The Revival of Promoting Interoperability

And I'll be taking care of business (every day)
Taking care of business (every way)
Takin’ Care of Business by Bachman – Turner Overdrive (Mercury Records, 1973)

I’m forgoing my usual newsletter ramblings so I can be taking care of business every day and every way with some pressing new business—the revival (for us) of Promoting Interoperability (PI). Anyone who was around before 2020 will remember that PI was a reporting category of the Merit-based Incentive Payment System (MIPS), the value-based program that arose from the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, (now called the Quality Payment Program (QPP)). Very simply put, Promoting Interoperability is CMS’ way to emphasize, encourage, and enforce the exchange of patient information using electronic health record technology. But we can’t entrust such a noble pursuit to just any old electronic health record technology, we have to use technology that meets government standards. Those standards come from the health IT certification criteria created by the Assistant Secretary for Technology Policy, which is part of the Office of the National Coordinator (ONC) for Health Information Technology. Fortunately for those of you who just can’t get enough acronyms, CMS uses yet another one for their certification standards for electronic health records: CEHRT (Certified Electronic Health Record Technology).

According to CMS, using CEHRT to exchange data has many benefits: it makes communicating patient information less burdensome; it improves patient access to their health information; it helps clinicians deliver safe, effective, patient-centered care; it offers patients and caregivers new ways to access electronic health information to manage and coordinate care; it facilitates the systemic collection, analysis, and interpretation of healthcare data; and it ultimately improves patient outcomes.

About now, some of you who were around before 2020 are questioning why the heck we need to go back to reporting PI after CNS freed us of that obligation. Part of the quid pro quo when we took on downside risk in MSSP in 2020 was foregoing the whole MIPS and PI reporting hassle. CMS’ only request was that we attest that 75 percent of our clinicians were utilizing CEHRT to gather and share patient information. Well, guess what, CMS decided to change the rules. MIPS clinicians were reporting the multiple measures for Promoting Interoperability, while we were just attesting “yes”, and gosh darn it, that just isn’t fair. So, in the interest of fair play (and promoting better care coordination), CMS implemented this PI change so all MSSP ACOs will be aligned with all the clinicians still stuck in MIPS.

For more background, the Promoting Interoperability measures focus on four main objectives: electronic prescribing (e-prescribing); health information exchange (HIE) with focus on the publicly sponsored health information exchanges; provider to patient information exchange; and exchange of information with public health agencies and clinical data registries. Within these objectives, there are five required measures to report, with the addition of five required attestations, and one bonus measure. Several of the required measures have exclusions and several measures have different options that fulfill the measure’s criteria. Under CMS’ new rules, unless your clinic qualifies for a measure exclusion or for a special status exclusion (and there are several), all MSSP clinics are required to report data for the PI category for the 2025 performance year. Although each clinic will be responsible for their own PI reporting, scoring will be done at the ACO level, with all clinic scores being weighted and averaged across the entire ACO. Therefore, all MSSP clinics will receive the same averaged PI score.

Before we get too deep into describing the measures, let’s look at the exclusions—the factors that get your clinic out of reporting for PI. CMS classifies these exclusions in two categories: special status exclusions and hardship exceptions. Within the QPP website, you will often see that CMS refers to these exclusions as qualifying clinicians for reweighting of PI, meaning PI will be scored at zero points and those PI points will be assigned to another MIPS category. MIPS has four categories that make up a MIPS score: Quality, Cost, Improvement Activities, and Promoting Interoperability. In MIPS world, reweighting makes sense because there are multiple categories available to receive the reweighted points. Just remember, PI is a MIPS thing; for ACOs in a MSSP advanced payment model, all of this reweighting talk becomes a moot point because we don’t have another category for point shifting. So if you’re lucky enough to get an exclusion from PI, don’t worry about the whole reweighting thing. However, you can still report PI even if you qualify for an exclusion. In the event that a clinic submits PI data despite qualifying for reweighting, CMS will calculate a score based on the submitted data, thereby overriding the reweighting. But if CMS determines that the PI data is inaccurate, unusable, or otherwise compromised due to circumstances outside of the control of the clinician, the data will be discarded and the reweighting will be upheld.

Special status exclusions

Key point: special status exclusions are provided automatically by CMS, based on data gleaned from Medicare claims during the performance year (total number of unique patients, dollar amount of claims, NPI/TIN billing combinations, site of service information, and provider type). They made a preliminary determination for a special status exclusion in December 2024, but the final determination for a special status exclusion won’t happen until December 2025. Special status exclusions include:

• Low volume threshold (less than 200 Medicare patients seen or less than $90,000 in Medicare claims)
• Small practice (less than 15 providers)
• Ambulatory Surgery Center (ASC) based (at least 75 percent of your Medicare claims come from ASC-based services)
• Hospital based (at least 75 percent of your Medicare claims come from hospital-based services)
• Non-patient facing (Radiology, Pathology, etc.)

Hardship exceptions

Hardship exceptions must be applied for using a CMS application form that is generally not available until late in the performance year. Exceptions are only provided after the application is reviewed and approved by CMS; they are not given automatically. These exceptions include:

• Lacking sufficient internet access and having insurmountable barriers that prevent the clinician from obtaining sufficient internet access
• Extreme and uncontrollable circumstances (natural disasters, pandemic, etc.) that caused CEHRT to be unavailable
• CEHRT was decertified. Your electronic health record platform was removed from the CMS’ certification list. The list of certified electronic health record platforms can be found on the Certified Health IT Product List
• No control over the availability of CEHRT.If fifty percent or more of your patient encounters occur in practice locations where you don’t have CEHRT and have no ability to obtain CEHRT.

Promoting Interoperability reporting preliminary steps

There are three ways to submit Promoting Interoperability performance data:

• Sign in to the Quality Payment Program (QPP) website (www.qpp.cms.gov) and manually attest and enter your data.
• Sign in to the QPP website and upload an electronic file with your data; or
• Direct data submission via an Application Programming Interface (API) with CMS.

CMS will also ask for your electronic health record’s identification code. This can be found on the Certified Health IT Product List

Promoting Interoperability measure data must be collected for at least a continuous 180-day performance period. July 4^thwould be a good day to keep in mind—because your data collection needs to start on July 5^th at the latest (which is a Saturday).

Lastly, you must decide at which level to report. CMS will accept Promoting Interoperability data from the individual provider level, and from the practice (group) level, including the option of creating a virtual group (CMS has an application for this) for PI reporting purposes.

Promoting Interoperability attestations

This is the group of questions that CMS will ask prior to reporting the rest of your Promoting Interoperability measures and you must answer “yes” to each question in order to move forward. There are no points associated with attesting to any of these, but they are required to complete the submission process.

High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides. To meet this measure, you must attest “yes” to conducting an annual self-assessment using the High Priority Practices Guide of the SAFER Guides (www.healthit.gov/topic/safety/safer-guides) during the 2025 performance period. There is no score for this attestation but it is required for PI reporting.

Security Risk Analysis. To meet this measure, you must attest “yes” to conducting or reviewing a security risk analysis, including addressing the security (including encryption) of protected health information, implementing security updates as necessary, and correcting any identified security deficiencies as part of a risk management process. There is no score for this attestation but it is required for PI reporting.

Support for health information exchange and the prevention of information blocking. To meet this measure, you must attest “yes” that you did not knowingly or willfully act (such as disabling electronic health record functionality) to limit or restrict the compatibility or interoperability of certified electronic health record technology. There is no score for this attestation but it is required for PI reporting.

ONC Direct Review Attestation. To meet this measure, an attestation statement must be made by a Certified Health IT developer confirming that they have not knowingly taken actions to limit or restrict the interoperability of their health IT system, and that they would cooperate with the Office of the National Coordinator (ONC) if they were subject to a direct review to assess their compliance with interoperability standards. Essentially, this is a declaration from your electronic health record vendor that they are committed to promoting data exchange and are open to further scrutiny by ONC if needed. There is no score for this attestation but it is required for PI reporting.

ONC-Authorized Certification Bodies (ACB) Surveillance Attestation. To meet this measure, your electronic health record vendor attests that they have gone through the ACB surveillance process and their product continues to meet certification requirements. There is no score for this attestation but it is required for PI reporting.

e-Prescribing

This section is a two-part measure, with the first part a numerator-denominator report that measures the prescriptions generated and transmitted electronically through CEHRT. The second part is an attestation for querying the Prescription Drug Monitoring Program (PDMP) prior to prescribing controlled substances.

e-Prescribing. You are excluded from this measure if there were less than 100 prescriptions written during the performance period. This part of the measure is worth between 1 – 10 points, depending on the numerator – denominator scoring. Here are the requirements for this measure:

• Prescriptions must be electronically transmitted to a pharmacy by CEHRT
• Numerator: Number of prescriptions generated and transmitted electronically using CEHRT during the performance period.
• Denominator: Total number of prescriptions written during the performance period (includes only drugs that require a prescription in order to be dispensed, meaning over-the-counter drugs are not included). The instances where patients specifically request a paper prescription may not be excluded from the denominator of this measure.
• The inclusion of controlled substances prescribing in the numerator of this report is optional. If controlled substances prescriptions are included, the reporting must be done uniformly across all patients and across all allowable drug schedules for the duration of the 180-day performance period.

Query of Prescription Drug Monitoring Program (PDMP).  If you are unable to electronically prescribe any Schedule II, Schedule III, or Schedule IV drugs, you are excluded from this measure. This measure is worth 10 points. To meet this measure, you must attest “yes” to conducting a query of the PDMP at least once prior to electronically prescribing a Schedule II, Schedule III, or Schedule IV drug .

Health Information Exchange

This section contains three reporting options, you may select only one of three options to report on. There are exclusions for Option 1, but no exclusions for Option 2 or Option 3. Each option is worth 30 points.

Health Information Exchange: Option 1, Support electronic referral loops. Option 1 is a two-part numerator-denominator reporting measure. You are excluded from this measure if you had less than 100 patients transferred or referred from your clinic. Each part of this measure is worth between 1 – 15 points, depending on the numerator – denominator scoring.

• Option 1, part 1
  • Support electronic referral loops by sending patient health information
  • Numerator: The number of transitions of care or referrals where a summary of care record was created using CEHRT and exchanged electronically
  • Denominator: Total number of transitions of care or referrals during the performance period for which you were the transferring or referring clinic.
  • Information that must be included in the summary of care:
    • Current problem list.
    • Current medication list.
    • Current medication allergy list.
    • Other allergies – where the patient has an exaggerated immune response or reaction to environmental or food substances that are generally not harmful.
  • Part 1 of this option is worth 1 – 15 points, depending on numerator – denominator scoring.
• Option 1, part 2
  • Support electronic referral loops by receiving and reconciling patient health information. This Includes all electronic summaries of care received by the clinic. The reconciliation requirements can be performed by the provider or clinic support staff.
    • Numerator: The number of electronic summary of care records for which clinical information reconciliation is completed. Three sets of clinical information must be reconciled:
    • Medication – Review of the patient's medication, including the name, dosage, frequency, and route of each medication.
    • Medication allergy – Review of the patient's known medication allergies; and
    • Current Problem List – Review of the patient’s current and active diagnoses.
    • Denominator: Total number of electronic summary of care records received for patients during the performance period.
• Part 2 of this option is worth 1 – 15 points, depending on numerator – denominator scoring.

Health Information Exchange: Option 2, Bi-directional exchange. There are no exclusions for this measure. This measure is worth 30 points. To meet this measure, you must attest “yes” to actively enabling a system where your providers can securely share patient data in both directions, allowing information to flow freely between different electronic health records and healthcare organizations. Criteria of active enabling include: using standardized data formats and messaging protocols to allow different electronic health records to understand and interpret the information being exchanged; secure access by data encryption and protection with access controls to ensure patient privacy; establish a query-based exchange where providers can request specific patient information from other health care organizations as needed; and directed exchange where patient data can be sent to a specific healthcare provider, like a referral summary or test results.

Health Information Exchange: Option 3, Enabling exchange under the Trusted Exchange Framework and Common Agreement (TEFCA). There are no exclusions for this measure. This measure is worth 30 points. Trusted Exchange Framework and Common Agreement is a nationwide framework in the United States that allows for the electronic sharing of health information. To meet this measure, you must attest “yes” that you have a signed agreement with TEFCA.

Provider to patient exchange. There are no exclusions for this measure. This measure is worth from 1 – 25 points, depending on numerator – denominator scoring. The objective for this measure is to provide patients with electronic access to their health information. This electronic access must include four functionalities: view, download, transmit, and access. Health information needs to be made available to patients within four business days of the information being available to the provider for each and every time that information is generated.

• Numerator: the number of unique patients who were provided with electronic access to their health information
• Denominator: the total number of unique patients who were provided with services during the 180-day performance period.

Public Health and clinical data exchange. There are several exclusions for this measure depending on your practice type, the diseases you care for, whether immunization services are provided, and the availability of public health data registries. This measure is worth 25 points. This measure addresses the degree to which you are prepared to electronically share information with public health agencies. The type of information shared would be things like immunization records, laboratory results, case reports of infectious diseases, or syndromic surveillance data—similar to data that was shared with public health agencies during COVID. To meet this measure, you must attest “yes” to one of two possible options. The first option is registering with the public health agency and going through the validation process in preparation to exchange data. If you are contemplating pursuing this first option, it should be done well before the 180-day reporting period has started. The second option is that your clinic has already gone through the registration and validation process and you’re actively exchanging data with the public health agency.

Bonus points: Report to public health or clinical data registries. This is an optional measure with no exclusions. This measure is worth 5 bonus points. To meet this measure, you must attest “yes” to one of the following:

• Public health registry data reporting.
• Clinical data registry data reporting.
• Syndromic surveillance data reporting.

Well, there you have it, everything you probably never wanted to know about PI. CMS has one big stick that they’re holding over us if we don’t report PI and get a score of 70 points or above. An ACO’s performance on the Promoting Interoperability performance category does not impact the calculation of shared savings or shared losses. However, to be eligible to receive shared savings, ACOs are required to comply with all Shared Savings Program requirements, including the requirement to report to the Promoting Interoperability performance category and score 70 points or above for the performance year.