 his or her authorized representative.  

 

Medicaid Promoting Interoperability Program 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.

 

Medicaid Promoting Interoperability Program 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.

The tester verifies that each report, including the numerator, is created correctly and without omission and includes 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. The tester will use the information provided in required Test 5 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.


Required Test 6 – Patient Generated Health Data

Stage 3 Objective 6 Measure 3

Promoting Interoperability Objective 4 Measure 3

System Under Test Test Lab Verification

The health IT developer records and creates four 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 patient generated data, or data from a non-clinical setting are incorporated during the reporting/performance period.

 

Measure Description

 

Medicaid Promoting Interoperability Program Measure:

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

 

Medicaid Promoting Interoperability Program 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.

 

Medicaid Promoting Interoperability Program 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.

The tester verifies that each report, including the numerator, 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. The tester will use the information provided in required Test 6 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.


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

Medicare and Medicaid Promoting Interoperability Programs

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

System Under Test Test Lab Verification

The health IT developer records and creates four 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 and Medicaid Promoting Interoperability Programs Measure:

  1. Medicaid EP: For more than 50 percent of transitions of care and referrals, the EP who transitions or refers his or her 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. Medicaid EH/CAH: For more than 50 percent of transitions of care and referrals, the EH or CAH that transitions or refers its 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.
  3. Medicare EH/CAH: For at least one transition of care or referral the EH or CAH that transitions or refers its 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 and Medicaid 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.

 

Medicare and Medicaid Promoting Interoperability Programs Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator:
      • Summary of care record created and exchanged;
      • Summary of care record receipt confirmed.

 

MIPS Promoting Interoperability Performance Category Measure:

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

 

MIPS Promoting Interoperability Performance Category English Statements:

  1. 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.

 

MIPS Promoting Interoperability Performance Category Measure Elements:

  1. Numerator:
    • Summary of care record created and exchanged;
    • Summary of care record receipt confirmed.

The tester verifies that each report, including the numerator, 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. The tester will use the information provided in required Test 7 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.

 

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 and inpatient settings:

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

Required Test 8 Receive and Incorporate

Medicaid Promoting Interoperability Program

System Under Test Test Lab Verification

The health IT developer records and creates four 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 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

 

Medicaid Promoting Interoperability Program Measure:

  1. Medicaid 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. Medicaid EH/CAH: For more than 40 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EH or CAH incorporates into the patient's EHR an electronic summary of care document.

 

Medicaid Promoting Interoperability Program Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: 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 CEHRT.

 

Medicaid Promoting Interoperability Program Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Summary of care record
      • Requested and available;
      • Received through query or request;
      • Incorporated into the record.

The tester verifies that each report, including the numerator, 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. The tester will use the information provided in required Test 8 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.


Required Test 9 – Medication/Clinical Information Reconciliation

Medicaid Promoting Interoperability Program

System Under Test Test Lab Verification

The health IT developer records and creates four 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. 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

 

Medicaid Promoting Interoperability Program Measure:

  1. Medicaid 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. Medicaid EH/CAH: For more than 80 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.

 

Medicaid Promoting Interoperability Program 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.
  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.

 

Medicaid Promoting Interoperability Program Measure Elements:

  1. Ambulatory:
    • Numerator: Indication that medication, medication allergy, and problem list reconciliation occurred.
  2. Inpatient:
    • Numerator: Indication that medication, medication allergy, and problem list reconciliation occurred.

The tester verifies that each report, including the numerator, 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. The tester will use the information provided in required Test 9 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.


Required Test 10 – Computerized Provider Order Entry (CPOE) Medications

Medicaid Promoting Interoperability Program

System Under Test Test Lab Verification

The health IT developer records and creates four 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 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 participate in both the Medicaid and Medicare Promoting Interoperability Programs or just the Medicare Promoting Interoperability Program are exempt from this measure. 

 

Measure Description

 

Medicaid Promoting Interoperability Program Measure:

  1. Medicaid EP/EH/CAH: More than 60 percent of medication orders created by the EP or authorized providers of the EH or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE.

 

Medicaid Promoting Interoperability Program Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of medication orders recorded using CPOE.

 

Medicaid Promoting Interoperability Program Measure Elements:

  1. Ambulatory/Inpatient:
  2. Numerator: Medication order recorded using CPOE.

The tester verifies that each report, including the numerator, is created correctly and without omission and includes 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. The tester will use the information provided in required Test 10 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.


Required Test 11 – Computerized Provider Order Entry (CPOE) Laboratory

Medicaid Promoting Interoperability Program

System Under Test Test Lab Verification

The health IT developer records and creates four 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 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 participate in both the Medicaid and Medicare Promoting Interoperability Programs or just the Medicare Promoting Interoperability Program are exempt from this measure. 

 

Measure Description

 

Medicaid Promoting Interoperability Program Measure:

  1. Medicaid EP/EH/CAH: More than 60 percent of laboratory orders created by the EP or authorized providers of the EH or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE.

 

Medicaid Promoting Interoperability Program Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of laboratory orders recorded using CPOE.

 

Medicaid Promoting Interoperability Program Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Laboratory order recorded using CPOE.

The tester verifies that each report, including the numerator, is created correctly and without omission and includes 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. The tester will use the information provided in required Test 11 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.


Required Test 12 – Computerized Provider Order Entry (CPOE) Radiology/Diagnostic Imaging

Medicaid Promoting Interoperability Program

System Under Test Test Lab Verification

The health IT developer records and creates four 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 Diagnostic Imaging 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 participate in both the Medicaid and Medicare Promoting Interoperability Programs or just the Medicare Promoting Interoperability Program are exempt from this measure. 

 

Measure Description

 

Medicaid Promoting Interoperability Program Measure:

  1. EP/EH/CAH: More than 60 percent of diagnostic imaging orders created by the EP or authorized providers of the EH or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE.

 

Medicaid Promoting Interoperability Program Measure English Statements:

  1. Ambulatory/Inpatient:
    • Numerator: The number of diagnostic imaging orders recorded using CPOE.

 

Medicaid Promoting Interoperability Program Measure Elements:

  1. Ambulatory/Inpatient:
    • Numerator: Diagnostic imaging order recorded using CPOE.

The tester verifies that each report, including the numerator, is created correctly and without omission and includes 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. The tester will use the information provided in required Test 12 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.


Required Test 14 – Verify Opioid Treatment Agreement

Medicare Promoting Interoperability Program

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

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.

 

 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.

 

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 EHR 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.

 

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.

 

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


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

Medicare Promoting Interoperability Program

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

System Under Test Test Lab Verification

The health IT developer records and creates four 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. 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.

 

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.

 

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 EC 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.

 

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, medications allergy, and current problem list occurred.

The tester verifies that each report, including the numerator, 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. The tester will use the information provided in required Test 15 and use ONC Test Data Scenario(s) 1, 2, 3, and 4.

 


Version 2.3 Updated on 06-15-2020
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 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. 

11-17-2017
1.3

Removed bullet point related to testing when systems are an ambulatory systems only or an inpatient systems only.

01-11-2017
1.4

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.   

04-24-2017
1.5

Added clarification for patient education materials, MU3 Objective 5 Measure 2 numerator eligibility.

05-26-2017
1.6

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

08-25-2017
1.7

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
1.8

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
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 PFS 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 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
Regulation Text
Regulation Text

§170.315 (g)(1) Automated numerator recording

For each Promoting Interoperability Programs percentage-based measure, technology must be able to create a report or file that enables a user to review the patients or actions that would make the patient or action eligible to be included in the measure's numerator. The information in the report or file created must be of sufficient detail such that it enables a user to match those patients or actions to meet the measure's denominator limitations when necessary to generate an accurate percentage.

Standard(s) Referenced

None

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

See the file "§170.315(g)(1) EH/CAH" below under the Attachments section.  Last updated on 06-15-2020.

Test Data Set 2 – EP/EC

See the file "§170.315(g)(1) EP/EC" below under the Attachments section.  Last updated on 06-15-2020.

Certification Companion Guide: Automated numerator recording

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)(1). 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 must be able to create a report or file to review patients or actions that would make the patient or action eligible to be included in a Promoting Interoperability Programs percentage-based measure’s numerator. The user must be able to use the information in the report or file to match those patients or actions to meet the measure’s denominator limitations.

Clarifications:

  • There is no standard required for this certification criterion.
  • The gap certification eligibility of this criterion at § 170.315(g)(1) depends on any modifications to the certification criteria to which this criterion applies and relevant Medicare and Medicaid Promoting Interoperability Programs 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 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 Stage 2 measures are no longer applicable for the 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 Medicaid Promoting Interoperability Program measures are eligible for gap certification: 1) Required Test 10 – CPOE Medications; 2) Required Test 11 – CPOE Laboratory ; and 3) Required Test 11 – CPOE Radiology/Diagnostic Imaging .
  • The test for (g)(1) 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 each Required Test, as well as what the tester must verify within each report.
  • 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.
    • 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.
  • The test data used for this criterion is supplied by ONC and is organized into 4 Test Data scenarios, with a single set of 8 Test Cases. Health IT developers are required to use the ONC-supplied test data and may not modify the test case names.
  • 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.
  • The Medicare and Medicaid 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 (EP) or 36 hours (EH/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 4 business days (EC). 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. 
  • The Support Electronic Referral Loops by Sending Health Information measure for the Medicare and Medicaid Promoting Interoperability Programs, and the MIPS Promoting Interoperability performance category 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.
  • EH/CAH/EP Medicaid Promoting Interoperability Program patient education measure requires that patient educational material identified by the patient rather than the provider do not qualify for inclusion in the numerator. 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 FAQs that provide additional guidance on the new Medicare Promoting Interoperability Program opioid measures for EHs 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 Promoting Interoperability performance category of MIPS. 
  • CMS has issued FAQs that provide additional guidance on the new Medicare Promoting Interoperability Program measure for EHs in 2019: Support Electronic Referral Loops by Receiving and Incorporating Health Information measure. The FAQs also apply in 2019 for the Support Electronic Referral Loops by Receiving and Incorporating Health Information measure in the Promoting Interoperability performance category of MIPS. 

Content last reviewed on June 23, 2020
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