General Notes


1: Each tab includes the Promoting Interoperability measure.
2: Health IT developers are required to use the same patient names, date of birth, and sex included in the test data and may not use their own test names, date of birth, and sex.
3: Where CMS allows for providers to include or exclude certain data, health IT developers must demonstrate the ability to record the denominator and numerator with and without the data (i.e. ePrescribing allows for the inclusion or exclusion of controlled substances).
4: Measures that are no longer included in the Promoting Interoperability programs will not be tested and therefore do not have test data.
5: If a Health IT Module performs a function automatically, such as making the patient education materials available electronically once identified, or automatically making data available to a patient via view, download, transmit, or an API, it is at the ONC-ATL's discretion not to test scenarios that assume this functionality is not automatic.
6: For Promoting Interoperability Measures, CMS clarified that a numerator is not constrained to an EHR reporting period when the EHR reporting period is less than one year. The numerator action may reasonably fall outside the EHR reporting period timeframe but must take place no earlier than the start of the calendar year and no later than the end of the calendar year in order for the patients to be counted in the numerator. As such, actions occurring after the end of the reporting period's calendar year will not count in the numerator. For applicable measures, the test data has been built to verify that a Health IT Module can record the numerator correctly for each scenario.
7: Starting in 2019, a Promoting Interoperability Measure numerator and denominator is constrained to the performance period chosen, with the exception of the Security Risk Analysis measure which may occur any time during the calendar year.
8: For the EC Individual and Group calculation methods, actions that accrue to the numerator have a transitive effect across all of the TINs that an individual NPI is included in. This transitive effect applies to measures that are unique patient based: Required Tests 3, 4a, 4b, 4c, 5, and 6.
9: Provider 1 is considered one unique NPI and Provider 2 is considered one unique NPI. Group/TIN A is calculated by adding together TIN A/Provider 1 and TIN A/Provider 2. Group/TIN B is calculated by adding together TIN B/Provider 1 and TIN B/Provider 2. Note that for the unique patient measures, patients must be deduplicated when adding together for Group/TIN A and Group/TIN B.

Objectives and Measures

Required Test 1 - Electronic Prescribing
Required Test 2a - Patient Electronic Access (certified to (e)(1) and (g)(9) or (g)(10))
Required Test 2b - Patient Electronic Access (certified to (e)(1))
Required Test 2c - Patient Electronic Access (certified to (g)(9) or (g)(10))
Required Test 7 - Transitions of Care
Required Test 15 - Electronic Referral Loops by Receiving and Incorporating/Reconciling Health Information

Revision History

Version #
Description of Change
Version Date
1.0
Final Test Data
10/30/2016
1.1
Reformatted data to account for testing indiviual EPs, individual ECs, and group ECs. Made corrections to data, reorganized the required tests to follow the order of CMS measure numbers, modified test notes.
12/30/2016
1.2
Removed note 5 from Required Test 2c. Fixed test note in Required Test 5. Modified Required Tests 4a and 4c to allow for use of an API for the Modified Stage 2 and ACI Transition measures. Modified test data in Required Test 1, Test Scenario 1.1 to change the numerator and denominator for Group/TIN A to 2 and Group/TIN B to 4 in the test that excludes controlled substances.
1/23/2017
1.3
Updated test notes in Required Tests 2a, b, c; 3, 4a, b, c; 5; 6; 7; and 8. Corrected data errors in Required Tests 1 and 2a. Updated test data in Required Tests 4a, 4b, and 4c.
2/16/2017
1.4
Modified Column I Row 50 in Required Test 2b to indicate No.
4/24/2017
1.5
Updated test notes in Required Tests 4a and 4c. Removed the reference to the CCG from Required Tests 4a, 4b, and 4c. Fixed test data for Required Tests 1, 2a, and 5.
5/26/2017
1.6
Updated General Notes. Updated test notes in Required Test 3, 4a, 4b, 4c, and 5.
8/25/2017
1.7
Updated test notes in Required Test 5 and 6.
9/29/2017
1.8
Updated test data in Required Test 3.
10/27/2017
1.9
Updated Required Test 3 test data note 6, Required Test 4 test data note 10, Required Test 5 test data note 8, and Required Test 6 test data note 5 to state that “it is up the discretion of the ONC-ATL to not test TIN B/Provider 1 and TIN A/Provider 2” not “it is up the discretion of the ONC-ATL to not test TIN B/Provider 1 and TIN B/Provider 2”. Updated General Note 3 to clarify that health IT developers must demostrate the ability to record both methods
11/14/2017
2.0
Updated the ACI measure in RT 4a, 4b, and 4c to clarify that the action is taken by the patient or patient authorized representative rather than the Eligible Clinician.
2/1/2018
2.1
Updated General Note 12 to clarify that both the EC Individual and EC Group methods must be tested by a Health IT Module supporting the ACI Transition or ACI calculation method. Modified the timely access requirement for the ACI Patient Electronic Access measure in RT 2a, 2b, and 2c based on a CMS policy change per the QPP CY 2018 final rule (82 FR 53568). Modified the test data in Required Test 5 scenario 1.5 to increment the Modified Stage 2 measure for Provider 1.
8/17/2018
2.1.1
Made the following changes based on CMS policy changes per the CY2019 PFS final rule: Updated the tab names for Required Test 2a, 2b, 2c, and 7 and added a test data note outlining the measure name change and that no other changes were made to the test data. Added a test data note to Required Test 7 noting that any document template within the C-CDA can be used to meet the measure. Added general note 14 noting Promoting Interoperability measures that are only applicable in 2018. Modified the information on when actions must occur to populate the numerator for Promoting Interoperability measures starting in 2019.
2/28/2019
2.1.2
Made the following changes based on CMS policy changes per the CY2019 PFS final rule: added Required Tests 13, 14, and 15. Added general note 15 stating that testing for Required Tests 13 and 14 is self-declaration. Added general note 16 noting Promoting Interoperability measures that are only applicable starting in 2019. Added general note 17 noting that testing to the Modified Stage 2 and Promoting Interoperability Transition calculation methods is optional starting in 2019.
9/30/2019
2.1.2
Updated general note 15 to remove RT 13. Modified general note 16 removing RT 13 and clarifying that RT 14 is only applicable in 2019. Added general note 18 clarifying that RT 13 is no longer available for testing as it is now a Yes/No measure. Updated RT 15 to replace the 'No' with 0 in the number of electronic summary of care records received column.
11/4/2019
2.1.3
Based on the sunsetting of the 2014 Edition in the Cures Final rule measure descriptions have been updated to reflect 2020 Promoting Interoperability requirements. RT 14 was for 2019 only and has been removed
6/15/2020
2.2
2021 Promoting Interoperability programs changed the name of the Support Electronic Referral Loops by Receiving and Incorporating Health Information measure by replacing incorporating with reconciling.
12/17/2020
2.3
Removed column in RT2b for Available to Access via API. Updated calculations for RT5.
5/5/2021
2.4
Added guidance to hide Automated Drug Queries for 2021 RT1 tests for MIPS. Removed references to encounters that happen outside Reporting/Performance Period for RT1, RT2, RT3, RT4, RT5, RT6, RT7, RT8, RT9, RT10, RT11, RT12 and RT15.
6/25/2021
2.5
Updated measure description for RT15, previously it was the exclusion. Fixed calculation errors when hiding automated steps for RT3.
8/4/2021
2.6
Fixed calculation errors when hiding automated steps for RT1.
11/8/2021
2.7
Removed references to 2020 Promoting Interoperability. Added references to 2022 Promoting Interoperability. Added indication that the Medicaid measures are for 2021 Only.
12/15/2021
2.8
Added references to 2023 Promoting Interoperability.
1/9/2023
2.9
Removed the required tests (RT3, RT4, RT5, RT6, RT8, RT9, RT10, RT11, RT12) only used by the 2021 Medicaid program. Removed formulary checking as part of the calculations for RT1.
3/31/2023
2.9.1
Removed result columns (Provider 1 and Provider 2) specific to Medicaid program.
4/3/2023
2.10
Updated references to (g)(8) and (g)(10) for RT2.
11/9/2023
2.11
Added references to 2024 Promoting Interoperability. Unique patient names given for each required test.
4/4/2024
2.12
RT7 and RT15 - Added note highlighting the increase to a continuous 180-day period for 2024 reporting.
4/18/2024