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Tools and Resources

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HSAG engages providers at all levels of performance for collaborative learning and action that accelerate healthcare quality improvement. Use the resources below to better understand and successfully implement the Quality Payment Program (QPP).

Merit-based Incentive Payment System (MIPS) Overview

MIPS Participation

Quality Performance Category

Promoting Interoperability (PI) Performance Category

Improvement Activities (IA) Performance Category

Cost Performance Category

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For up-to-date information and guidance on QPP reporting, visit our Learning Forum Friday webpage for registration to our live training webinars and for access to our web recording archive.

QPP and Merit-based Incentive Payment System (MIPS)

APMs

Quality Category

Promoting Interoperability Category

Cost Category

Creating a HARP Account for QPP
(HARP = Healthcare Quality Information System [HCQIS] Access Roles and Profile)

HSAG has assembled important Merit-Based Incentive Payment System (MIPS) Quality measure-related resources to help you stay on track. Start here at the CMS Centralized Repository that provides a list of specialized and other registries.

HSAG has assembled helpful IA-based resources and tools to assist you.

HSAG encourages your use of the following resources to help guide your understanding of PI (formerly known as ACI).

Anti-Ransomware Resources

Practices using health information technology, including electronic health records (EHR), are required to conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process. Providers are under a duty to protect data in accordance with security risk analysis. The guidance below offers ways to help keep your data safe from a ransomware attack and what to do if an attack occurs.

If You Are a Victim of an Attack

If your organization is the victim of a ransomware attack, Health and Human Services (HHS) recommends the following steps:

  1. Please contact your FBI Field Office Cyber Task Force (www.fbi.gov/contact-us/field/field-offices) immediately to report a ransomware event and request assistance. These professionals work with state and local law enforcement and other federal and international partners to pursue cyber criminals globally and to assist victims of cyber-crime.
  2. Please report cyber incidents to the U.S. Computer Readiness System (US-CERT) (www.us-cert.gov/ncas) and FBI’s Internet Crime Complaint Center (www.ic3.gov).
  3. **NEW** If your facility experiences a suspected cyberattack affecting medical devices, you may contact FDA’s 24/7 emergency line at 1.866.300.4374. Reports of impact on multiple devices should be aggregated on a system/facility level.
  4. For further analysis and healthcare-specific indicator sharing, please also share these indicators with HHS’ Healthcare Cybersecurity and Communications Integration Center (HCCIC) at HCCIC@hhs.gov.

How to Mitigate Against an Attack

  • Educate users on common Phishing tactics to entice users to open malicious attachments or to click links to malicious sites.
  • Patch vulnerable systems with the latest Microsoft security patches: https://technet.microsoft.com/en-us/security/bulletins.aspx.
  • Verify perimeter tools are blocking Tor .Onion sites.
  • Use a reputable anti-virus (AV) product whose definitions are up-to-date to scan all devices in your environment in order to determine if any of them have malware on them that has not yet been identified. Many AV products will automatically clean up infections or potential infections when they are identified.
  • Monitor the US-CERT website for the latest updates from the U.S. government. See below for current reporting.
  • Utilize HPH Sector Information Sharing and Analysis Center (ISAC) and Information Sharing and Analysis Organization (ISAO) resources. See below for further information.

US-CERT Resources

Original release date: June 27, 2017 US-CERT has received multiple reports of Petya ransomware infections occurring in networks in many countries around the world. Ransomware is a type of malicious software that infects a computer and restricts users' access to the infected machine until a ransom is paid to unlock it. Individuals and organizations are discouraged from paying the ransom, as this does not guarantee that access will be restored. Using unpatched and unsupported software may increase the risk of proliferation of cybersecurity threats, such as ransomware.

Petya ransomware encrypts the master boot records of infected Windows computers, making affected machines unusable. Open-source reports indicate that the ransomware exploits vulnerabilities in Server Message Block (SMB). US-CERT encourages users and administrators to review the US-CERT article on the Microsoft SMBv1 Vulnerability and the Microsoft Security Bulletin MS17-010. For general advice on how to best protect against ransomware infections, review US-CERT Alert TA16-091A. Please report any ransomware incidents to the Internet Crime Complaint Center (IC3).

Sector ISAO and ISAC Resources

National Health Information-Sharing and Analysis Center (NH-ISAC) has shared the following TLP-White Message and will continue to share information at nhisac.org. Health Information Trust Alliance (HITRUST) has shared the following Threat Bulletin for distribution.

Office of the National Coordinator (ONC) and Office for Civil Rights (OCR) Resources

From time to time, resources are from CMS and are updated and posted regularly as new updates come online.

HSAG has gathered relevant QPP materials and tools into one place. In addition, download a handy graphic icon for conversion into a desktop widget by following easy step-by-step instructions. To get started, review these essential tools for your state:

2018 Resources

2018 QPP Guide (PDF)

Tips for Successful Participation in the Quality Payment Program 2018 (PDF)

QPP Audit Resource (PDF)

Countdown to MIPS Timeline (PDF)

MIPS Year 1 (2017) and Year 2 (2018) Requirements Comparison (PDF)

Summary of Quality Data Submission Criteria (PDF)

CMS Quality Payment Program: Opportunities Towards Health Equity (PDF)

Other Helpful Resources

The Centers for Medicare & Medicaid Services (CMS) have assembled QPP-related resources at https://qpp.cms.gov/about/resource-library. These materials include a MIPS Activity Fact Sheet, MIPS participation Fact Sheet, and MIPS 2018 CMS-Approved Qualified Registries Guide.

Be sure to visit these CMS resources:

* CAHPS = Consumer Assessment of Healthcare Providers and Systems

* HARP = Health Care Quality Information System (HCQIS) Access Roles and Profile System