Promoting Interoperability

How Do I Meet the Requirements?

To meet the requirements of the PI category, an EHR is required.

• If you do not currently use an EHR, you will have to select, purchase, and implement an EHR. Be sure the product you select is certified. TMA has numerous resources to help practices with selection.
• If you currently use a certified EHR, check with your EHR vendor to ensure the product you use will be upgraded to meet the required metrics. As vendors upgrade, the product must be certified. The latest upgrade is to the 2015 certification criteria. View the list of certified products here.

2022 PI Objectives and Measures

For 2022, eligible clinicians must use technology certified to the 2015 Edition (2015 CEHRT).

Participants must submit collected data for certain measures from each of the 4 objectives measures (unless an exclusion is claimed) for 90 continuous days or more during 2022.

In addition to submitting measures, clinicians must:

• Submit a “yes” to the Prevention of Information Blocking Attestation,
• Submit a “yes” to the ONC Direct Review Attestation,
• Submit a "yes" to Safety Factors for EHR Resilience (SAFER) Guides, High Priority Practices, and
• Submit a “yes” for the security risk analysis measure

• 
  View the 2022 measures at-a-glance.

View Details on 2022 Objectives and Measures

The above link is to a CMS Zip file, so it may take longer to load than normal files.

Resources for Objectives and Measures

Use the following resources to meet the PI objectives and measures. 

E-prescribing

• TMA E-prescribing Resource Center
• Texas Prescription Monitoring Program (Online Registration) - Texas State Board of Pharmacy

• Texas PMP Requirements: Who, What, When, and How (TMA Webinar)

• Sample Opioid Treatment Agreement (Texas Pain Society)
  An informed consent and opioid treatment agreement is a contract between a doctor and a patient. The goal of the agreement is to ensure that patients who are taking opioid drugs do so exactly as their doctor has prescribed. This sample agreement can be used as a template for your practice. Once it is signed, be sure to incorporate it into the patient’s record in the EHR. Thank you to the Texas Pain Society for allowing TMA to link to the sample agreement.
  
  

Health Information Exchange

• TMA Health Information Exchange Resource Center
  
  

Provider to Patient Exchange

• Patients, Portals, and PHRs
  
  

Public Health and Clinical Data Exchange

• Immunization Registry Reporting (Immtrac)
• Public Health Registry Reporting (Texas Cancer Registry)
• Clinical Data Registry Reporting
  Check with your specialty society for clinical data registries applicable to your specialty.
• Syndromic Surveillance Reporting
  DSHS is only accepting syndromic surveillance reporting registrations from hospitals, and professionals in urgent care centers or free-standing emergency centers at this time.
  
  

Security Risk Analysis

• Security Risk Analysis Is Not a Do-It-Yourself Project (Texas Medicine, Aug. 2019)
• Free Security Risk Assessment Tool (HealthIT.gov)

How Is the PI Category Scored in 2022?

How PI Performance Points are Calculated

PI Scoring Example

Reporting Options

Notes: 

• Be sure to ask your EHR vendor about MIPS reporting options.
• You don’t have to use the same reporting mechanism for all MIPS categories. For example, you can report PI via attestation, but submit quality measures via a qualified registry. 
• When using the Group Reporting option, you must use the same identifier for all reporting methods. For example, you cannot individually report PI and then group report quality measures.

Don't Forget About Audits

CMS could tap you for a MIPS audit in the future. Here are some things to know to prepare your practice.

• Document everything (take screen shots)
• Maintain documentation for 6 years
• Maintain practice email addresses for notification
  
  

Yes, You Do Have to Comply With a MIPS Audit Request Texas Medicine Today, Aug. 14, 2019

Audit Readiness – What You Need to Know (TMF Quality Innovation Network)

Learn More About Audit Documentation

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MIPS Participation Drops per Preliminary Report Texas Medicine Today, Feb. 9, 2022

Medicare’s Quality Payment Program Won’t Support Internet Explorer 11 Texas Medicine Today, Sept. 29, 2021

MIPSperceptions: Study Confirms Doctors’ View of Medicare Program as Burdensome Texas Medicine, June 2021

Do Your Security Risk Assessment Before Dec. 31 Texas Medicine Today, Dec.3, 2020 

A Social Shift: COVID-19 Disparities Prompt Emphasis on Value-Based Care Texas Medicine, Sept. 2020 

Going Nowhere: APM Committee Resignations Cast Doubt on Payment Models' Future Texas Medicine, April 2020 

An Unfair Game: Quality Payment Program Rules Still Stacked Against Physicians Texas Medicine, Jan. 1, 2020

AMA House Rejects MIPS Plan Texas Medicine Today, Nov. 20, 2019

More Pain for Small Shops? Texas Medicine, Oct. 1, 2019

Yes, You Do Have to Comply With a MIPS Audit Request Texas Medicine Today, Aug. 14, 2019

Be On the Lookout for MIPS Audit Request Texas Medicine Today, June 25, 2019

False Impression: Medicine Says Medicare Report Inflates Success of Quality Program Texas Medicine, June 2019

Making the CEHRT Switch: EHR Upgrade Required for Incentive Payment Programs Texas Medicine, Jan. 2019