MyMipsScore

2025 Real World Test Plan

For Criteria §170.315 (b)(10), §170.315 (c)(1), §170.315 (c)(2) and §170.315 (c)(3)

General Information

Plan Report ID Number: 20241111dar

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: https://www.mymipsscore.com/onc-hti1-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 (b)(10), §170.315 (c)(1), §170.315 (c)(2) and §170.315 (c)(3) criteria for the ONC EHR Certification Program. We will test the §170.315 (b)(10) criteria separately. The testing of (b)(10) will cover both single and bulk data requests for all criteria. The C-series 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)
     N/A

    Updated certification criteria and associated product
    N/A

    Health IT Module CHPL ID
     N/A

    Date of ONC-ACB notification
    N/A

    Date of customer notification
    N/A

    Conformance method and measurement
    N/A

Measures Used in Overall Approach

The Measure/Metrics and the Descriptions listed below will apply to the individually tested §170.315 (b)(10) and the simultaneous and seamless use of the functionality of certified measures §170.315 (c)(1), §170.315 (c)(2) and §170.315 (c)(3). The RWT be witnessed via a Zoom 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 Export the EHI data for (b)(10) and 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: Export USCDIv1 clinical data for a population of patients for use in a different health information technology product or a third-party system. This export can be used for many purposes, including data portability when a physician's practice switches to a new EHR platform.
     We chose to concentrate on the aspects of this criterion that would:
1) Demonstrate an EHR's ability to export batches of patient data in a straightforward fashion
2) Facilitate interoperability by providing the exported data in the form of valid C-CDA files that conform to the HL7 standards as described in the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm).
Additionally, it includes a publicly accessible hyperlink to the export’s format.


    MEASURE 2: The user logs into the MyMipsScore™ on demand without needing 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 the provider or by the group. This step will indicate that the application has successfully created an interface with the EHR, and that 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 3: Navigation from the Dashboard to allow the participant to import from their EHR, a generated QRDA-I 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 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 eCQMs 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 4: The process will continue by observing that the imported QRDA-I or QRDA-III file was able to automatically rank the eCQMs by individual provider or by a Group (2 or more) 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, as well as the full Quality Score, will signal a successful import of the data. 
     Once the generated QRDA-I or QRDA-III file is 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 to measure their progress throughout the year.
This process is designed to confirm that the designated user within a practice can complete all the steps on demand without involving 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 (b)(10)
    MeldRx 2.0

    MEASURE 2
    §170.315 (c)(1)
    N/A

    MEASURE 3
    §170.315 (c)(2)
    N/A

    MEASURE 4
    §170.315 (c)(3)
    N/A

JUSTIFICATION FOR SELECTED MEASUREMENT/METRIC

    Measurement/Metric
    Justification

    MEASURE 1:Count of single patient export files created during a 3-month timeframe. This demonstrates the ability to export single patient files containing all their EHI. 
    Count of single patient export files created during a 3-month timeframe. This demonstrates the ability to export single patient files containing all their EHI. This metric will also provide information on the demand for this capability.  
  
    MEASURE 2: The user logs into the MyMipsScore™ on demand without Tech support. The successful login is achieved and observed. The user will demonstrate the initial navigation within their practice Dashboard and switch views by the provider or by the group. This step will allow for the indication that the application has successfully created an interface with the EHR, and that 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 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 3: Navigation from the Dashboard allows the participant to import from their EHR a generated QRDA-I or QRDA-III file format based on encounters documented over a calendar year. Successful file import will be observed when the Dashboard is populated with eCQMs Quality data without errors or timeouts. Both file formats will be tested through the data population process.
     This test plan will capture all the steps from QRDA file (I or III) generation to analyzing and reporting 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 show the speed and accuracy of the encounter data converting to eCQM performance rates and MIPS scores.

    MEASURE 4: The process will continue by observing that the imported QRDA-I or QRDA-III file was able to automatically rank the eCQMs by individual provider or by the 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, as 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 eCQMs 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 and acute care settings that range from a single provider to a group of up to 150 providers. These providers will all be using the MyMipsScore application for the Quality category of the MIPS program. 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 export or 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 providers' data collection and is mapped to the specifications of each eCQM. As the required parameters are captured within the UI of the EHR the program logic will capture the information, and it will be generated as a QRDA-I or QRDA-III file format. QRDA-III is the preferred format for the ambulatory setting. QRDA-I will be used in the hospital settings. When these QRDA files are imported into MyMipsScore™, we will demonstrate that the users can review their Quality information often 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 the ambulatory providers in Internal Medicine, Orthopedics, Wound Care Specialists, Podiatry, Behavioral Health, and Physical Therapy. Feedback will also be obtained from Acute Care Hospitalists. The process will be the same in all specialties and will confirm that the type of specialty does not play a role in the generating, calculating, analysing, and reporting of the eCQMs. The ability to achieve individual and bulk data export will also be evaluated.

EXPECTED OUTCOMES

    Measurement/Metric
    Expected Outcomes

    MEASURE 1:  §170.315 (b)(10)
    The number of single-patient export files generated over a 3-month period will be tracked. Real-world testing will demonstrate an organization's ability to create single-patient EHI export files in compliance with the 170.315(b)(10) criterion. The expected outcome is a non-zero count, though we anticipate low numbers since many organizations may continue using their existing methods for exporting single-patient data, such as interoperability tools or manual processes. 

    MEASURE 2: §170.315 (c)(1), §170.315 (c)(2), and §170.315 (c)(3)
     MyMipsScore™ users are expected to have secure, individualized access to their practice and an overview of their eCQM Quality reports. Success is measured by each user’s ability to reliably login to their MyMipsScore™ account using their secure credentials. A zero-error rate is expected, as the data must be submitted to CMS for the MIPS program, with all information pre-validated to ensure no errors.

    MEASURE 3: §170.315 (c)(1), §170.315 (c)(2), and §170.315 (c)(3)
    Users of MyMipsScore™ will be able to track their eCQM progress throughout the year independently, without needing assistance from us as developers. Success is defined by the system’s ability to provide an accurate view of numerators, denominators, data completeness, and performance rates within the Quality category. eCQMs will be added to each account either manually or automatically, depending on the specific setup. A zero-error rate is expected, as the data must be reported to CMS for the MIPS program, with all submissions pre-validated to ensure no errors.

     MEASURE 4: §170.315 (c)(1), §170.315 (c)(2), and §170.315 (c)(3)
    MyMipsScore™ users are expected to be able to collect, calculate, analyze, and report their MIPS eCQMs to fully meet their MIPS requirements. Success will be determined by the ability to accurately review the quality measure reports for both groups and individual providers. A zero-error rate is expected, as the data must be submitted to CMS for the MIPS program, with all reports pre-validated to ensure no errors.

SCHEDULE OF KEY MILESTONES

    Key Milestone
    Care Setting
    Date/Timeframe

     Prepare the MyMipsScore™ application for collecting eCQM data for the 2025 MIPS performance year, including the data export capabilities
    Ambulatory and Acute Care Settings
    December 2024

    Identify the user practices that will participate in the test plan
    Ambulatory and Acute Care Settings for
    Multiple Specialties
    
    December 2024 & January 2025

    Confirm that the Real World Test Plan participants can log into their accounts and are ready to start MIPS Quality documentation for the 2025 Performance Year and are prepared for an EHI data export process
 Ambulatory and Acute Care Settings for Multiple Specialties
    
    January 2025

    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 and Acute Care Settings for
    Multiple Specialties
    
    Quarterly 2025

    End the Real World Test to coincide with the end of the MIPS 2025 Performance Year
Ambulatory and Acute Care Settings for
    Multiple Specialties
    
    January 2026

    Real World Test analysis and generation of the report
Ambulatory and Acute Care Settings for
    Multiple Specialties
    
    January 2026

    Submit Real World Test Report to ACB before established deadline
Ambulatory and Acute Care Settings for
    Multiple Specialties
    
    January 2026

Attestation

This Real-World Testing plan has all the required elements, including measures that address all certification criteria and care settings. All the 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: 11/11/2024

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

Measurement/Metric	Description
MEASURE 1: Export USCDIv1 clinical data for a population of patients for use in a different health information technology product or a third-party system. This export can be used for many purposes, including data portability when a physician's practice switches to a new EHR platform.	We chose to concentrate on the aspects of this criterion that would: 1) Demonstrate an EHR's ability to export batches of patient data in a straightforward fashion 2) Facilitate interoperability by providing the exported data in the form of valid C-CDA files that conform to the HL7 standards as described in the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm). Additionally, it includes a publicly accessible hyperlink to the export’s format.
MEASURE 2: The user logs into the MyMipsScore™ on demand without needing 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 the provider or by the group. This step will indicate that the application has successfully created an interface with the EHR, and that 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 3: Navigation from the Dashboard to allow the participant to import from their EHR, a generated QRDA-I 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 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 eCQMs 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 4: The process will continue by observing that the imported QRDA-I or QRDA-III file was able to automatically rank the eCQMs by individual provider or by a Group (2 or more) 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, as well as the full Quality Score, will signal a successful import of the data.	Once the generated QRDA-I or QRDA-III file is 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 to measure their progress throughout the year. This process is designed to confirm that the designated user within a practice can complete all the steps on demand without involving 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:Count of single patient export files created during a 3-month timeframe. This demonstrates the ability to export single patient files containing all their EHI.	Count of single patient export files created during a 3-month timeframe. This demonstrates the ability to export single patient files containing all their EHI. This metric will also provide information on the demand for this capability.
MEASURE 2: The user logs into the MyMipsScore™ on demand without Tech support. The successful login is achieved and observed. The user will demonstrate the initial navigation within their practice Dashboard and switch views by the provider or by the group. This step will allow for the indication that the application has successfully created an interface with the EHR, and that 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 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 3: Navigation from the Dashboard allows the participant to import from their EHR a generated QRDA-I or QRDA-III file format based on encounters documented over a calendar year. Successful file import will be observed when the Dashboard is populated with eCQMs Quality data without errors or timeouts. Both file formats will be tested through the data population process.	This test plan will capture all the steps from QRDA file (I or III) generation to analyzing and reporting 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 show the speed and accuracy of the encounter data converting to eCQM performance rates and MIPS scores.
MEASURE 4: The process will continue by observing that the imported QRDA-I or QRDA-III file was able to automatically rank the eCQMs by individual provider or by the 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, as 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 eCQMs 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.

Measurement/Metric	Expected Outcomes
MEASURE 1: §170.315 (b)(10)	The number of single-patient export files generated over a 3-month period will be tracked. Real-world testing will demonstrate an organization's ability to create single-patient EHI export files in compliance with the 170.315(b)(10) criterion. The expected outcome is a non-zero count, though we anticipate low numbers since many organizations may continue using their existing methods for exporting single-patient data, such as interoperability tools or manual processes.
MEASURE 2: §170.315 (c)(1), §170.315 (c)(2), and §170.315 (c)(3)	MyMipsScore™ users are expected to have secure, individualized access to their practice and an overview of their eCQM Quality reports. Success is measured by each user’s ability to reliably login to their MyMipsScore™ account using their secure credentials. A zero-error rate is expected, as the data must be submitted to CMS for the MIPS program, with all information pre-validated to ensure no errors.
MEASURE 3: §170.315 (c)(1), §170.315 (c)(2), and §170.315 (c)(3)	Users of MyMipsScore™ will be able to track their eCQM progress throughout the year independently, without needing assistance from us as developers. Success is defined by the system’s ability to provide an accurate view of numerators, denominators, data completeness, and performance rates within the Quality category. eCQMs will be added to each account either manually or automatically, depending on the specific setup. A zero-error rate is expected, as the data must be reported to CMS for the MIPS program, with all submissions pre-validated to ensure no errors.
MEASURE 4: §170.315 (c)(1), §170.315 (c)(2), and §170.315 (c)(3)	MyMipsScore™ users are expected to be able to collect, calculate, analyze, and report their MIPS eCQMs to fully meet their MIPS requirements. Success will be determined by the ability to accurately review the quality measure reports for both groups and individual providers. A zero-error rate is expected, as the data must be submitted to CMS for the MIPS program, with all reports pre-validated to ensure no errors.