American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Promoting Interoperability Program

Please note. The Centers for Medicare & Medicaid Services (CMS) has renamed the EHR Incentive Program to the Promoting Interoperability (PI) Program as part of the Merit-based Incentive Payment System (MIPS). For more information on the MIPS program, please visit the ACS Quality Payment Program Resource Center. The information below was published in the July 2016 issue of the Bulletin of the American College of Surgeons.

In 2017, the Centers for Medicare & Medicaid (CMS) merged its previous physician quality programs into the Merit-based Incentive Payment System (MIPS). MIPS includes four components:

  • Quality, formerly known as the Physician Quality Reporting System (PQRS)
  • Promoting Interoperability, formerly known as Advancing Care Information (ACI) or the Electronic Health Record Incentive Payment Program
  • Cost, formerly known as the Physician Value-Based Payment Modifier (VM) program
  • Improvement Activities, a new category

These four components combine to form a MIPS Final Score that determines a MIPS eligible clinician’s Medicare Part B incentive payment.

For 2018, the MIPS final score is composed of Quality for 50 percent, Cost for 10 percent, Promoting Interoperability for 25 percent, and Improvement Activities for 15 percent.

For more information on the MIPS program, please visit the ACS Quality Payment Program Resource Center.

Meeting Meaningful Use Requirements in 2016

CMS Medicare EHR Incentive Program is divided into three stages, each intended to incentivize providers to demonstrate meaningful use (MU) of an EHR system through a progression of measures and objectives. Stage 1 established the foundation for the program by instituting requirements for the electronic capture of clinical data and by providing patients with electronic access to their health information. Stage 2 expands on Stage 1 by encouraging the use of health information technology for continuous quality improvement at the point of care and the exchange of information in a structured format. Stage 3 focuses on improving clinical outcomes. In 2019, MU will transition into the new MIPS program as required under the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) enacted in 2015.

CMS released a modified version of Stage 2 (Modified Stage 2) requirements in 2015 in an effort to align the first two stages with Stage 3. The new regulation has changed the reporting requirements for providers participating in the EHR Incentive Program in 2016. This column discusses what surgeons need to know to successfully participate in the program.

Reporting Requirements in 2016

Surgeons who are participating in the EHR Incentive Program for the first time will report using the Modified Stage 2 requirements for 90 consecutive days. They will need to report on all measures as required, with special accommodations for measures that were not required previously for Stage 1 providers. Providers participating in their second year or beyond are required to report on Modified Stage 2 for the full calendar year. They will have to report on all measures as required. (See Table 1.)

Changes in Reporting from 2015 to 2016

There are very few changes in reporting from 2015 to 2016. Providers are expected to continue to report on the same Modified Stage 2 objectives and measures in 2016 that were required in 2015. Because major changes were made to the program in 2015, such as the elimination of Stage 1 and the consolidation of core and menu objectives, CMS offered measure or objective exceptions that allowed providers to skip reporting on a measure or objective without being penalized. CMS refers to these exceptions as “alternate exclusions.”

The Modified Stage 2 rule includes alternate exclusions in the following circumstances:

  • A particular measure does not have a Stage 1 measure equivalent
  • A previously optional measure is now required
  • Additional technology, such as an upgraded certified EHR system, is required

Many of the alternate exclusions that were available in 2015 are no longer available in 2016. In 2016, alternate exclusions are available for two MU objectives: computerized provider order entry (CPOE) and public health reporting. Providers scheduled to be in Stage 1 (providers in their first two years of participation in the EHR Incentive Program) may claim an alternate exclusion for two measures under the CPOE objective. Providers who choose to use the alternate exclusion for the CPOE objective will not have to report their use of CPOE for laboratory or radiology orders. They also may use an alternate exclusion for the public health reporting objective for two measures. Because the measures were previously optional, providers are not required to submit syndromic surveillance data to a public health agency or submit data to a specialized registry. Providers are required to successfully report on the remaining objectives and measures in order to avoid a penalty. (See Table 2 for a list of alternate exclusions in 2016.)

The Best Way for Surgeons to Meet the Public Health Registry Objective

In the Modified Stage 2 regulation, CMS finalized a consolidated public health reporting objective that combined three separate registry reporting measures that were previously optional. Providers are asked to report immunization data to a public health agency, report syndromic surveillance data to a public health agency, or report data to a specialized registry to improve public health information. CMS believes these measures can help track the spread of infectious diseases, foodborne illnesses, and other issues that affect public health. Although the information is useful, in 2016 this objective caused concern for both providers with little time to identify registries and with state health organizations and medical associations that lack the infrastructure to accept data from certified electronic heath record technology (CEHRT).

To complete the objective, providers must be in “active engagement” with a public health agency to submit health data using CEHRT. Active engagement can be demonstrated through completed registration to submit data to a registry. To meet the public health registry objective, surgeons must attest to any combination of two of the following three measures:

  • Measure 1—Immunization registry reporting: The provider or hospital is in active engagement with a public health agency (PHA) to submit immunization data.
  • Measure 2—Syndromic surveillance reporting: The provider or hospital is actively engaged with a PHA to submit syndromic surveillance data.
  • Measure 3—Specialized registry reporting: The provider or hospital is actively engaged to submit data to a specialized registry.

Measure 3 may be counted more than once to satisfy the requirement of two measures if more than one public health registry is available. Providers are encouraged to contact their specialty societies and state health departments to determine whether their registries meet the requirements for MU. Due to pending resolution of federal technical and administrative requirements, it is unclear which registries can meet Measure 3.

The American College of Surgeons strongly recommends that surgeons who cannot otherwise meet this objective choose the exclusion option on the attestation form. Any surgeon may be excluded from the specialized registry reporting measure if he or she meets at least one of the following criteria:

  • Does not diagnose or treat any disease or condition associated with, or collect relevant data through, a specialized registry in their jurisdiction during the EHR reporting period
  • Operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period
  • Operates in a jurisdiction where no specialized registry for which the surgeon is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period

Is There a Blanket Hardship Exemption in 2016 Like There Was in 2015?

No blanket hardship exemption is available for the 2016 MU reporting period.

When Does Stage 3 Begin?

Starting in 2017, providers have the option of attesting to Stage 3 measures and objectives for the EHR reporting period using CEHRT that meets either the 2014 or 2015 certification criteria. All providers must attest to Stage 3 beginning in 2018.


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For further information, please contact Molly Murray at or 202-672-1506.