MyMipsScore

2024 Real World Test Plan

For Criteria §170.315 (c)(1), §170.315 (c)(2) and §170.315 (c)(3) Cures Update

General Information

Plan Report ID Number: 20231114dar

Developer Name: Darena Solutions LLC

Product Name(s): MyMipsScore™

Version Number(s): 2018

Certified Health IT: 15.02.05.1322.DARE.01.01.1.211119

Product List (CHPL) ID(s): IG-4105-18-0004

Developer Real World Testing Page URL: http://www.mymipsscore.com/2015-ehr-certification

Justification for Real World Testing approach

Currently the Certified Health IT module, MyMipsScore™ is sold as a stand-alone module to EHRs to provide a solution for their §170.315 (c)(1), §170.315 (c)(2) and §170.315 (c)(3) Cures Update criteria for the 2015 Edition Certification. These criteria were tested individually during the ONC certification process. However, in the real world, these certified modules provide one seamless approach to accomplish the eCQM documentation requirements of all three criteria mentioned above. To that end, the Real World Test plan will be designed to demonstrate how these combined modules perform in the production environment. This certified product is deployed with many EHRs covering multiple specialties within the ambulatory marketplace. We will design our Real World Test plan to reinforce the capabilities that we encounter in these ambulatory use cases. The MyMipsScore™ application does allow providers to fully satisfy their reporting requirements for the Quality category of MIPS.

  
STANDARDS UPDATES (INCLUDING STANDARDS VERSION ADVANCEMENT PROCESS (SVAP) AND UNITED STATES CORE DATA FOR INTEROPERABILITY (USCDI)) 

    Standard (and version)
    CMS Implementation Guides (IG) 2020 for
Quality Reporting Document Architecture (QRDA)
Category I Hospital Quality Reporting   AND
Category III Eligible Clinicians and Eligible Professionals Programs. Also - CMS Implementation Guide for Quality Reporting Document Architecture: Category I; Hospital Quality Reporting; Implementation Guide for 2023 (March 2023)

    Updated certification criteria and associated product
    170.315(c)(3) (Cures Update) Clinical quality measures (CQMs) - report MyMipsScore version 2018/td>

    Health IT Module CHPL ID
    15.02.05.1322.DARE.01.01.1.211119

    Method used for standard update
    Cures Update

    Date of ONC-ACB notification
    11/14/2023

    Date of customer notification (SVAP only)
    11/14/2023

    Conformance Measure
    170.315(c)(3) (Cures Update) Clinical quality measures (CQMs) — report Measure 3

    USCDI-updated certification criteria (and USCDI version)
    N/A

Measures Used in Overall Approach

DESCRIPTION OF MEASUREMENT/METRIC

Describe the measure(s) that will be used to support the overall approach to Real World Testing.

The Measure/Metrics and the Descriptions listed below will apply to the simultaneous and seamless use of the functionality of certified measures §170.315 (c)(1), §170.315 (c)(2) and §170.315 (c)(3) Cures Update. The RWT will be witnessed via a GoToMeeting session with the participants using a production environment and real patient data. Upon completion, we will observe the successful conformance of the certified technology to be able to Record and Export the required eCQM data, followed by the ability to Import and Calculate the data into the certified technology ultimately providing the ability to generate a report displayed on a Dashboard.

  

    Measurement/Metric
    Description

    MEASURE 1: User logs into the MyMipsScore™ on demand with no need of Tech support. The successful log in is achieved and observed. The user will demonstrate the initial navigation within their practice Dashboard and switch views by provider or by group. This step will allow for the indication that the application has successfully created an interface with the EHR, and the necessary logic has been programmed for the desired eCQMs 
    Each designated user is provided with unique credentials that will allow them to log into the MyMipsScore™ application via an interface within the EHR to view their MIPS Dashboard. From the Dashboard the user will be able to navigate to a “By Provider” view or an aggregated “Group” view (2 or more providers). Upon completion of these steps, we will have observed the ability to demonstrate conformance to the requirements of the above-mentioned certified technology. 

    MEASURE 2: Navigation from the Dashboard to allow the participant to import from their EHR, a generated QRDA 1 or QRDA III file format based on encounters documented over a calendar year. Successful file import with be observed when the Dashboard is populated with their eCQM Quality data without errors or timeouts. Both file formats will be tested through to the data population process.
    Once in the MyMipsScore™ application the authorized user will import generated QRDA 1 or QRDA III files that will allow for automatic calculation of the eCQM numerators, denominators, exceptions and or exclusions. Additionally, they will be able to see the patients who are within each of the segments mentioned above.  Upon completion of these steps, we will have observed the ability to demonstrate conformance to the requirements of the above-mentioned certified technology.

    MEASURE 3: The process will continue by observing that the imported QRDA 1 or QRDA III file was able to automatically rank the eCQMs, by individual provider or by a Group (2 or more) and based on the encounter data documented during patient visits throughout the year, by performance rate and MIPS point value. The observed rank order and point value and well as the full Quality Score will signal a successful import of the data
    Once the generated QRDA 1 or QRDA III file in imported into the MyMipsScore™ application the user will see the appropriate eCQMs listed based on their MIPS scores and performance rates (High to Low). The MyMipsScore™ application will also display the aggregated Quality MIPS Composite Score. The process can be repeated by the user multiple times per year as a way to measure their progress throughout the year.
This process is designed and will confirm that the designated user within a practice can complete all of the steps on demand and without the need to involve the EHR developer. Upon completion of these steps, we will have observed the ability to demonstrate conformance to the requirements of the above-mentioned certified technology.

ASSOCIATED CERTIFICATION CRITERIA

    Measurement/Metric
    Associated Certification Criteria
    Relied Upon Software

    MEASURE 1
    §170.315 (c)(1)
    N/A

    MEASURE 2
    §170.315 (c)(2)
    N/A

    MEASURE 3
    §170.315 (c)(3) Cures Update
    N/A

JUSTIFICATION FOR SELECTED MEASUREMENT/METRIC

    Measurement/Metric
    Justification

    MEASURE 1: User logs into the MyMipsScore™ on demand with no need of Tech support. The successful log in is achieved and observed. The user will demonstrate the initial navigation within their practice Dashboard and switch views by provider or by group. This step will allow for the indication that the application has successfully created an interface with the EHR, and the necessary logic has been programmed for the desired eCQMs.
    The certification of this technology requires that a user can gain access, run their data, analyze the results and report the findings without the assistance from the developer. The test plan will allow us to reinforce that this capability is in place and functioning throughout the year. The Quality reporting period for MIPS is the full calendar year.

    MEASURE 2: Navigation from the Dashboard to allow the participant to import from their EHR, a generated QRDA 1 or QRDA III file format based on encounters documented over a calendar year. Successful file import with be observed when the Dashboard is populated with their eCQM Quality data without errors or timeouts. Both file formats will be tested through to the data population process.
    This test plan will capture all of the steps from QRDA file (I or III) generation to analyzing and reporting of the Quality MIPS scores for either a single provider or aggregated as a Group (2 or more providers). Testing with both single and multiple providers will demonstrate the performance of all three certified criteria and the show the speed and accuracy of the encounter data converting to eCQM performance rates and MIPS scores.

    MEASURE 3: The process will continue by observing that the imported QRDA 1 or QRDA III file was able to automatically rank the eCQMs, by individual provider or by a Group (2 or more) and based on the encounter data documented during patient visits throughout the year, by performance rate and MIPS point value. The observed rank order and point value and well as the full Quality Score will signal a successful import of the data.
    Upon completion of this designed full process, the user will be able to evaluate their practice’s performance rates related to a specific set of pre-identified eCQM’s pertaining to their scope of practice. This application will allow them to submit their data to CMS to complete the MIPS requirement for each performance year.

CARE SETTING(S)

    Care Setting
    Justification

    This plan will test within ambulatory settings with individual providers and up to 150 providers. The plan will include testing within practices of different specialties to confirm that the type of specialty does not play a role in the data collection, eCQM calculation, analysis, and reporting.
    The process for reporting the MIPS Quality category using eCQMs entails encounter data collection throughout the full calendar year. This process relies on the data collection of the providers and is mapped to the specifications of each eCQM. As the required parameter(s) is captured within the UI of the EHR the program logic will capture the information and it will be generated as a QRDA 1 or QRDA III file format.  QRDA III is the preferred format for the ambulatory setting. When these QRDA files are imported into MyMipsScore™ we will demonstrate that the uses can review their Quality information as many times during the year as necessary. Additionally, we will confirm that the Quality data can be sent to CMS as a part of the MIPS process.

    Testing will include multiple specialties. 
    The MyMipsScore™ is currently used by providers of multiple specialties. This test plan will demonstrate that the process is the same regardless of the specialty. We will get feedback from Internal Medicine, Orthopedics, Wound Care Specialists, Podiatry, Behavioral Health, and Physical Therapy. The process will be the same in all specialties and will confirm that the type of specialty does not play a role in the generate, calculate, analyze and reporting of the eCQMs.

EXPECTED OUTCOMES

    Measurement/Metric
    Expected Outcomes

    §170.315 (c)(1), §170.315 (c)(2) and §170.315 (c)(3)Cures Update
    It is expected that the users of MyMipsScore™ will have unique and secure access to their practice and provide an overview of their eCQMs Quality reports. Success we be determined when each user can successfully and consistently log into their MyMipsScore™ account using their assigned secure credentials. A zero error rate is expected due to the need to report the data to CMS for the MIPS program, pre-validated to have zero errors.

    §170.315 (c)(1), §170.315 (c)(2) and §170.315 (c)(3)Cures Update
    It is expected that the users MyMipsScore™ will be able to review their eCQM progress throughout the year as often and needed without assistance from us as the developer. Success we be determined when an accurate view of the numerators, denominators, data completeness and performance rate is present in the Quality category. The eCQMs will be either manually or automatically added to each account based on their specific setup. A zero error rate is expected due to the need to report the data to CMS for the MIPS program, pre-validated to have zero errors.

    §170.315 (c)(1), §170.315 (c)(2) and §170.315 (c)(3)Cures Update
    It is expected that the users of MyMipsScore™ will have the ability to collect, calculate, analyze, and report their MIPS eCQMs to fully satisfy their MIPS requirements. The determination od success is the ability to review the quality measure report for the group or individual provider. A zero error rate is expected due to the need to report the data to CMS for the MIPS program, pre-validated to have zero errors.

SCHEDULE OF KEY MILESTONES






  

    Key Milestone
    Care Setting
    Date/Timeframe

    Prepare the MyMipsScore™ application for use in collecting eCQM data for the 2024 MIPS performance year
    Ambulatory Setting
Multiple Specialties 
    December 2023

    Identify the user practices the will participate in the test plan
    Ambulatory Setting
    December 2023 & January 2024

    Confirm that the Real World Test Plan participants are able to log into their accounts and are ready to start MIPS Quality documentation for the 2024 Performance Year
    Ambulatory Setting
Multiple Specialties

    January 2024

    Follow-up with the Real World Test Plan participants on a regular basis (minimum, once a quarter) to obtain feedback on their progress and or if there are any issues to address
    Ambulatory Setting
Multiple Specialties

    Quarterly 2024

    End the Real World Test to coincide with the end of the MIPS 2024 Performance Year
    Ambulatory Setting
Multiple Specialties

    January 2025

    Real World Test analysis and generation of the report
    Ambulatory Setting
Multiple Specialties

    January 2025

    Submit Real World Test Report to ACB before established deadline
    Ambulatory Setting
Multiple Specialties

    February 2025

Attestation

The Real World Testing plan must include the following attestation signed by the health IT developer authorized representative.

Note: The plan must be approved by a health IT developer authorized representative capable of binding the health IT developer for the execution of the plan and include the representative's contact information.[i]

This Real World Testing plan is complete with all required elements, including measures that address all certification criteria and care settings. All information in this plan is up to date and fully addresses the health IT developer’s Real World Testing requirements.

Authorized Representative Name: Wayne Singer

Authorized Representative Email: wayne@darenasolutions.com

Authorized Representative Phone: 832-736-2552

Authorized Representative Signature: /Wayne Singer/

Date: 11/14/2023

[i] https://www.federalregister.gov/d/2020-07419/p-3582

Measurement/Metric	Description
MEASURE 1: User logs into the MyMipsScore™ on demand with no need of Tech support. The successful log in is achieved and observed. The user will demonstrate the initial navigation within their practice Dashboard and switch views by provider or by group. This step will allow for the indication that the application has successfully created an interface with the EHR, and the necessary logic has been programmed for the desired eCQMs	Each designated user is provided with unique credentials that will allow them to log into the MyMipsScore™ application via an interface within the EHR to view their MIPS Dashboard. From the Dashboard the user will be able to navigate to a “By Provider” view or an aggregated “Group” view (2 or more providers). Upon completion of these steps, we will have observed the ability to demonstrate conformance to the requirements of the above-mentioned certified technology.
MEASURE 2: Navigation from the Dashboard to allow the participant to import from their EHR, a generated QRDA 1 or QRDA III file format based on encounters documented over a calendar year. Successful file import with be observed when the Dashboard is populated with their eCQM Quality data without errors or timeouts. Both file formats will be tested through to the data population process.	Once in the MyMipsScore™ application the authorized user will import generated QRDA 1 or QRDA III files that will allow for automatic calculation of the eCQM numerators, denominators, exceptions and or exclusions. Additionally, they will be able to see the patients who are within each of the segments mentioned above. Upon completion of these steps, we will have observed the ability to demonstrate conformance to the requirements of the above-mentioned certified technology.
MEASURE 3: The process will continue by observing that the imported QRDA 1 or QRDA III file was able to automatically rank the eCQMs, by individual provider or by a Group (2 or more) and based on the encounter data documented during patient visits throughout the year, by performance rate and MIPS point value. The observed rank order and point value and well as the full Quality Score will signal a successful import of the data	Once the generated QRDA 1 or QRDA III file in imported into the MyMipsScore™ application the user will see the appropriate eCQMs listed based on their MIPS scores and performance rates (High to Low). The MyMipsScore™ application will also display the aggregated Quality MIPS Composite Score. The process can be repeated by the user multiple times per year as a way to measure their progress throughout the year. This process is designed and will confirm that the designated user within a practice can complete all of the steps on demand and without the need to involve the EHR developer. Upon completion of these steps, we will have observed the ability to demonstrate conformance to the requirements of the above-mentioned certified technology.

Measurement/Metric	Justification
MEASURE 1: User logs into the MyMipsScore™ on demand with no need of Tech support. The successful log in is achieved and observed. The user will demonstrate the initial navigation within their practice Dashboard and switch views by provider or by group. This step will allow for the indication that the application has successfully created an interface with the EHR, and the necessary logic has been programmed for the desired eCQMs.	The certification of this technology requires that a user can gain access, run their data, analyze the results and report the findings without the assistance from the developer. The test plan will allow us to reinforce that this capability is in place and functioning throughout the year. The Quality reporting period for MIPS is the full calendar year.
MEASURE 2: Navigation from the Dashboard to allow the participant to import from their EHR, a generated QRDA 1 or QRDA III file format based on encounters documented over a calendar year. Successful file import with be observed when the Dashboard is populated with their eCQM Quality data without errors or timeouts. Both file formats will be tested through to the data population process.	This test plan will capture all of the steps from QRDA file (I or III) generation to analyzing and reporting of the Quality MIPS scores for either a single provider or aggregated as a Group (2 or more providers). Testing with both single and multiple providers will demonstrate the performance of all three certified criteria and the show the speed and accuracy of the encounter data converting to eCQM performance rates and MIPS scores.
MEASURE 3: The process will continue by observing that the imported QRDA 1 or QRDA III file was able to automatically rank the eCQMs, by individual provider or by a Group (2 or more) and based on the encounter data documented during patient visits throughout the year, by performance rate and MIPS point value. The observed rank order and point value and well as the full Quality Score will signal a successful import of the data.	Upon completion of this designed full process, the user will be able to evaluate their practice’s performance rates related to a specific set of pre-identified eCQM’s pertaining to their scope of practice. This application will allow them to submit their data to CMS to complete the MIPS requirement for each performance year.