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Security Risk Analysis | MIPS PI Measures for 2021 Reporting


For use with CEHRT certified to the 2015 edition.

Measure Description

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.

 ObjectiveMeasureMaximum Points
 Protect Patient Health InformationSecurity Risk Analysis0*


*This measure remains part of the requirements for the Promoting Interoperability performance category, but will no longer receive points towards the total PI score.

Reporting Requirements

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.

Definition of Terms & Additional Information