Protect Patient Health Information

Security Risk Analysis

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 electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician’s risk management process.

To meet this measure, MIPS eligible clinicians must attest YES to conducting or reviewing a security risk analysis and implementing security updates as necessary and correcting identified security deficiencies.

There are several options to complete this measure, including:

• You may complete the Security Risk Assessment Tool (SRA Tool) found on the HealthIT website.
• You may hire a vendor
• You may do the research and complete the security risk analysis on your own; making sure that it meets the requirements described in the measure specification

Protect electronic protected health information (ePHI) created or maintained by the CEHRT through the implementation of appropriate technical, administrative, and physical safeguards. For auditing purposes, keep a copy of your security risk analysis in your MIPS Audit Folder.

SAFER Guide Review

High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides Conduct an annual assessment of the High Priority Practices Guide SAFER Guide.

The MIPS eligible clinicians must attest YES or NO to conducting an annual self-assessment of the High Priority Practices Guide of the SAFER Guides in the 2023 performance period.