Navigating the Updated 2024 SAFER Guide Requirements for MIPS Reporting
As we embark on the journey of navigating the 2024 MIPS reporting requirements, it's crucial to stay updated on the latest changes and expectations set forth by CMS. In particular, understanding the updated requirements for the Safety Assurance Factors for EHR Resilience (SAFER) Guides is essential for successful reporting and compliance.
In the past, simply responding "No" to certain attestations could fulfill the SAFER Guides Measure. However, as of 2024, a mere "No" response will no longer suffice. Let's delve into the specifics of what's required for the SAFER Guides Measure this year.
What's New for 2024?
In addition to submitting measures, MIPS reporters must provide their EHR’s CMS identification code from the Certified Health IT Product List (CHPL) and attest "yes" to the following:
The Actions to Limit or Restrict Compatibility or Interoperability of CEHRT (previously named the Prevention of Information Blocking) Attestation.
The ONC Direct Review Attestation.
The Security Risk Analysis Measure.
The Safety Assurance Factors for EHR Resilience (SAFER) Guides Measure.
As emphasized, a "no" response will no longer satisfy this measure in 2024.
What Does This Mean for You?
For many MIPS reporters, especially those focusing on the high Priority Practice Guide, understanding and meeting the SAFER Guides requirements is critical. Compliance ensures not only adherence to regulatory standards but also contributes to the overall safety and resilience of electronic health records.
To ensure compliance with the recent mandate from the Centers for Medicare & Medicaid Services (CMS) regarding the Safety Assurance Factors for EHR Resilience (SAFER) Guides, medical practices must adopt a diligent approach to completing these essential self-assessments. The integration of SAFER Guides into the Protect Patient Health Information objective aims to advance and secure the use of certified electronic health record (EHR) technology. Here are the detailed steps and considerations for medical practices to remain compliant, focusing on the High Priority Practices SAFER Guide:
Understanding SAFER Guides Requirements
For MIPS Eligible Clinicians:
Annual Self-Assessment: Must report "yes" or "no" to completing an annual self-assessment using the High Priority Practices SAFER Guide.
Deadline: The self-assessment must be completed by December 31 of the performance year.
Outside the EHR System: Although EHR vendors can provide assistance, the self-assessment is to be conducted independently by the practice, emphasizing the practice's responsibility.
For Eligible Hospitals and CAHs:
Comprehensive Assessment: Required to attest to completing annual self-assessments using all nine SAFER Guides.
Guide Categories: Includes Foundational Guides (e.g., High Priority Practices), Infrastructure Guides, and Clinical Process Guides.
Deadline: Similar to MIPS, the assessment must be done by December 31 of the program year.
Steps to Compliance
Familiarization with SAFER Guides:
Start by understanding the scope and content of the SAFER Guides relevant to your practice. Focus particularly on the High Priority Practices guide for MIPS eligible clinicians or all nine guides for hospitals and CAHs.
Conducting the Self-Assessment:
Engage a multidisciplinary team within your practice to conduct the self-assessment. This team should include clinical, IT, and administrative staff.
Use the action-based worksheets, checklists, and best practices provided in the SAFER Guides to evaluate your current EHR safety practices, identify potential risks, and plan mitigations.
Action Plan Development:
Based on the assessment findings, develop an action plan to address identified risks and optimize the safe use of EHR technology. Prioritize actions based on the level of risk and feasibility of implementation.
Implementation and Monitoring:
Implement the action plans and monitor progress. This step might involve revising EHR system configurations, enhancing training programs, or improving clinical processes.
Documentation:
Document all activities related to the SAFER Guides self-assessment, including the assessment findings, action plans, and evidence of implementation. This documentation will be crucial for attesting to the completion of the self-assessment.
Reporting and Attestation:
For MIPS eligible clinicians, report "yes" upon completion of the self-assessment by the designated deadline. For eligible hospitals and CAHs, attest to completing the self-assessment(s) accordingly.
Remember, while EHR vendors may assist with some aspects of the SAFER Guides assessment, the primary responsibility for conducting the assessment and implementing necessary changes lies with the medical practice. This initiative not only ensures compliance with CMS requirements, but significantly contributes to enhancing patient safety and the quality of care delivered through the effective use of EHR technology.
Help with the SAFER Guides
For more on the CMS MIPS SAFER guide, you can access the 2024 PI specification sheet here.
Stay informed, stay compliant, and together, let's continue to elevate the standards of healthcare delivery.
