2023 Promoting Interoperability Requirements

The Promoting Interoperability (PI) Program originally was known as the Meaningful Use program and began in 2009. The program was initiated to get hospitals up and running with their Electronic Health Record (EHR) systems. Hospitals could receive incentive money for successfully proving (attesting) that they were using their EHR in a meaningful way. In 2018, the program got a name change and an overhaul. Now, there is no incentive money to earn, but there is a penalty if you don't complete your requirements.

On that note, let's dive right in and review your 2023 Promoting Interoperability requirements.

Summary of changes to the PI requirements

Below is a summary of the major changes to PI requirements for the 2023 reporting year.

• Your overall attestation points score will be publicly reported on Care Compare for the first time. Your eCQM performance (which is already public) will be reported on Care Compare as well.
• You are required to submit the Query of Prescription Drug Monitoring Program (PDMP) measure. It used to be optional.
• In the Public Health and Clinical Data Exchange objective you are required to submit the level of active engagement you have. There are two levels to choose from. There is also a new measure in this objective.
• There is a new measure available in the Health Information Exchange Objective which is an alternative to the 3 measures currently available. (TEFCA)
• The same new eCQMs added to the IQR program are added to this program as well. (PC-02 Caesarean birth and PC-07 Severe Obstetric Complications)

2023 PI Requirements Summary

THESE ARE YOUR MANDATORY REQUIREMENTS:

1. Report on the measures within the four objectives (categories) and score a minimum of 60 points. 
   1. Electronic Prescribing
   2. Health Information Exchange
   3. Provider to Patient Exchange
   4. Public Health and Clinical Data Exchange
2. Attest (yes/no) to the following 2 measures within the Protect Patient Information objective.
   1. Security Risk Analysis measure
   2. Safety Assurance Factors for EHR Resilience (SAFER) Guides measure
   3. Complete the actions to limit or restrict the compatibility or interoperability of CEHRT attestation.
      
3. Successfully submit 4 eCQMs for 4 quarters of data. 
   1. 3 self-selected eCQMs and the Safe Use of Opioids eCQM (eOPI-1).

Additionally, all hospitals and Critical Access Hospitals are required to use CEHRT that has been updated to meet 2015 Edition Cures Update criteria.

Measure Reporting Requirements

There are four categories of measures you must submit in the PI program. CMS calls these objectives. You must report certain measures within each category (outlined below). Based on what you submit for these measures you will be awarded points. You must score a minimum of 60 points to satisfy your PI requirements.

ELECTRONIC PRESCRIBING (EPRESCRIBING) CATEGORY

Requirement: You must report 2 measures in this category (possible 20 points).

ePrescribing

Measure Description:  For at least one hospital discharge, medication orders for permissible prescriptions are transmitted electronically using CEHRT.

Denominator:  The number of new or changed prescriptions written for drugs requiring a prescription for patients discharged during the reporting period.(Does not include controlled substances.)

Numerator:  The number of prescriptions in the denominator generated and transmitted electronically.

Exclusion: If you do not have an internal pharmacy that can accept electronic prescriptions and no pharmacies accepting electronic prescriptions within 10 miles at the start of the reporting period.

Reporting Period: Any continuous 90-day period within the calendar year.

Scoring:

• Maximum Points:  10
• Failure to report at least “1” for all required measures with a numerator will result in 0 points for the Medicare Promoting Interoperability Program.
• If you claim an exclusion the 10 points will be redistributed among the Health Information Exchange category measures.

Query PDMP (Prescription Drug Monitoring Program)

Measure Description:  For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed during the reporting period, you must use data from CEHRT to conduct a query of a PDMP for prescription drug history.

Exclusions:

1. Hospital with no internal pharmacy that can accept electronic prescriptions for controlled substances and is not located within 10 miles of any pharmacy that accepts electronic prescriptions for controlled substances; OR
2. Any hospital that could not report on this measure in accordance with applicable law; OR
3. Any hospital for which querying a PDMP would impose an excessive workflow or cost burden prior to start of the reporting period.

Reporting Period: Any continuous 90-day period within the calendar year.

Scoring:

• Maximum Points:  10
• Must attest "yes" or "no" to meeting the measure as described above.
• If you claim an exclusion 10 points will be redistributed to the ePrescribing measure.

Health Information Exchange CATEGORY

Requirement: Hospitals now have 3 reporting options to meet this objective.

Option 1: Report these two measures

MEASURE 1: Support Electronic Referral Loops by Sending Health Information 

Measure Description: For at least one transition of care or referral, (e.g. you transition or refer your patient to another setting of care or provider of care) you must (1) create a summary of care record using CEHRT; and (2) electronically exchanges the summary of care record.

Denominator:  The number of transitions of care and referrals during the reporting period for which the hospital or Emergency Department (ED) was the transitioning or referring provider.

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.

Exclusion: None

Reporting Period: Any continuous 90-day period within the calendar year.

Scoring:

• Maximum points: 15

MEASURE 2: Support Electronic Referral Loops by Receiving and Reconciling Health Information

Measure Description: For at least one electronic summary of care record received using CEHRT for patient encounters during the reporting period for which your hospital was the receiving party of a transition of care or referral.

OR for patient encounters for which you have never before encountered the patient, you conducted clinical information reconciliation for medication, medication allergy, and current problem list using CEHRT.

Denominator:  The number of electronic summary of care records received using CEHRT for patient encounters during the reporting period in which your hospital has never before encountered the patient.

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 mediation; (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.

Exclusion: None

Reporting Period: Any continuous 90-day period within the calendar year.

Scoring:

• Maximum points: 15

Option 2: Report the HIE Bi-Directional Exchange measure

Measure Description: You must attest that you engage in bi-directional exchange with a Health Information Exchange (HIE) to support transitions of care. You are attesting to the following statements: 

1. You participate in an HIE to enable secure, bi-directional exchange of information to occur for all unique patients admitted to or discharged from the hospital inpatient or emergency department, and all unique patient records stored or maintained in the EHR for these departments, during the EHR reporting period are in accordance with applicable law and policy.
2. You participate in an HIE that is capable of exchanging information across a broad network of unaffiliated exchange partners including those using disparate EHRs, and are not engaging in exclusionary behavior when determining exchange partners.
3. You are using the functions of CEHRT to support bi-directional exchange with an HIE.

Exclusion: None

Reporting Period: Any continuous 90-day period within the calendar year.

Scoring: 

• Maximum points: 30

Option 3: Report the Enabling Exchange under the Trusted Exchange Framework and Common Agreement (TEFCA) measure

Measure Description: Read more about TEFCA here. You are attesting to the following statements: 

1. You participate as a signatory to a Framework Agreement (in good standing, that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for all unique patients discharged from your hospital or emergency department, and all unique patient records stored or maintained in the EHR for these departments.
2. You participate in an HIE that is capable of exchanging information across a broad network of unaffiliated exchange partners including those using disparate EHRs, and are not engaging in exclusionary behavior when determining exchange partners.
3. You are using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.

Exclusion: None

Reporting Period: Any continuous 90-day period within the calendar year.

Scoring: 

• Maximum points: 30

Provider to Patient Exchange CATEGORY

Requirement: You must report 1 measure in this category (possible 25 points).

Provide Patients Electronic Access to Their Health Information

Measure Description:  For at least one patient discharged from your hospital or ED:

1. The patient (or patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; AND
2. Your hospital ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice.

Denominator: The number of unique patients discharged from your hospital or ED during the reporting period.

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.

Exclusion: None.

Reporting Period: Any continuous 90-day period within the calendar year.

Scoring:

• Maximum Points:  25
• Failure to report at least “1” for all required measures with a numerator will result in
  0 points.

Public Health and Clinical Data Exchange CATEGORY

Requirement: Report on all four measures under the Public Health and Clinical Data Exchange objective.

Measure 1: Immunization Registry Reporting

Measure Description: Your hospital is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system.

Exclusions: 

1. Your hospital does not administer any immunizations to any of the populations for which data is collected by their jurisdiction’s immunization registry during the reporting period; AND/OR
2. Your hospital operates in a jurisdiction for which no immunization registry is capable of accepting the specific standards required to meet the CEHRT definition at the start of the reporting period; AND/OR
3. Your hospital operates in a jurisdiction where no immunization registry has declared readiness to receive immunization data as of six months prior to the start of the reporting period.

Measure 2: Syndromic Surveillance Reporting

Measure Description: Your hospital is in active engagement with a public health agency to submit syndromic surveillance data from an ED. 

Exclusions: 

1. Your hospital does not have an ED; AND/OR
2. Your hospital operates in a jurisdiction for which no public health agency is capable of accepting the syndromic surveillance data to the specific standards required to meet the CEHRT definition at the start of the reporting period; AND/OR
3. Your hospital operates in a jurisdiction where no no public health agency has declared readiness to receive syndromic surveillance data as of six months prior to the start of the reporting period.

Measure 3: Electronic Case Reporting

Measure Description: Your hospital is in active engagement with a public health agency to submit case reporting of reportable conditions.

Exclusions: 

1. Your hospital does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the reporting period; AND/OR
2. Your hospital operates in a jurisdiction for which no public health agency is capable of accepting the case reporting data to the specific standards required to meet the CEHRT definition at the start of the reporting period; AND/OR
3. Your hospital operates in a jurisdiction where no no public health agency has declared readiness to receive case reporting data as of six months prior to the start of the reporting period.

Measure 4: Electronic Reportable Laboratory (ELR) Result Reporting

Measure Description: Your hospital is in active engagement with a public health agency to submit ELR results.

Exclusions: 

1. Your hospital does not perform or order laboratory tests that are reportable in their jurisdiction during the reporting period; AND/OR
2. Your hospital operates in a jurisdiction for which no public health agency is capable of accepting the specific ELR standards required to meet the CEHRT definition at the start of the reporting period; AND/OR
3. Your hospital operates in a jurisdiction where no no public health agency has declared readiness to receive ELR results from a hospital as of six months prior to the start of the reporting period.

Reporting Period: Any continuous 90-day period within the calendar year.

Scoring:

• Maximum Points:  25
• You must attest "yes" to being in an active engagement for each measure.
• You must also submit your level of active engagement for each measure.

• If your hospital can claim an exclusion for three or fewer of the four required measures, you’ll receive the full 25 points if you report “yes” for one or more of the measures and claim applicable exclusions on the remaining measures. If you claim exclusions for all four required measures, the 25 points will be redistributed to the Provide Patients Electronic Access to their Health Information measure.

Bonus Measures

Bonus Measure: Public Health Registry Reporting

Measure description: Your hospital is in active engagement with a public health agency to submit data to public health registries.

Bonus Measure: Clinical Data Registry Reporting

Measure description: Your hospital is in active engagement with a public health agency to submit data to a clinical data registry.

Maximum points: 5 bonus points (for reporting on one of the two bonus measures).

Other Program Requirements (no points awarded)

SUBMIT YOUR ECQM PERFORMANCE DATA

Requirements:

• You must submit 4 eCQMs with 4 quarters of data. One of the eCQMs must be the Safe Use of Opioids eCQM (eOPI-1). If you participate in the IQR program and submit your eCQMs for that program, you do not need to submit them again.

You must complete SECURITY RISK ANALYSIS

Requirement:

• You must conduct an annual security risk assessment and attest that it has been completed.

You must Complete the actions to limit or restrict the compatibility or interoperability of CEHRT attestation

You MUST attest to using (or not using) all 9 SAFER Guides

The Safety Assurance Factors for EHR Resilience (SAFER) Guides were designed to help you optimize the safety and safe use of your EHRs. Your hospital must complete an assessment of all 9 SAFER Guides:

• High Priority Practices
• Organizational Responsibilities
• Contingency Planning
• System Configuration
• System Interfaces
• Patient Identification
• Computerized Provider Order Entry with Decision Support
• Test Results Reporting and Follow-up
• Clinician Communication

The good news is that, at this point, CMS is only tracking if hospitals are using the Guides. So, you can attest ‘Yes’ or ‘No’ without getting a penalty. If you’re new to the concept of SAFER Guides, we’ve created a detailed primer to help you understand each Guide and how to use them.

DON’T WORRY: YOU’VE GOT THIS (AND US)

As a Medisolv client, your Clinical Quality Advisors are always on hand to help you translate CMS-speak into real, manageable steps you can take to make sure you’re not only meeting your Promoting Interoperability requirements but also achieving the requirements’ ultimate goal: better patient care through the power of more accessible data.

If you aren't a client, contact us now to schedule a time to chat, or check out our other resource guides for more info:

• 2023 Hospital IQR Program Requirements

• What is TEFCA?

• What is Health Information Bi-Directional Exchange?
• Understanding SAFER Guides & 2022 PI Requirements (For Hospitals)