The Promoting Interoperability (PI) component of the Merit-Based Incentive Payment System (MIPS) is one of four performance categories under which MIPS eligible clinicians, including psychiatrists, are scored under Medicare's Quality Payment Program (QPP), which focuses on quality and value-based care. The PI category, formerly known as Advancing Care Information (ACI), emphasizes an increased focus on electronic health record (EHR) interoperability and improving patient access to health information

How Much Does PI Count in My MIPS Score?

The PI category accounts for 25% of your total MIPS Composite Score. Your score for reporting year 2019 determines whether your Medicare Part B payments are subject to a positive, negative, or neutral adjustment in Payment Year 2021. The weighting of the PI performance category—and the other categories of MIPS—is subject to possible reweighting for future reporting years.

How Do I Successfully Report on the PI Category?

Beginning for the 2019 reporting year, the PI category requires psychiatrists and other eligible clinicians to use the 2015 Edition Certified Electronic Health Record Technology (CEHRT), as defined by the Office of the National Coordinator for Health Information Technology (ONC). In previous reporting years, ECs had the option of using 2014, 2015 or a combination of 2014/2015 CEHRT.

• View Frequently Asked Questions (FAQs) on what exactly CEHRT is and to find EHR systems that are ONC certified.
• The APA also maintains a set of FAQs for how to select an EHR system.

Are There Hardship Exceptions for the PI Category?

It is important for psychiatrists to understand that the failure to use 2015 Edition CEHRT, or to report on all required measures within the PI category (whether a yes/no attestation, submitting for a measure exclusion, or reporting at least a "1" in the numerator for required measures) will result in receiving a score of zero for the PI MIPS category. However, CMS has maintained limited hardship exceptions for which an eligible clinician may apply, so that their performance in the PI category is "weighted to zero," and the associated 25 percentage points will be reallocated to the Quality performance category score. Most of these hardship exceptions are subject to an application process by the clinician to CMS.

These hardships include:

• Insufficient Internet Connectivity: The psychiatrist or eligible clinician must show they lacked "sufficient internet access, during the performance period, and that there would be insurmountable barriers to obtaining such infrastructure, such as a high cost of extending internet infrastructure to their facility."
• Extreme and Uncontrollable Circumstances: These would include extreme circumstances, such as "a natural disaster in which an EHR or practice building are destroyed." These circumstances must cause the eligible clinician to be unable to collect information necessary to submit for a performance category, or to submit information that would be used to score a performance category for an extended period of time.
• Lack of Control over Availability of CEHRT: This is for clinicians who practice at multiple locations or in practices where they cannot control the selection of health information technology. For example, this could include physicians who treat patients in several nursing home facilities. The patients seen at multiple locations must account for at least half of that clinician's patients.
• Non-patient Facing Clinicians: This is designed for clinicians whose work during the performance period did not involve seeing patients face-to-face, such as pathologists and radiologists. Telepsychiatry and other forms of telehealth are considered "face-to-face" and do not count for this hardship exception.
• Hospital-Based Clinicians: MIPS eligible clinicians who furnish 75% or more of their covered professional services at sites identified by the following Place of Service (POS) codes will have their PI performance score weighted to zero: 19 (off-campus outpatient hospital); 21 (inpatient hospital); 22 (on-campus outpatient hospital); or 23 (emergency room). This requires no application process as CMS will automatically tabulate this information via claims data.
• Decertification of CEHRT: Clinicians whose CEHRT was decertified by the ONC, either during the performance period or during the preceding calendar year, are eligible for this exception.
• Small Practices: Clinicians in practices with 15 or fewer clinicians who wish to receive an exception must demonstrate in their application that there are "overwhelming barriers that prevent the MIPS eligible clinician from complying with the requirements for the PI category."

CMS will be releasing a draft of the hardship application with more information. Applications can be submitted on a rolling basis and must be received by the close of the submission period for the relevant performance year (e.g., for the 2018 performance period, these applications must have been submitted no later than December 31, 2018; the deadline for the 2019 reporting year will be announced by CMS at a later date). A new application must be submitted each year.

What Are the PI Reporting Requirements?

The PI category requires that psychiatrists and other eligible clinicians report on four objectives and their associated measures, as indicated in the table below.

• These objectives and measures are aligned with ONC 2015 standards for CEHRT.
• For the 2019 reporting year, clinicians must use 2015 Edition CEHRT. Failure to do so will result in a PI score of zero.

How Is the PI Category Scored?

In previous years, the ACI category was broken down into performance and base scores, resulting in a single composite score. For PI, this has been simplified and is scored based on performance on each measure. Each measure will be scored by multiplying the performance rate (calculated from the numerator and denominator submitted, where so indicated) by the available amount of points for the measure. A total of 100 points are possible within the PI category. The Public Health and Clinical Data Exchange measures will be awarded full points if a "yes" responsible is submitted for 2 registries, or one "yes" for one registry, and one exclusion claimed. When exclusions are claimed, points for those measures will be reallocated to other measures within PI.

What Is Required?

Eligible clinicians must submit data for certain measures from each of the four objectives (unless an exclusion is claimed) for ninety continuous days or more during 2019. In addition to submitting measure data, clinicians must 1) submit a "yes" to the Prevention of Information Blocking Attestation, 2) Submit a "yes" to the ONC Direct Review Attestation, 3) Submit a "yes" for the Security Risk Analysis measure. 4) Report to two different public health registries (or one registry and one exclusion), 5) submit a numerator of at least "1" for measures that are based on patient data (unless exclusions are taken).

What Is a "Security Risk Analysis"?

The Security Risk Analysis (SRA) measure is similar to the HIPAA requirement that clinicians conduct "an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of e-PHI held by the organization . . . this includes all e-PHI an organization creates, receives, maintains, or transmits. All forms of electronic media, such as hard drives, floppy disks, CDs, DVDs, smart cards, or other storage devices, personal digital assistants, transmission media, or portable electronic media." See Appendix I below, on conducting a Security Risk Analysis.

What Are PI "Bonus Points"?

Bonus points can be earned in by reporting on two new measures for 2019 (which may become required in future reporting years of MIPS). These measures are:

• Query of Prescription Drug Monitoring Program (PDMP): For at least one Schedule II opioid electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history, except where prohibited and in accordance with applicable law.
• Verify Opioid Use Agreement: For at least one unique patient for whom a Schedule II opioid was electronically prescribed by a MIPS eligible clinician using CEHRT during the performance period, if the total duration of the patient's Schedule II opioid prescriptions is at least 30 cumulative days within a six-month look-back period, the MIPS eligible clinician seeks to identify the existence of a signed opioid treatment agreement and incorporates it into the patients EHR using CEHRT.

What if I still have questions or issues regarding the MIPS PI performance category?

• APA members may consult APA staff experts by sending an email to [email protected], or by calling the Practice Management Helpline at 1-800-343-4671.
• The CMS Quality Payment Program Service Center accepts questions from the public at [email protected] or 1-866-288-8292.

What CMS resources are available?

• MACRA Year 3 Final Rule
• QPP Resource Library
• 2019 QPP PI Final Rule Overview Fact Sheet
• QPP PI Year 3 Summary
• CMS Executive Summary (8 pages)

Appendix I: Security Risk Analysis Resources

1. The ONC/Office of Civil Rights/HHS Office of the General Counsel Security Risk Assessment (SRA) Tool
2. The ONC Security Risk Assessment (SRA) Video
3. Centers for Medicare and Medicare Services (CMS) Security Risk Analysis Tipsheet: Protecting Patients' Health Information