Complete MIPS and MVP Attestations from Program Attestations Pages

This became a mandatory measure in performance year 2023. The PDMP attestation is at the provider level for group and provider. Select the Individual or Group tab and then select the provider to attest for. You may qualify for an exclusion if your MIPS eligible clinicians do not electronically prescribe any Schedule II opioids or Schedule III or IV drugs during the performance period. If you meet Exclusion #2 (PI_EP_2_EX_2), you satisfy the measure and will be auto-attested.

1. From the Main menu in athenaClinicals, click Quality, and then click Program Attestations. The Program Attestations page opens.

2. Click the Query of Prescription Drug Monitoring Program (PDMP) measure. The Query of Prescription Drug Monitoring Program page opens.
   

3. Review the measure requirement:
   

4. Select the clinicians on the Individual tab, or click the Group tab if you're attesting for a group.

   • To bulk select clinicians or groups, click the check box beside the column heading to select all entities in the list. For a group, bulk select means attesting for all providers in that group.

   • Once you select the entities, the attestation statements display above the list:
     

   • Here's a closer look at the attestation statements:
     
     

5. Select the attestation statement applicable to your practice. The Attest button becomes enabled.

6. Click Attest. Your PDMP attestation is complete for all selected providers and a confirmation message appears:
   

7. Note the values in the Status column advance from Pending to Completed - User attested. You can hover over the Status column to see any applicable exclusions.

   • To undo the attestation for any providers, click Retract under the Actions column and in the row of the applicable provider or group.

   • To bulk retract for all entities in the list, click the check box beside the column heading. The number of providers selected appears above the list along with the Retract button.
     

   • Click Retract. Respond to the message that opens by clicking Retract again. The attestation is retracted and the status returns to Pending.

These instructions are to be used when manually attesting to any of the new MIPS or MVP Improvement Activity attestations. For a complete list of the new IA measures and to learn how athenaClinicals implements the Activity, review the details described on the Improvement Activities Measure Satisfaction Guides landing page of the Quality Help Center.

The procedure to attest to an IA measure is the same for all Improvement Activities. These instructions use the Promote Use of Patient-Reported Outcome Tools activity:

1. From the Main menu in athenaClinicals, click Quality, and then click Program Attestations.

2. Select an Improvement Activity from the list, such as the Promote Use of Patient-Reported Outcome Tools. The attestation page opens.
   

3. Review the Improvement Activity attestation description. See the Quality Help Center for more information.

4. Select the clinicians on the Individual tab, or click the Group tab if you're attesting for a group. To bulk select clinicians or groups, click the check box beside the column heading to select all entities in the list. For a group, bulk select means attesting for all providers in that group.

   • Once you select the entities, the attestation statement displays above the list:

   • I attest to CMS that I have met the requirements of this improvement activity per the activity description for the entirety of the performance period for which I am reporting. I understand that I am solely responsible for ensuring the accuracy of my attestation and in the event of an audit, it is my responsibility to record and maintain documentation per the CMS data validation criteria.

5. Select the check box to the left of the statement and then click Attest. A confirmation message appears.
   

6. Note the values in the Status column advance from Pending to Completed.

   • To undo the attestation for any providers, click Retract under the Actions column and in the row of the applicable provider or group.

   • To bulk retract for all entities in the list, click the check box beside the column heading. The number of providers selected appears above the list along with the Retract button.
     

   • Click Retract. Respond to the message that opens by clicking Retract again. The attestation is retracted and the status returns to Pending.

The process to attest to the Immunization Registry Reporting requirement remains the same as the previous workflow when the attestation was located on the Submission Dashboard. This attestation happens at the NPI level.

1. From the Main menu in athenaClinicals, click Quality, and then click Program Attestations.

2. Click Immunization Registry Reporting. The Immunization Registry Reporting attestation page opens.
   

3. Review the measure requirement statement:
   

4. Select the clinicians for whom you're attesting—click the check box beside their name. To bulk attest, click the check box beside the Medical Group column heading to select all clinicians in the list. Once you select the clinicians, the number of providers selected and the ROI date entry field display above the list:
   

5. Click the calendar icon in the Indicate ROI date field and select the date on which your Registration of Intent (ROI) was done for those providers.

6. Click Attest. Your ROI date is saved for all selected providers and a confirmation message appears:
   

7. Note the value in the Active Engagement status (AE Status) column advances to Option 1.

   • If you need to change the date for any providers, click Retract beside the provider.

   • To bulk change the ROI date for all providers in the list, click the check box beside the Medical Group column heading. The number of providers selected appears above the list along with the Retract button.
     

   • Click Retract. Respond to the message that opens by clicking Retract again. The attestation is retracted and the AE Status returns to Pending.

   Tip

   If a check box beside an entity's name is disabled, that is likely because the entities' AE status is Option 2. They are likely further along in the attestation process than the other providers you're bulk attesting.

The process to attest to the Electronic Case Reporting requirement remains the same as the previous workflow when the attestation was located on the Submission Dashboard. This attestation happens at the NPI level.

1. From the Main menu in athenaClinicals, click Quality, and then click Program Attestations.

2. Click Electronic Case Reporting. The Electronic Case Reporting attestation page opens.
   

3. Review the measure requirement statement:

   Reporting the Electronic Case Reporting measure is required to earn a score in the Promoting Interoperability category and Active Engagement (AE) may be demonstrated by one of the following:
   Option 1 - A completed Registration of Intent (ROI) or initiation of Testing and Validation
   Option 2 - Submitting Production data
   Registration of Intent (ROI) date must be within 60 days of the start of the reporting period to meet the program requirement.
   By entering the Registration of Intent (ROI) date and attesting to this measure, I acknowledge that MIPS eligible clinicians are actively engaged with an Electronic Case Reporting registry, by Registering Intent to Submit Data, and I am authorized to make the attestation on behalf of MIPS eligible clinicians in the practice.

4. Select the clinicians for whom you're attesting—click the check box beside their name. To bulk attest, click the check box beside the Medical Group column heading to select all clinicians in the list. Once you select the clinicians, the number of providers selected and the ROI date entry field display above the list:
   

5. Click the calendar icon in the Indicate ROI date field and select the date on which your Registration of Intent (ROI) was done for those providers.

6. Click Attest. Your ROI date is saved for all selected providers and a confirmation message appears:
   

7. Note the value in the Active Engagement status (AE Status) column advances to Option 1.

   • If you need to change the date for any providers, click Retract beside the provider.

   • To bulk change the ROI date for all providers in the list, click the check box beside the Medical Group column heading. The number of providers selected appears above the list along with the Retract button.
     

   • Click Retract. Respond to the message that opens by clicking Retract again. The attestation is retracted and the AE Status returns to Pending.

   Tip

   If a check box beside an entity's name is disabled, that is likely because the entities' AE status is Option 2. They are likely further along in the attestation process than the other providers you're bulk attesting. To complete a bulk attestation, all selected entities must have the same status.

The Security Risk Analysis attestation is another Promoting Interoperability (PI) measure. Attestations for this measure happen at the NPI TIN level. A provider that crosses two TINs will have two separate rows for each TIN that they belong to. However, the attestation itself is at the participating entity level; therefore you attest as a group, or as a provider, which satisfies the measure for the whole TIN.

1. From the Main menu in athenaClinicals, click Quality, and then click Program Attestations. The Program Attestations page opens.

2. Click Security Risk Analysis. The Security Risk Analysis attestation page opens.
   

3. Review the attestation statement:
   
   

4. Select the clinicians for whom you're attesting—click the check box beside their name/group name. Once you select the clinicians/groups, the number of entities selected, and the attestation confirmation message appear above the list:
   

5. Click the check box next to the message, Yes, my practice has conducted a Security Risk Analysis. The Attest button becomes enabled.

6. Click Attest. Your SRA attestation is complete for all selected providers and a confirmation message appears:
   
   

7. Note the value in the Status column advances from Pending to Completed.

   • If you need to change the date for any providers, click Retract beside the provider and start over.

   Tip

   If the message above the list of entities says, # Entities selected Actions disabled that is because the clinicians or groups do not have the same status. You can only multi-select entities with the same status in order to complete attestations for more than one entity at a time.

The Actions to Limit or Restrict the Compatibility of CEHRT, previously known as the Info Blocking attestation, is another PI task that happens at the unique TIN level for each clinician.

1. From the Main menu in athenaClinicals, click Quality, and then click Program Attestations. The Program Attestations page opens.

2. Click Actions to Limit or Restrict the Compatibility of CEHRT. The Actions to Limit or Restrict the Compatibility of CEHRT attestation page opens.
   

3. Review the attestation statement:
   

4. Select the clinicians for whom you're attesting—click the check box beside each name. To bulk attest, click the check box beside the Clinician column heading to select all clinicians in the list. Once you select the clinicians, the number of providers selected and the attestation message display above the list of providers:
   

   • You can also attest at the group level. Click the Group tab to see the list of the entitites organized by participating Groups. Use the check box beside each group to make your selections. On the Group tab, you can only attest by participating groups-you cannot select individual providers within a group for this attestation.

5. Click the check box next to the message, Yes, I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology. The Attest button becomes enabled.

6. Click Attest. The attestation is complete for all selected entities and a confirmation message appears:
   

7. Note the value in the Status column advances from Pending to Completed.

   • If you need to change the date for any providers, click the Retract button within the appropriate row.

   • To bulk change the attestation for all providers in the list, click the check box beside the Clinician or Group column heading. The number of providers selected appears above the list along with the Retract button.
     

   • Click Retract. Respond to the message that opens by clicking yes, retract . The attestation is retracted and the Status values return to Pending.

The Health Information Exchange (HIE) Bi-Directional Exchange measure is an alternative option to the Support Electronic Referral Loops by Sending Health Info and the Support Electronic Referral Loops by Receiving and Reconciling Health Information measures in the HIE objective.

You have these options for satisfying this measure:

• athenahealth will automatically attest on your behalf if Patient Record Sharing (PRS) is enabled for the entire reporting period, or

• You can use another HIE of your choice and self-attest to satisfy the measure, or

• Use the alternative Sending and Receiving measures to meet the HIE objective.

These instructions are for practices where PRS is disabled, or if you want to retract an automatic attestation and manually attest on behalf of specific clinicians.

1. From the Main menu in athenaClinicals, click Quality, and then click Program Attestations. The Program Attestations page opens.

2. Click HIE bi-directional Measure. The HIE bi-directional measure attestation page opens.
   Tip: For practices with PRS enabled, the status column will show Completed - Auto attested.
   

3. Review the attestation statement.

4. Select the clinicians for whom you're attesting—click the check box beside each name. To bulk attest, click the check box beside the Clinician column heading to select all clinicians in the list. Once you select the clinicians, the number of entities selected and the attestation message display above the list of providers:

   • You can also attest at the group level. Click the Group tab to see the list of the entitites organized by participating Groups. Use the check box beside each group to make your selections. On the Group tab, you can only attest by participating groups-you cannot select individual providers within a group for this attestation.

5. Click the check box next to the three bulleted message. The Attest button becomes enabled.

6. Click Attest. The attestation is complete for all selected entities and a confirmation message appears.
   

7. Note the value in the Status column advances from Pending to Completed - User attested.

   • If you need to change the date for any providers, click the Retract button within the appropriate row.

   • To bulk change the attestation for all providers in the list, click the check box beside the Clinician or Group column heading. The number of providers selected appears above the list along with the Retract button.

The Safety Assurance Factors for EHR Resilience Guides (SAFER Guides) requirement is a Promoting Interoperability task. To complete an attestation for the SAFER Guides requirement, you select one of either two statements. Attesting to either statement satisfies the requirement and moves the status from Pending to Completed.

This measure is required.

1. From the Main menu in athenaClinicals, click Quality, and then click Program Attestations.

2. Click High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides. The attestation page opens.
   

3. Review the attestation statement:

   • MIPS eligible clinicians 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 or No" attestation statement accounting for the complete self-assessment using the Guide. Either a "Yes or No" response will satisfy this measure and is required to earn a PI score regardless of whether other measures in this category are reported.
     In the event of an audit, CMS will likely require you to provide proof that you conducted the annual assessment of the High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience Guides (SAFER Guides). After completing the assessment, you may upload the supporting documents to Practice Files for convenient storage while your practice is live on athenaOne.
     

4. Select the clinicians/group for whom you're attesting—click the check box beside their name. You can bulk select clinicians.

5. Select the attestation statement in the blue bar above the list of selected entities:
   

6. Click Attest. Your attestation is complete.

7. Note the value in the Status column advances from Pending to Completed.

   • If you need to change the status for any entities, click the Retract button within the appropriate row.