Under the Merit-based Incentive Payment System (MIPS) pathway of the MACRA Quality Payment Program, the Advancing Care Information (ACI) category replaces the Medicare EHR Incentive Program (Meaningful Use). ACI is one of the three performance categories that will be considered and weighted for scoring a clinician’s performance under MIPS (four categories will be included starting in 2018). A clinician’s score for the Security Risk Analysis measure is dependent on the clinician meeting the measure’s base score requirements. For more information on ACI scoring methodology, please click here.
Protect Patient Health Information
Security Risk Analysis
YES/NO: To meet this measure, eligible clinicians must attest YES to conducting or reviewing a security risk analysis and implementing security updates as necessary and correcting identified security deficiencies.
ONC Security Risk Analysis (SRA) Tool
In collaboration with the HHS Office for Civil Rights, the ONC released a tool to help practices conduct and document a comprehensive assessment to identify risks in their organizations. The SRA tool also produces a report that can be useful for audits.
Since your practice is unique and you know your practice best, you are ultimately responsible for adopting and implementing security and privacy measures that are appropriate and reasonable for your practice's needs and capabilities.
For additional support, you should consult with a qualified professional who can use his or her expertise to help mitigate potential risks, identify potential areas for improving security, and train your staff. CMS has also created a Security Risk Analysis Tip Sheet to help you understand this requirement.
Make sure to keep any documentation you use for your records to prove you have completed this measure during your reporting year: It is acceptable for the security risk analysis to be conducted outside the selected MIPS performance period, however, the analysis must be unique for each MIPS performance period, the scope must include the full MIPS performance period, and the analysis must be conducted within the calendar year of the MIPS performance period (January 1st – December 31st).
CMS has published guidance to help providers better understand the documentation they should retain around meeting MIPS requirements. CMS calls this guidance "MIPS Data Validation Criteria" because it describes the types of documentation that would validate the data the provider submits to CMS at the end of the performance period. You can learn more about this by reviewing CMS’ MIPS Data Validation Fact Sheet and you can see the specific documentation guidelines applicable to the ACI Transition Measures in CMS’ MIPS Data Validation Criteria for ACI Transition Measures.
- Review the CMS specifications for more information about the Advancing Care Information Transitional measures.
- For more information on the Merit-based Incentive Payment System (MIPS) program, you can visit Practice Fusion’s Quality Payment Program Center.
- CMS also provides further resources about the Quality Payment Program here.