Dear Valued Clients:
This is an important notification to alert you to an upcoming 2022 CMS MIPS requirement, which impacts our gGastro® clients.
Per the final rule by the Centers for Medicare & Medicaid Services (CMS) and Health and Human Services (HHS), a new attestation has been added for a self-assessment using the SAFER High Priority Practice Guide. The attestation has been added to the MIPS Promoting Interoperability (PI) Protect Patient Health Information objective, beginning with the CY 2022 performance period/2024 MIPS payment year.
What are the SAFER Guides?
The Office of the National Coordinator for Health Information Technology (ONC) developed and initially released the Safety Assurance Factors for EHR Resilience Guides (SAFER Guides) in 2014 and later updated them in 2016. The series of nine user guides supports the ability of health care providers to address EHR safety. Collectively, the SAFER Guides help health care organizations at all levels, from small practices to multi-system chains and tertiary care facilities, to conduct self-assessments that optimize the safety and safe use of EHRs. The SAFER Guides were intended to be utilized by EHR users, developers, patient safety organizations, and those who are concerned with optimizing the safe use of health IT.
What does this mean for gGastro clients?
For this measure, a MIPS eligible clinician must attest to having conducted an annual self-assessment using the High Priority Practices Guide, at any point during the calendar year in which the performance period occurs, with one “yes/no” attestation accounting for the complete self-assessment using the High Priority Practices Guide. In order to complete a “self-assessment” using the High Priority Practices Guide, the user would complete a review and mark the associated checkboxes (fully, partially, or not implemented) of recommended practices included at the beginning of the Guide.
Please note, the attestation requirement is ONLY for The High Priority Practices Guide (not all nine Guides), which identifies “high risk” and “high priority” recommended safety practices, intended to optimize the safety and safe use of EHRs.
We are providing the following details regarding gGastro’s established EHR processes and recommended best practices, as pertinent to the High Priority Practices Guide, to assist you with completing the self-assessment and thus meeting the assessment requirement. Please refer to Figure 1.
We encourage you to retain documentation of your completed self-assessment.
The complete Guide can be accessed here.
Figure 1: High Priority Practices Guide
Note: Source of Input = EHR Developer
|SAFER Guide Recommended Practice||gGastro Safe Use Recommendations|
|1.3 Allergies, problem list entries, and diagnostic test results, including interpretations of those results, such as “normal” and “high,” are entered/stored using standard, coded data elements in the EHR||gGastro utilizes RxNorm and NDC ID for coding medications and allergies. SNOMED-CT codes for allergies manifestations/reactions. SNOMED-CT and ICD-10 for problems and diagnosis list entries. LOINC codes for coding clinical laboratory results|
|1.4 Evidence-based order sets and charting templates are available for common clinical conditions, procedures, and services.||Clinical Decision Support is available and utilized in gGastro. Also, gGastro provides CPOE (Computerized Provider Order Entry) for all orders.|
|1.5 Interactive clinical decision support (CDS) features and functions (e.g., interruptive warnings, passive suggestions, info buttons) are available and functioning||Interactive clinical decision support (CDS) is integrated and built into the gGastro system. These include guidelines, patient education, and standard CDS for BMI, smoking, ROS alerts, drug allergies, drug/drug interactions, etc.|
|1.6 Hardware and software modifications and system-system interfaces are tested (pre-and post-go-live) to ensure that data are not lost or incorrectly entered, displayed, or transmitted within or between EHR system components.||All modifications and interfaces undergo full Quality Assurance testing prior to beta and/or general availability.
gGastro utilizes a third-party (Redox), and HL7 for interfaces, and tests interfaces as appropriate. We recommend confirming interfaces are performing as expected, and to contact MMI if any issues are observed.
|1.8 Policies and procedures ensure accurate patient identification at each step in the clinical workflow.||As a best practice, we recommend your practice institute the following processes:
|2.1 Information required to accurately identify the patient is clearly displayed on screens and printouts||Patient identification information including: patient name, gender, DOB, and other patient demographic data are clearly and distinctly displayed within the gGastro EHR and on printouts from the system.|
|2.2 The human-computer interface is easy to use and designed to ensure that required information is visible, readable, and understandable.||gGastro is designed to clearly and distinctly read the displayed information, and to mark areas within the system.|
|2.3 The status of orders can be tracked in the system.||gGastro is designed with alerting flags within the system to track orders status such as completed. We recommend familiarizing your staff with these flags as well as utilization and review of the Orders Log.
In addition, we recommend designating a point person within your practice for ongoing tracking and monitoring of orders’ status and staff education regarding these processes.
|2.4 Clinicians are able to override computer-generated clinical interventions when they deem it necessary.||gGastro allows users to void and override clinical interventions such as prescriptions and cancel orders, as well as generate amendments as needed. We recommend users familiarize themselves on how to edit and cancel orders.|
|3.1 Key EHR safety metrics related to the practice/organization are monitored||ModMed tracks and monitors EHR uptime rates and system response times for our customers using our cloud offering. On premise customers should develop their own tracking and monitoring system for their gGastro EHR servers.
Responsibility for ongoing active surveillance of EHR safety metrics is a dual responsibility. Practices are responsible for surveillance of potential and active adverse events/patient errors, and ModMed is responsible for reporting potential EHR errors to practices.
|3.2 EHR-related patient safety hazards are reported to all responsible parties, and steps are taken to address them||EHR-related patient safety hazards are reported and communicated to all appropriate parties by MMI via communications coordinated with the MMI Compliance-Patient Safety, Knowledge Services, and Support teams, including delineation of the issue and workaround workflows, if available. Communications are targeted to all potentially impacted practices. It is the responsibility of the practices to act upon the notifications and follow any recommended workarounds provided, until the issue is resolved.
Where EHR-related issues originate from the practice’s use of gGastro (i.e. the source of the issue is not gGastro), the practice is responsible for addressing the issue.
|3.3 Activities to optimize the safety and safe use of EHRs include clinician engagement.||We recommend designating a primary patient safety point of contact at your practice to receive and coordinate dissemination of patient safety communications provided by ModMed. Communication methods including written notifications within Salesforce that are used to notify practices.
Practices are also encouraged to contact the ModMed Support team with any questions or concerns.
If you would like to designate a patient safety point of contact for all patient safety-related messages, please update your practice contact information in Salesforce. If you have any questions regarding this notice, you may contact us by phone at (561) 866-459-4227, or by email at gSupport@modmed.com.
The ModMed Gastroenterology Team