The CEHRT / Base EHR Gap

The practice has responsibilities under the MIPS program that 2015 Edition “CEHRT” has been implemented for the duration of the minimum-90-day MIPS Promoting Interoperability performance period. As will become clear below, there is some confusion regarding the defined term “CEHRT”. The practice should be clear on what it is attesting to and have the necessary documentation in place so that it can survive a possible MIPS pre-payment or post-payment audit; the practice should “trust but verify” that the HIT vendor is delivering on its obligations. After explaining the painful regulatory terminology, we provide a simple step-by-step procedure for how to verify and document that the practice does in fact have the required CEHRT.

“CEHRT” is a regulatory term defined by CMS; the current definition in the Federal Register reads as follows:

“2015 Edition Base EHR” is in turn another regulatory term, but defined by ONC; the definition currently reads as follows in the Federal Register:

 
To summarize in more plain language, “CEHRT” requires additional mandatory certified capabilities beyond “2015 Edition Base EHR”, creating a “CEHRT / Base EHR Gap”

Figure 1 – the CEHRT / Base EHR Gap

The details of the CEHRT / Base EHR Gap are listed in Table 1 below (references to § 170 are for technical standards required for the ONC HIT Certification program):

Table 1 – the CEHRT / Base EHR Gap

Unfortunately, neither the current CMS web page

 
nor the “fact sheet” linked to it (“2020 Promoting Interoperability Programs: 2015 Edition Certified Electronic Health Record Technology Fact Sheet”) detail the issue of the CEHRT / Base EHR gap; instead, CMS “punts” and refers to ONC:

 
Visiting that ONC CHPL website provides the visitor a “CMS ID Creator” tool for creating a “CMS EHR Certification ID”. The problem is that this tool only verifies completeness relative to “2015 Edition Base EHR” and not “CEHRT”! The tool might say “Base Criteria: 100%” but with a disclaimer:

 
Such as, for example, requirements for the Quality Payment Program and its MIPS track!

Thus, the practice should use the CMS ID Creator tool, but then manually verify the gap requirements in Table 1. The practice shouldn’t simply take the HIT vendor’s verbal reassurances, but rather perform the following verification steps:

CEHRT Verification Procedure

1. Find the product listing(s) for all the practice’s certified software as required for the MIPS program on the ONC CHPL website, possibly including multiple software applications, such as for example:
   1. EHR,
   2. eRx,
   3. Direct messaging,
   4. patient portal and
   5. QCDR – see below;
2. Add the product(s) to the CMS ID Creator;
3. Print the individual product’s CHPL description out for the practice’s MIPS audit file, showing all the certified capabilities and associated eCQMs;
4. Verify that the CMS ID Creator shows 100%, and print this out for the MIPS audit file (including the CMS EHR Certification ID); and
5. Verify that all items needed in Table 1 are accounted for; in particular verify that all eCQMs being reported by the practice are certified by the software.

It is worth pointing out that ONC removed the CQM certified capabilities (c)(2) and (c)(3) from its definition of Base EHR because it expected these to be provided by a registry rather than the EHR; ONC expects the Base EHR to implement certified capability (c)(1) “Clinical Quality Measures – capture and export”. This can be visualized as follows:

Figure 2 – EHR & QCDR Roles for CQMs

If the practice is using a QCDR for MIPS Quality reporting, that registry’s software may very well be certified for these mandatory CQM capabilities. In that case, the registry software should be added as a “product” in the above steps 1-5. For example, the FIGmd Registry Platform used by the great majority of professional society QCDR registries is in fact certified in this manner:

Figure 3 – FIGmd Registry Platform V7.0 Listing on the ONC CHPL Site 

What if the practice finds that it is missing mandatory CEHRT capabilities? Hopefully this would be early enough in the MIPS performance year to take corrective action. The practice should first reach out to its EHR vendor to see if there is a solution, perhaps by implementing additional software products. If this is not possible in a timely manner but the practice qualifies as a small practice, it should consider to file for an EHR Hardship Exclusion (the deadline for such filing being Dec. 31, 2020 for the 2020 MIPS performance year). In other circumstances, it may be necessary for the practice to skip reporting MIPS Promoting Interoperability and forfeit the corresponding 25% of its MIPS Final Score; it is not recommended to intentionally falsify the practice’s CEHRT attestation, since this may result in greater penalties. In case of such negative situations, it may be necessary to begin searching for new CEHRT solutions from different vendors.