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Security Risk Analysis | MIPS PI Measures for 2022 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.

Objective Measure Maximum Points
Protect Patient Health Information Security Risk Analysis 0*

*This is a required measure for 2022 for the Promoting Interoperability performance category and must be answered in the affirmative for PI to be successfully reported.

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