Security Risk Analysis

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.

 Exclusion/Exceptions

None.

 Reporting Requirements

YES/NO

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.

 Required Measure

Yes, attest yes or cannot attest to PI category.

 Scoring

None

 RESOURCES

HHS SRA Toolkit

2024MIPSPIMeasuresSecurityRiskAnalysis.pdf
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