(a) ASM performance year for the Promoting Interoperability ASM performance category. Beginning with the 2029 ASM payment year, the ASM performance year for Promoting Interoperability measures is the minimum of a continuous 180-day period within the calendar year that occurs 2 years prior to the applicable ASM payment year, up to and including the full calendar year.
(b) Reporting for the Promoting Interoperability ASM performance category. To earn an ASM performance category score greater than zero for the Promoting Interoperability ASM performance category for inclusion in the final score, an ASM participant must be a meaningful EHR user and meet the following criteria:
(1) CEHRT. Use CEHRT as defined at § 414.1305 for the ASM performance year.
(2) ASM Promoting Interoperability objectives and measures. Report on the following MIPS Promoting Interoperability measures, as specified by CMS through rulemaking:
(i) An ASM Participant must report both of the following measures or claim an exclusion or exclusions to fulfill the e-Prescribing objective:
(A) e-Prescribing (Measure ID #: PI_EP_1).
(B) Query of PDMP (Measure ID # PI_EP_2).
(ii) An ASM Participant must fulfill the Health Information Exchange objective through one of the following three options:
(A) Report the Support Electronic Referral Loops by Sending Health Information (Measure ID # PI_HIE_1) and Support Electronic Referral Loops by Receiving and Reconciling Health Information (Measure ID # PI_HIE_4).
(B) Health Information Exchange (HIE) Bi-Directional Exchange (Measure ID # PI_HIE_5).
(C) Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA) (Measure ID # PI_HIE_6).
(iii) An ASM Participant must fulfill the Provider to Patient Exchange objective by reporting the Provide Patients Electronic Access to Their Health Information measure (Measure ID # PI_PEA_1).
(iv) An ASM Participant must fulfill the Public Health and Clinical Data Exchange objective by reporting both measures:
(A) Immunization Registry Reporting (Measure ID # PI_PHCDDR_1).
(B) Electronic Case Reporting (Measure ID PI_PHCDRR_3).
(3) Reporting ASM Promoting Interoperability objectives and measures. Comply with the following reporting requirements:
(i) For each measure under paragraph (b)(2) of this section, report—
(A) The numerator (of at least one) and denominator;
(B) Yes/no statement; or
(C) An exclusion that includes an option for the exclusion.
(ii) Report that the ASM participant completed the actions included in the MIPS Promoting Interoperability Security Risk Analysis measure (Measure ID # PI_PPHI_1) within the calendar year of the ASM performance year.
(iii) Submit an affirmative attestation regarding the ASM participant's completion of the annual self-assessment checklist under the MIPS Promoting Interoperability High Priority Practices Guide of the SAFER Guides measure (Measure ID # PI_PPHI_2) within the calendar year of the ASM performance year.
(4) Supporting use of CEHRT. ASM participants must support the use of CEHRT by fulfilling the following requirements:
(i) Supporting the use and performance of CEHRT. To fulfill ASM requirements to engage in activities related to supporting clinicians with the performance of CEHRT, the ASM participant:
(A) Must attest by providing all of the following:
(1) Acknowledgement of the requirement to cooperate in good faith with ONC direct review of the ASM participant's health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received.
(2) If requested, cooperation in good faith with ONC direct review of the ASM participant's health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that the technology meets, or can be used to meet, the definition of CEHRT, including by permitting timely access to the technology and demonstrating its capabilities as implemented and used by the ASM participant in the field.
(B) May attest to the following objectives and measures:
(1) Acknowledgement of the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received.
(2) If requested, cooperation in good faith with ONC-ACB surveillance of the ASM participant's health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that the technology meet, or can be used to meet, the definition of CEHRT, including by permitting timely access to the technology and demonstrating its capabilities as implemented and used by the ASM participant in the field.
(ii) Actions to limit or restrict the compatibility or interoperability of CEHRT. To fulfill ASM requirements for activities related to limiting or restricting the compatibility or interoperability of CEHRT, the ASM participant must not knowingly and willfully take action, such as to disabling functionality, to limit or restrict the compatibility or interoperability of CEHRT.
(c) Scoring the Promoting Interoperability ASM performance category—(1) ASM measure achievement points.
(i) An ASM participant earns a score for each measure by fulfilling the reporting requirements specified at paragraph (b) of this section. Score amounts are set forth in the MIPS measure specifications.
(ii) If an exclusion is reported for a measure, the points available for that measure are redistributed to another measure as set forth in the MIPS measure specifications.
(2) Promoting Interoperability ASM performance category score. Unless otherwise specified by CMS, CMS sums the scores for each of the required measures and divides this sum by the total number of available Promoting Interoperability points. The Promoting Interoperability ASM performance category score cannot exceed 100 percent.