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MIPS (MACRA)- Advancing Care Information (ACI)/Promoting Interoperabiltiy (PI)

 

The Advancing Care Information (ACI)/Promoting Interoperability (PI) section of MIPS is meant to replace the old Meaningful Use program, so the requirements are nearly identical. This guide will walk you through each of the measures required for the ACI/PI section of MIPS, Medicare's Quality Payment Program and the replacement for Meaningful Use, PQRS, and VBM programs.  This guide includes what is required, any corresponding Measure Calculation report in MacPractice, and each of the options within MacPractice for recording the necessary information. 

Contact MacPractice Support if you wish to attest to MIPS so that we may enable the appropriate Abilities if you do not already have them.

 

It is VERY IMPORTANT to understand that because MacPractice is a 2014 certified software, you will be attesting to the "2018 Transition Objectives and Measures" found on this site. (You will need to select that second tab labeled as such, about halfway down the page.)

Required Abilities
MacPractice version 5.1, build 7.3 (Only version 2014 Certified and updated for MIPS)

*EMR/EHR Ability (Only way to record all structured data for MIPS)

*PHI Portal set up 

*Comprehensive ePrescribe 

*Lab Requisition - either integration with an outside Lab company that sends structured data or the Other Labs ability (Required for structured data needed for certification)

Secure Direct Messaging address configured and vetted

*These are purchased abilities.

Actions outside of MacPractice

Security Risk Analysis 

Contact with a local Immunization Registry

Contact with a local Public Health Agency 

External Resources

https://qpp.cms.gov


Configuration
Configure each provider that will attest to MIPS.

In the User Reference for the provider, set the First Year Attesting to the first year that this provider successfully attested to Meaningful Use or MIPS. This will allow you to set up the next set of adjustments with the proper exclusions and supplemental information.


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In the Reports ability, select the "Measure Calculation Adjustments" folder in the sidebar. Use this to add in supplemental information not otherwise entered into MacPractice, note the exclusions a provider plans to claim on specific measures for the reporting period, and choose the federal and state holidays on which the provider and office staff are not available.

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Security Risk Analysis

Objective

Protect Patient Health Information

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 certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.

MacPractice Report
There is no Measure Calculation report in MacPractice for this measure. Attesting to this is a simple yes/no answer that requires a "yes" to be considered accepted.

How
This measure is not recorded in MacPractice. When attesting to this measure, it is a simple yes/no question (which must be answered with a "yes" to submit a successful and accepted attestation). MacPractice highly recommends hiring an outside IT or security company to perform a security risk analysis for your office that provides a report of this analysis. This analysis should include things outside of your MacPractice software such as network and building security. For this reason, this is not something that MacPractice can assist with.

It is important to note that in audits that MacPractice has assisted with, this is the most common reason we have seen for failed audits. In the event your office does get audited, you must furnish proof of a Security Risk Analysis in the form of a report. For more information on what is accepted for a Security Risk Analysis, we suggest contacting CMS with any questions you may have.

Additional Resources
The Office of the National Coordinator for Health Information Technology (ONC), HHS Office for Civil Rights (OCR), and HHS Office of General Counsel (OGC) have collaborated to create a number of tools, guides, and additional resources for security risk assessment:

Doing A Proper Risk Analysis video with Healthcare Scene

Security Risk Assessment Tool and Video on healthit.gov

Template for a Do It Yourself Security Risk Analysis

- meaningfuluseexperts.com

- hipaasecurenow.com

- hipaaone.com

 

EPrescribing

Objective

Electronic Prescribing

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

MacPractice Report
Electronic Prescribing Measure

How
The use of ePrescribe in MacPractice will help you record and send these prescriptions as required.

Denominator: All prescriptions written by the provider that meet one of the following conditions: a) Destination type is Electronic Retail or Electronic Mail Order and the DEA Schedule is None b) Destination type is Print and the DEA Schedule is None c) Destination type is Print, Fax or None and the pharmacy type is Electronic.

Numerator: Total prescriptions with the destination type of Electronic Retail or Electronic Mail Order.

There are two reporting options for this measure. Attest with numbers from either report. (You are not required nor permitted to submit both.) The first report will only count permissible prescriptions. The second report counts controlled substances in the denominator. Even if you prescribe controlled substances, you are still allowed to attest with numbers from the first report that does not include them.

 

Provide Patient Access

Objective

Patient Electronic Access

At least one patient seen by the MIPS eligible clinician during the performance period is provided timely access to view online, download, and transmit to a third party their health information subject to the MIPS eligible clinician's discretion to withhold certain information.

MacPractice Report

View, Download, Transmit (Measure 1)

How
This measure will require the use of the Patient Portal.

Denominator: All unique patients seen within the filtered date range.

Numerator:

A patient is added to the numerator if the office exports a clinical summary to that patient via the patient portal within 4 days of their office visit procedure date, as well as within 4 days of any change or addition to any clinical information on the patient's file.

***A New clinical summary must be exported to the portal within 4 business days each time any change or addition to clinical information on a patient is made. This is not limited to office visits and can include things like adding an allergy, filling a prescription, changing an address, and so on. If you miss exporting the summary within 4 business days of any change, that patient will remain in your denominator and there will be no way to ever get them back into the numerator for that reporting period.***

The export of this summary can be done in several areas of MacPractice. If you would like to do it as part of billing, there is a simple "Export Clinical Summary to the Patient Portal" checkbox that will prompt you to export the summary when you create an insurance claim.

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With this box checked, you will get a second prompt after your claim printing window. From here, you can export to the portal and opt whether to physically print the summary as well.

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You can also export summaries from the Clinical tab in the Patients ability. Select the incident that contains the office visit code in the ledger, then select To Patient from the Export Incident menu in the upper right corner of the Clinical screen. This will bring up the same clinical summary preview window shown above, where you can export and print the summary.

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Finally, summaries can be created and exported in the EHR ability. Select the incident that includes the office visit code, then select To Patient from the Export Incident menu. You will see the prompt to export and print the summary.

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The next step is vital and necessary regardless of how the clinical summary is exported. You must set up the patient with Portal Access in the Patient tab AND save them with the "Relationship to Patient" set as "Self". This must be done prior to or within four business days following the office visit or change to clinical information. If you are just exporting without setting up an actual Portal User for your patients, you are not really providing electronic access. This will require a work flow change for many offices, as this measure is time sensitive and you will not be able to go back and increase your percentage if the View, Download, Transmit report does not meet the required 50% at the end of your attestation period. MacPractice highly recommends running the View, Download, Transmit report at least twice a week to monitor and watch for changes in your numbers. Doing so will allow you to 'catch' the patients that are removed from the numerator and allow you enough time to export them an updated summary within 4 days of your changes.

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Health Information Exchange

Objective

Health Information Exchange

The MIPS eligible clinician that transitions or refers their patient to another setting of care or health care clinician (1) uses CEHRT to create a summary of care record; and (2) electronically transmits such summary to a receiving health care clinician for at least one transition of care or referral.

MacPractice Report

Summary of Care Measure

How

Denominator: All instances of a referral of the type Transition To. This means that if you multiple Transition To referrals on the same patient, they will appear multiple times in the denominator.

Numerator: A Summary of Care document (CDA) must be made available for the referral electronically via a direct address. This can be done either on the Clinical tab in the Patient ability or in EHR. You must first select the incident itself that you wish to export and then either export it to an existing referral for the patient or add a new referral to the patient at that time.

Exported from the Clinical tab

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Exported from EHR

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A patient will be added to the numerator of the report only if you transmit the summary to another provider's secure direct address. Summaries that are just printed out will NOT count towards the numerator.

If you have difficulties finding providers that you refer your patients to who have secure direct addresses to send summaries to, CMS has posted this FAQ regarding this situation. They allow the summaries to be sent to a third party. MacPractice has no further information on this since it's outside of our software, so we recommend contacting CMS for questions regarding these third parties. (CMS can be reached at 888-734-6433.)

 

View, Download, or Transmit (VDT)

Objective

Patient Electronic Access

At least one patient seen by the MIPS eligible clinician during the performance period (or patient-authorized representative) views, downloads or transmits their health information to a third party during the performance period.

MacPractice Report

View, Download, Transmit (Measure 2)

How

This measure will require the use of the Patient Portal.

Denominator: All unique patients seen within the filtered date range.

Numerator: The patient (or their authorized representative) must log into the Patient Portal with the username and password created by the office and either view, download, or transmit their clinical summary. 

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Patient Specific Education

Objective

Patient Specific Education

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

MacPractice Report

Patient Education Measure

How

Denominator: All unique patients seen within the filtered date range.

Numerator: The patient must have a Patient Education added to their account within the same year as your reporting period.

Patient Education records can be added to a patient in two ways. The first involves creating custom Patient Education Resources in References. Once the Patient Education Resources are created, they can be added to any patient who meets all of the qualifications on their Clinical tab in the Patients ability or in an EHR form.

In the Clinical Tab:

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In an EHR form:

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In addition to creating Patient Education Resources in References, MacPractice has added an InfoButton Standard to Allergies, Problems, Medications, and Labs on a patient's clinical tab and EHR summary. The use of this will also count as providing the education to the patient. Remember to check the "Gave Resource to Patient" button at the bottom of the window to add the education to the patient's account.

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Secure Messaging

Objective

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) during the performance period. 

MacPractice Report

Secure Electronic Messaging Measure

How
This measure requires the setup and use of the Patient Portal.

Denominator: All unique patients that were seen within the filtered date range.

Numerator: A patient will be added to the numerator if they or their authorized representative receive a message from a provider user.

Patients can be set up with a Patient Portal User on the Portal Access tab. Once this is set up, providers will be able to search by their name or portal username within the Messaging ability to send them a secure message.
NOTE: The message that the patient or their authorized representative receives from the office MUST be sent by a user in MacPractice that is a provider. Messages sent from front desk staff, billing staff, etc. do not count towards the numerator of this report.

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Medication Reconciliation

Objective

Medication Reconciliation

The MIPS eligible clinician performs medication reconciliation for at least one transition of care in which the patient is transitioned into the care of the MIPS eligible clinician.

MacPractice Report

Medication Reconciliation Measure

How

Denominator: Patient must meet one of the following conditions to be included in the report:

A) An incident with the First Encounter box checked, which also must include an office visit code.

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B) Electronic receipt of a transition of care document to your office from another office using an EHR capable of sending these. The document must then be tied to an incident, and that incident's ledger must also include an office visit code.

C) A patient coming into your office with a list of their current medications, which will then need to be entered in as a list to reconcile. (For this case, the act of entering in a list to reconcile and reconciling will add the patient to the denominator and numerator at the same time.)

Numerator: You must perform a medication reconciliation in EHR or EMR. This must be done on a form that is tied to the incident you added the CPT code to for their office visit. You must be sure to go through the Reconcile process, and not just add Medications manually or check the No Medications checkbox.

In EHR

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In EMR

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Immunization Registry Reporting

Objective

Public Health Reporting

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

*Active Engagement Option 1 - Completed Registration to Submit Data: The EP registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the EP is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows providers to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. Providers that have registered in previous years do not need to submit an additional registration to meet this requirement for each EHR reporting period.

 *Active Engagement Option 2 - Testing and Validation: The EP is in the process of testing and validation of the electronic submission of data. Providers must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that provider not meeting the measure.

*Active Engagement Option 3 - Production: The EP has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

MacPractice Report
There is no Measure Calculation report for this measure. Attesting to this is a simple yes/no answer that requires a "yes" to be considered accepted.

How

With the proper setup, the HL7 immunization files required by immunization registries will be automatically exported to a folder that you choose in Preferences, or directly to an integrated immunizations registry. For more information on weather or not MacPractice is integrated with your state's/jurisdiction's immunizations registry and for assistance in testing and setting up immunizations interfaces, please contact our HL7 support department.

 

Syndromic Surveillance Reporting

Objective

Public Health Reporting

The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data. Earn a 5 % bonus in the ACI/PI performance category score for submitting to one or more public health or clinical data registries.

MacPractice Report

There is no Measure Calculation report for this measure. Attesting to this is a simple yes/no answer that requires a "yes" to be considered accepted.

How

There is a report in MacPractice designed to collect this format of data and generate the necessary files for submission to PHAs. This can be found in Reports under the Clinical folder. Running the Syndromic Surveillance Export report and using the Export button at the bottom will generate the files and save them in a folder that you set up in HL7 Preferences.

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NOTE: MacPractice Support can only assist with setting up data export for this measure. It is up to you and your office staff to contact local Public Health Agencies to see if they can accept these files and if so, maintain contact and submission with them.

 

Specialized Registry Reporting

Objective
Public Health Reporting

The MIPS eligible clinician is in active engagement to submit data to specialized registry. Earn a 5 % bonus in the ACI/PI performance category score for submitting to one or more public health or clinical data registries.

How

MacPractice does not currently have the ability to generate the necessary electronic files for reporting to specialized registries, as there is no industry wide standard for doing so. Every registry that exists has the potential to collect different data in different formats which means a unique process for each request we receive. This is something that we will consider adding on a case by case basis as requested. To request an interface or integration with any specialized registry, please contact Doug Fenn in our Sales department.

NOTE: MacPractice Support can only assist with setting up data export for this measure. It is up to you and your office staff to contact local Public Health Agencies to see if they can accept these files and if so, maintain contact and submission with them.

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