Promoting Interoperability Attestation Checklist

For the 2021 reporting year, the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR) is collecting and submitting Promoting Interoperability (PI) data on behalf of qualified registry or qualified clinical data registry (QCDR) participants to CMS. MIPS-Eligible Clinicians (ECs) and groups who do not qualify for a PI performance category exemption or those who are considering participating in PI regardless of an exemption should review the following steps for deciding the best path for possible PI attestation and data submission.

STEP 1: Check your MIPS Participation Status on the Quality Payment Program (QPP) website.

Enter your 10-digit National Provider Identifier (NPI) number in the QPP site to determine whether you are exempt from MIPS. 

STEP 2: Determine whether you qualify for a "Special Status" exception.

The QPP MIPS Participation Status website will display whether the EC or group qualifies for any special status exception. This includes ECs who are:

•  Ambulatory Surgery Center-based
• Hospital-based
• Non-patient facing

ECs and groups eligible for the special status exception will have their PI category automatically reweighted to zero and those points will be shifted to the Quality component. Those ECs who wish to participate despite having the exception may submit PI data and, when submitting data, will receive a PI score even if they were not required to submit data. 

STEP 3: Determine whether you qualify for additional exemptions and apply using the CMS Hardship Application. 

If an EC or group does not have a special status exemption, they may proactively apply for a CMS Hardship Application. There are five PI hardship exemptions that require the EC or group to submit an application:

1. Insufficient internet connection: Practicing in an area without sufficient internet access or facing insurmountable barriers to obtaining infrastructure, such as a lack of broadband access
2. Extreme and uncontrollable circumstance: Natural disasters, practice or hospital closure, severe financial distress, EHR certification/vendor issues
3. Lack of control over availability of CEHRT: Inability to control CEHRT availability in more than 50 percent of patient encounters
4. You have decertified EHR technology
5. You are a small practice: ECs who are part of a practice with 15 or fewer clinicians

ECs or groups earning a hardship exemption will have their PI category automatically reweighted to zero and those points shifted to the MIPS Quality category. Those ECs that wish to participate despite having the exemption may submit PI data and, when submitting data, will receive a PI score even if they were not required to submit data.

Those ECs and groups who have an exemption from PI in 2021 and do not wish to submit PI data need not review Steps 4 - 8. ECs and groups that must report PI or those who want to submit PI may wish to follow the steps below for participating in the PI performance component.  

STEP 4: Check your Certified Electronic Health Record Technology (CEHRT) to determine that you have the correct edition required.
Make plans to acquire, verify or update your system to ensure you use an Electronic Health Record (EHR) that meets the 2015 Edition certification criteria, 2015 Edition Cures Update certification criteria, or a combination of both for participation in this performance category. The Office of the National Coordinator for Health Information Technology (ONC) has developed a comprehensive database of certified EHR technology (CEHRT) where ECs can check their CEHRT.

STEP 5: If you are participating in PI, pick a performance period of at least 90 days.
ECs participating in PI must attest to and submit at least 90 days of 2021 data to CMS. This must be a continuous 90-day period. 

STEP 6: Review the PI Scoring Requirements and determine which score components are most applicable to you and your practice.

In order to secure full credit towards the 25% weight of the MIPS Promoting Interoperability (PI) performance category, MIPS eligible clinicians must report on four different objectives consisting of a total of five measures for the 2021 performance year. Those four objectives are:

• Submit yes that you use an Electronic Health Record (EHR) that meets the 2015 Edition certification criteria, 2015 Edition Cures Update certification criteria, or a combination of both for participation in this performance category.
• Submit yes for the Prevention of Information Blocking Attestation,
• Submit yes for the ONC Direct Review Attestation, and;
• Submit yes for the security risk analysis measure.

The other PI measures will be scored, depending on the measure, on the EC’s performance through the submission of a numerator or denominator or a “yes or no” attestation.

Promoting Interoperability measures are available in the QPP Resource Library.

STEP 7: Choose your submission methods and verify their capabilities.
ECs and groups who are reporting PI can submit measures via multiple collection types. Practices can explore submitting data via the QPP website or by finding an appropriate vendor via the QPP Resource Library.

STEP 8: Submit your PI data as required by the third-party vendor or directly to CMS via the Quality Payment Program webpage by March 31, 2022.