The summaries below are for the MIPS Advancing Care Information (ACI) Measures that can be submitted through a the HASA registry and TurboMACRA tool. All requirements are defined by CMS QPP https://qpp.cms.gov/measures/aci. Users can still submit for measures not supported by HASA by entering the details manually into TurboMACRA.


Icon Key:

 HASA Supported               Eligible for Bonus Score

Required for Base Score      Measure Description         

Attestation Type


Clinical Data Registry Reporting

The MIPS eligible clinician is in active engagement to submit data to a clinical data registry

 

Yes/No

 


Clinical Information Reconciliation

For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician performs clinical information reconciliation. The MIPS 781 eligible clinician must implement clinical information reconciliation for the following three clinical information sets:

  1. Medication: Review of the patient’s medication, including the name, dosage, frequency, and route of each medication
  2. Medication allergy: Review of the patient’s known medication allergies
  3. Current Problem list: Review of the patient’s current and active diagnoses

Numerator/Denominator

  • Numerator: The number of transitions of care or referrals in the denominator where the following three clinical information reconciliations were performed: Medication list, medication allergy list, and current problem list
  • Denominator: Number of transitions of care or referrals during the performance period for which the MIPS eligible clinician was the recipient of the transition or referral or has never before encountered the patient

Electronic Prescribing

At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using CEHRT

Numerator/Denominator

  • Numerator: The number of prescriptions in the denominator generated, queried for a drug formulary, and transmitted electronically using CEHRT 
  • Denominator: Number of prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances during the performance period; or number of prescriptions written for drugs requiring a prescription in order to be dispensed during the performance period

Electronic Case Reporting

The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions

Yes/No

 


Immunization Registry Reporting

The MIPS eligible clinician 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 (IIS)

Yes/No

 

Patient-Generated Health Data

Patient-generated health data or data from a non-clinical setting is incorporated into the CEHRT for at least one unique patient seen by the MIPS eligible clinician during the performance period

Numerator/Denominator

  • Numerator: The number of patients in the denominator for whom data from nonclinical settings, which may include patient-generated health data, is captured through the CEHRT into the patient record during the performance period
  • Denominator: Number of unique patients seen by the MIPS eligible clinician during the performance period

Patient-Specific Education

The MIPS eligible clinician must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to at least one unique patient seen by the MIPS eligible clinician

Numerator/Denominator

  • Numerator: The number of patients in the denominator who were provided electronic access to patient-specific educational resources using clinically relevant information identified from CEHRT during the performance period
  • Denominator: The number of unique patients seen by the MIPS eligible clinician during the performance period

Provide Patient Access

For at least one unique patient seen by the MIPS eligible clinician: 

  1. The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information
  2. The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programing Interface (API) in the MIPS eligible clinician's CEHRT.

Numerator/Denominator

  • 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 that is configured meet the technical specifications of the API in the MIPS eligible clinician's CEHRT
  • Denominator: The number of unique patients seen by the MIPS eligible clinician during the performance period

Public Health Registry Reporting

The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries

 

Yes/No

 


Request/Accept Summary of Care

For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician receives or retrieves and incorporates into the patient’s record an electronic summary of care document

Numerator/Denominator

  • Numerator: Number of patient encounters in the denominator where an electronic summary of care record received is incorporated by the clinician into the CEHRT
  • Denominator: Number of patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition or referral or has never before encountered the patient and for which an electronic summary of care record is available

Secure Messaging

For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative)

Numerator/Denominator

  • Numerator: The number of patients in the denominator for whom a secure electronic message is sent to the patient (or patient-authorized representative) or in response to a secure message sent by the patient (or patient-authorized representative), during the performance period
  • Denominator: Number of unique patients seen by the MIPS eligible clinician during the performance period

Security Risk Analysis

Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by CEHRT in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician’s risk management process

Yes/No

 


Send a Summary of Care

For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care clinician-

  1. Creates a summary of care record using CEHRT
  2. Electronically exchanges the summary of care record

Numerator/Denominator

  • 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
  • Denominator: Number of transitions of care and referrals during the performance period for which the MIPS eligible clinician was the transferring or referring clinician

Details: Use HASA Care Coordination to manage patient campaigns and closed loop referrals, and get CMS credit for every transaction by adding a CCDA with a single click


Syndromic Surveillance

The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from a non-urgent care ambulatory setting where the jurisdiction accepts syndromic data from such settings and the standards are clearly defined

Yes/No

 


View, Download, or Transmit (VDT)

During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician. A MIPS eligible clinician may meet the measure by either-

  1. View, download or transmit to a third party their health information
  2. Access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician’s CEHRT 
  3. A combination of (1) and (2)

Numerator/Denominator

  • Numerator: The number of unique patients (or their authorized representatives) in the denominator who have viewed online, downloaded, or transmitted to a third party the patient’s health information during the performance period and the number of unique patients (or their authorized representatives) in the denominator who have accessed their health information through the use of an API during the performance period
  • Denominator: Number of unique patients seen by the MIPS eligible clinician during the performance period

Details: Use the HASA GoAccount for your patients to access their community record; complement your own portal if you have one, or use instead of your EHR patient portal to get full credit for every patient who views their record, even if they looked at a visit to a different physician.