The Quality Payment Program under the Centers for Medicare & Medicaid Services (CMS) introduced a new measure within the Protect Patient Health Information objective starting from Calendar Year 2022. This measure, called the High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide measure, aims to enhance safety and utilization of electronic health records (EHRs).

Understanding SAFER Guides:

Developed by the Office of the National Coordinator for Health Information Technology (ONC), SAFER Guides serve the purpose of improving EHR safety and usage. They consist of self-assessment tools designed to assist healthcare organizations in evaluating their EHR safety practices, identifying potential risks, and mitigating them. Each guide comprises a self-assessment checklist, action-based worksheets, and recommended practices to reduce EHR-related patient safety risks, optimize EHR usage, and foster a culture of safety. The interactive PDF format of SAFER Guides facilitates ease of use, sharing, collaboration, and future assessments.

Attesting to SAFER Guide Measures:

For MIPS eligible clinicians reporting on the Promoting Interoperability performance category, attesting to the High Priority Practices SAFER Guide measure is mandatory. Groups reporting collectively must also attest to this measure, with the group’s response applying to all MIPS eligible clinicians within it. To earn a score greater than 0 for the Promoting Interoperability performance category, clinicians must attest “YES” to completing the self-assessment checklist in the High Priority Practices SAFER Guide. Failure to do so or leaving the attestation blank will result in a score of 0.

To attest “YES,” clinicians must complete the self-assessment checklist found within the High Priority Practices SAFER Guide annually. They must indicate the level of implementation achieved for each recommended practice: “Fully in all areas,” “Partially in some areas,” or “Not implemented.”

High Priority Practices SAFER Guide Attestation Statement:

The attestation statement confirms completion of actions outlined in the SAFER Guides measure during the relevant calendar year’s performance period. By affirming “YES,” clinicians confirm conducting the annual self-assessment in the High Priority Practices Guide.

Additional Resources:

• 2024 MIPS Promoting Interoperability Performance Category Quick Start Guide: Offers an overview and practical information regarding data collection and submission for the 2024 MIPS Promoting Interoperability performance category.
• 2024 MIPS Promoting Interoperability Measure Specifications: Provides a detailed overview of the requirements for the 2024 Promoting Interoperability performance category objectives and measures.

Key Points:

• MIPS is a CMS program incentivizing eligible clinicians and hospitals to enhance quality, cost, and interoperability.
• Promoting Interoperability (PI) is one of MIPS’ performance categories, within which participants must complete the SAFER Guides Measure.
• Eligible clinicians must conduct an annual self-assessment using the High Priority Practices SAFER Guide by December 31 of the performance year, independently from EHR vendors.
• Eligible hospitals and Critical Access Hospitals (CAHs) must attest to completing annual self-assessments using all nine SAFER Guides.
• Compliance with CMS guidelines and contribution to EHR safety and resilience are ensured through completion of the SAFER Guides self-assessment.
• Addressing HIPAA Security Risk Analysis (SRA) and SAFER Guides separately is crucial for compliance and patient safety, as each requirement is independent.

Reference: 2024 Merit-based Incentive Payment System (MIPS) Promoting Interoperability Performance Category: High Priority Practices SAFER Guide Fact Sheet