Stage 1 – 2014 Edition
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
You must retain ALL relevant supporting documentation to support attestation data for Meaningful Use objectives and clinical quality measures for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.
- MU-EH-Stage 1-Attestation
- MU-EP-Stage 1-Attestation
Beginning in 2014, EHs and CAHs will no longer be permitted to count an exclusion toward the minimum of five menu objectives on which they must report if there are other menu objectives which they can select.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
- MU-EP-Stage 1-Interfaces
- MU-EP-Stage 2-Interfaces
The universal feeds do not include the internal mapping and/or translations utilized to meet the implementation guidelines/criteria outlined in the Meaningful Use objectives and therefore cannot be used for Meaningful Use attestation.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
- MU-EP-Stage 1-Interfaces
- MU-EP-Stage 2-Interfaces
Orders need to be placed as soon as possible. The minimum lead time for all interface orders is 90 days. Interfaces must be purchased in production prior to the start of the Meaningful Use reporting period.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
To validate provider attestation for these objectives, CMS and its contractor may request additional supporting documentation. A few examples of suggested documentation are listed:
- Drug-Drug/Drug-Allergy Interaction Checks and Clinical Decision Support: One or more screenshots from the certified EHR system that demonstrate the enabling of the interventions during the EHR reporting period selected for attestation.
- Report clinical quality measures: Report from the certified EHR system to validate all clinical quality measure data entered during attestation
- Protect Electronic Health Information: Documentation of security risk analysis of the certified EHR technology was performed prior to the end of the reporting period
- Drug Formulary Checks: One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation.
- Generate Lists of Patients by Specific Conditions: Report from the certified EHR system that is dated during the EHR reporting period selected for attestation. Patient-identifiable information may be masked/blurred before submission.
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Immunization Registries Data Submission, Reportable Lab Results to Public Health Agencies, and Syndromic Surveillance Data Submission:
- Dated screenshots from the EHR system that document a test submission to the registry or public health agency (successful or unsuccessful). Should include evidence to support that it was generated for that provider’s system
- A dated record of successful or unsuccessful electronic transmission (e.g, screenshot from another system, etc.). Should include evidence to support that it was generated for that provider o Letter or email from registry or public health agency confirming the receipt (or failure of receipt) of the submitted data, including the date of the submission, name of parties involved and whether the test was successful.
- Exclusions: Documentation to support each exclusion to a measure claimed by the EH.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
To ensure you are prepared for a potential audit, save any electronic or paper documentation that supports your attestation. Also save the documentation that supports the values you entered in the Attestation Module for clinical quality measures. Hospitals should also maintain documentation that supports their payment calculations. The primary documentation that will be requested in all reviews is the source document(s) that the provider used when completing the attestation. This document should provide a summary of the data that supports the information entered during attestation. Ideally, this would be a report from the certified EHR system. Providers should retain a report from the certified EHR system to validate all clinical quality measure data entered during attestation, since all clinical quality measure data must be reported directly from the certified EHR system.
This primary document will be the starting point of most reviews and should include, at minimum:
• The numerators and denominators for the measures.
• The time period the report covers.
• Evidence to support that it was generated for that eligible hospital, or CAH (e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.).
Although the summary document is the primary review step, there could be additional and more detailed reviews of any of the measures, including review of medical records and patient records. The provider should be able to provide documentation to support each measure to which he or she attested, including any exclusions claimed by the provider.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
- MU-EP-Stage 1-Interfaces
- MU-EP-Stage 2-Interfaces
No, the email triggers, statistic tracking, etc. require use of the Thrive Patient Portal to meet the View, Download & Transmit objective.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
- MU-EP-Stage 1-Interfaces
- MU-EP-Stage 2-Interfaces
Only the public health agencies or an authorized entity of the state can provide exemption or exclusion status. This documentation must be stored with the rest of your attestation information for audit purposes. It is also recommended that the facility provide a copy of the exclusion to Evident for audit/tracking purposes.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
- MU-EP-Stage 1-Audits
- MU-EP-Stage 2-Audits
Meaningful Use auditing is performed by Figliozzi and Company. If you are selected for an audit, your facility will receive a letter from them with the CMS and EHR Incentive Program logos on the letterhead.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
- MU-EP-Stage 1-Interfaces
- MU-EP-Stage 2-Interfaces
A Health Information Exchange (HIE) or Regional Health Information Organization (RHIO) is not required to certify for Meaningful Use and may not meet the federal requirements that are included in the Meaningful Use audits. Keep in mind that the interface is typically developed per the HIE/RHIO specifications, not the federal guidelines. Given this, Evident recommends that you confirm with the RHIO/HIE, and with the state to whom the reportable data is sent, that use of the HIE/RHIO for attestation to the public health reporting objectives will comply with federal regulations and standards and ensure you pass an Meaningful Use audit should one be issued for your facility.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
- MU-EP-Stage 1-Audits
- MU-EP-Stage 2-Audits
If you are selected for an audit you will receive a letter from Figliozzi and Company with the CMS and EHR Incentive Program logos on the letterhead. The request letter will be sent electronically from a CMS email address and will include the audit contractor’s contact information.
- MU-EH-Stage 1-System Requirements
- MU-EH-Stage 1-Misc.
- MU-EP-Stage 1-System Requirements
- MU-EP-Stage 1-Misc.
Your facility will attest using the Stage 1 2014 Edition. To get started you will need to contact the Sales Account Manager assigned to your facility. The Account Manager will conduct a gap analysis to determine if you still need to purchase any necessary applications. Once all required applications have been ordered, the process will be turned over to Software Services. Software Services will schedule any needed application installations and educate your team on the each of the Meaningful Use objectives.
- MU-EH-Stage 1-Attestation
- MU-EP-Stage 1-Attestation
No, you do not need to have a certified EHR in order to register for the Medicare and Medicaid EHR Incentive Programs.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
The term “structured data” is somewhat ambiguous but the criteria included in the Laboratory Results Interface (LRI) and Electronic Laboratory Reporting (ELR) implementation guidelines from ONC define use of HL7 v2.5.1 with incorporation of universal code sets per value reported.
If the comments are received as structured data per the implementation guidelines in the Thrive System, there is no need for changes to the reference lab result delivery. If the comments are not received as structured data, the reference lab result format could impede the facility’s ability to achieve Meaningful Use.
Any results entered into Thrive manually via the Thrive Laboratory Information System (LIS) application are stored and transmitted out in a discrete format. All results that are received from external entities will require additional examination. Evident has performed a general review of current interface configurations and identified that many vendors are not transmitting all results in a structured format. To ensure your laboratory interfaces meet the requirements, please contact your Reference Lab (or LIS if you do not use the Thrive LIS application) vendor and ask the following:
- Do you have the ability to transmit results to Evident in the discrete/structured format for ALL laboratory results – including micro/culture results – as outlined in the ELR objective inclusive of the LOINC and SNOMED-CT data sets?
- Do you require a product upgrade to transmit all results in a structured format?
- What is the timeline for implementation and subsequently validation testing?
Please note that vendor modifications will necessitate changes in the Thrive System as well and validation testing is crucial to ensuring accurate reporting of the results. Evident will require a lead time of 90 days to modify an existing interface so it’s important to contact us as soon as you determine a need to change an inbound lab results interface.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
- MU-EP-Stage 1-Interfaces
- MU-EP-Stage 2-Interfaces
Syndromic Surveillance interfaces typically send demographic data as well as the patient’s chief complaint. It is Evident’s recommendation that each facility transition the chief complaint field in the Census tab to a required field, thereby ensuring it’s included with every registration.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
- MU-EP-Stage 1-Interfaces
- MU-EP-Stage 2-Interfaces
No, the third party systems do not have to be certified since the Thrive EHR is the certified product for attestation. However, if Thrive is using data received from a third party system to meet interoperability requirements, all data elements and formatting must comply with the implementation guidelines needed to attest. For instance, in order for Thrive to transmit lab results to the public health agencies in the manner outlined in the implementation guide, ie: structured and with LOINC/SNOMED-CT, that information must be received from any laboratory vendor that sends results to the HIS.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
Please reference the question/answer regarding structure or discrete format for more information on Evident compliance with the Meaningful Use objective requirements associated with Electronic Laboratory Reporting (ELR). Scanned documents are blurbs of text that cannot be parsed and therefore do not meet the requirements and are not included in the Thrive transmissions for public health reporting.
From Section 170 page 44602 of 45 CFR, the ONC final rule page:
“We recognize that Certified EHR Technology may also store health information in scanned documents, images, and other non-interoperable non-computable formats and, consequently, do not expect Certified EHR Technology to be capable of reading or accessing the information in these other formats.”
Based on this statement and Evident specifications, a paper report that is scanned and attached will not be considered structured data.
- MU-EH-Stage 1-Attestation
- MU-EP-Stage 1-Attestation
Yes, this online tool assists providers and hospitals to test whether or not they would successfully demonstrate Meaningful Use for the EHR Incentive Programs.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
Most of the analyzers do not incorporate the universal coding (LOINC and SNOMED CT) that is required for Meaningful Use reporting. However, Evident can incorporate the required elements and format with the use of the Thrive Laboratory Information System (LIS) Infection Control application. Evident assistance with this is necessary as the interface program to initiate the use of Infection Control must be changed by Evident personnel. Each facility will be required to complete the entries in the Infection Control application and item setup for this option to be functional.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
- MU-EP-Stage 1-Interfaces
- MU-EP-Stage 2-Interfaces
Technically, yes. We can convert HL7 v2.3 to v2.5.1 but all of the required data elements must be included in the v2.3 message for it to be successfully updated to the public health agency.
- MU-EH-Stage 1-Attestation
- MU-EH-Stage 2-Attestation
- MU-EP-Stage 1-Attestation
- MU-EP-Stage 2-Attestation
Your facility will need to contact CMS for payment information.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
- MU-EP-Stage 1-Audits
- MU-EP-Stage 2-Audits
Yes, CMS conducts random pre-payment audits to validate submitted attestation as well as post-payment audits.
- MU-EH-Stage 1-Interfaces
- MU-EP-Stage 1-Interfaces
Technically, yes because the transmissions sent from the Thrive system must be per the configuration and format utilized in the EHR certification. However, keep in mind that in Stage 1, the CMS guideline includes provisions for an unsuccessful test to submit electronic data to public health agencies to be considered valid.
CMS addressed a similar question with the following:
"If the immunization registry does not accept information in the standard to which your EHR technology has been certified-that is, if your EHR is certified to the HL7 2.3.1 standard and the immunization registry only accepts HL7 2.5.1, or vice versa-and if the immunization registry is the only immunization registry to which you can submit such information, then you can claim an exclusion to this Meaningful Use objective because the immunization registry does not have the capacity to receive the information electronically. The capacity of the immunization registry is determined by the ability of the immunization registry to test with an individual EP or eligible hospital. An immunization registry may have the capacity to accept immunization data from another EP or hospital, but if for any reason (e.g. waiting list, on-boarding process, other requirements, etc) the registry cannot test with a specific EP or hospital, that EP or hospital can exclude the objective. It is the responsibility of the EP or hospital to document the justification for their exclusion (including making clear that the immunization registry in question is the only one it can submit information to). If the immunization registry, due to State law or policy, would not accept immunization data from you (e.g., not a lifespan registry, etc), you can also claim the exclusion for this objective. Please note, this FAQ applies in principle to all of the Stage 1 public health meaningful use measures (syndromic surveillance and reportable lab conditions)."
- MU-EH-Stage 1-Objectives
- MU-EH-Stage 2-Objectives
- MU-EP-Stage 1-Objectives
- MU-EP-Stage 2-Objectives
According to the final rule, an Eligible Hospital or Critical Access Hospital may be exempt if they do not administer any of the immunizations to any of the populations for which data is collected by their jurisdiction’s immunizations registry or immunization information system during the EHR reporting period. Evident recommends each facility contact the state public health agency for confirmation of exclusion - and to request a letter of exclusion (for auditing purposes).
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
- MU-EP-Stage 1-Interfaces
- MU-EP-Stage 2-Interfaces
Evident is doing everything we can to encourage interoperability opportunities, to accelerate development and to deploy our piece of the integration progression in a timely manner. Every interface requires the coordination of three different organizations: Evident (the EHR vendor), the third party vendor and the facility, along with the various timelines of each group. In addition, it is the responsibility of the facility to validate every interface. While it may only take a week or two to actually deploy the interface, the testing and validation process can take much longer.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
- MU-EP-Stage 1-Audits
- MU-EP-Stage 2-Audits
Yes, states will have separate audit processes for their Medicaid EHR Incentive Program. For more information about these audit processes, please contact your state Medicaid Agency.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
Once the audit is concluded, the EH will receive an Audit Determination Letter from the audit contractor. This letter will inform the EH whether they were successful in meeting Meaningful Use of electronic health records. If, based on the audit, an EH is found not to be eligible for an EHR incentive payment, the payment will be recouped. CMS may also pursue additional measures against EHs who attest fraudulently to receive an EHR incentive payment. Punishment may involve imprisonment, significant fines or both. In some states, health care organizations may lose their licenses. Convictions also may result in exclusion from Medicare participation for a specified length of time. Medicare fraud may also result in civil liability.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
- MU-EP-Stage 1-Audits
- MU-EP-Stage 2-Audits
CMS has an appeals process for EPs, EHs and CAHs that participate in the Medicare EHR Incentive Program. Providers may contact the EHR Information Center through a toll free number, 888-734-6433, between 9 a.m. and 5 p.m. EST, Monday through Friday, for general questions on how to file appeals and the status of any pending appeals. States will implement appeals processes for the Medicaid EHR Incentive Program. Medicaid program participants should contact their State Medicaid Agency for more information about these appeals.
- MU-EH-Stage 1-Objectives
- MU-EH-Stage 2-Objectives
- MU-EP-Stage 1-Objectives
- MU-EP-Stage 2-Objectives
The Meaningful Use Stage 1-2011, Stage 1-2014 and the Meaningful Use Stage 2 Statistics Reports are now found under the following path: Hospital Base Menu > Other Applications And Functions > Word Processing > AdHoc Report
These new reports will now be listed under the middle column.
- MU-EH-Stage 1-Objectives
- MU-EH-Stage 2-Objectives
No. Patients who transition within the same facility that shares the same certified EHR should not be included in the numerator or denominator of this objective. Additional software set-up is required. Please contact Software Support.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
- MU-EP-Stage 1-Audits
- MU-EP-Stage 2-Audits
CMS has an appeals process for eligible professionals, eligible hospitals and critical access hospitals that participate in the Medicare/Medicaid EHR Incentive Program. If your facility wishes to appeal they must complete the appropriate filing request found in the below link. The appeals submission process is time sensitive with a 30 day window for submission period. The filing request and supporting documentation must be submitted. The appeal will only be processed if all documentation needed is provided at the time of submission.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
- MU-EP-Stage 1-Audits
- MU-EP-Stage 2-Audits
The Centers for Medicare and Medicaid Services do not process appeals for provider’s, hospital’s or CAH’s who dispute the amount of their EHR inventive payment. After an EP successfully attests, a monthly report determines whether the allowable claims threshold for the program participation year has been met. After the close of the incentive payment year, incentive payments are made based on 75% of Medicare allowed charges for covered professional services furnished during the payment year that have been successfully submitted by the EP. After a hospital or critical access hospital successfully attests, an initial incentive payment is issued based on the latest available cost report which is then reconciled when the cost report is finalized.
Here is the CMS Frequently Asked Question regarding appeals regarding the dispute of the amount of the incentive payment.
- MU-EH-Stage 1-System Requirements
- MU-EH-Stage 2-System Requirements
- MU-EP-Stage 1-System Requirements
- MU-EP-Stage 2-System Requirements
Each facility should be running Version 19 (CMS 2014 version) in order to attest for Meaningful Use Stage 1 or Stage 2 in the fiscal year of 2014.
- MU-EH-Stage 1-System Requirements
- MU-EH-Stage 2-System Requirements
- MU-EP-Stage 1-System Requirements
- MU-EP-Stage 2-System Requirements
All EPs, EHs and CAHs must have EHR technology certified to the 2014 Edition EHR certification criteria that meets the Base EHR definition and would support the objectives, measures, and their ability to successfully report the Clinical Quality Measures (CQMs), for the Meaningful Use stage that they seek to achieve. CMS reiterates that an EP, EH or CAH must continue to possess all of a certified Complete EHR or certified EHR Module (i.e., the capabilities for which certification is required) in order to receive the benefit of such certification. An EP, EH or CAH cannot purchase or possess only “components” of a certified Complete EHR or certified EHR Module for the purposes of meeting the CEHRT definition. That is, unless independently certified, those “components” could not be used to meet the CEHRT definition.
- MU-EH-Stage 1-Objectives
- MU-EP-Stage 1-Objectives
Beginning in 2013, the objective for electronic exchange of key clinical information will no longer be required for Stage 1 for EPs, EHs and CAHs. CMS is moving instead to a more robust requirement for electronic health information exchange as a part of the Stage 2 objective for providing a summary of care record following a transition of care or referral.
- MU-EH-Stage 1-Objectives
- MU-EH-Stage 2-Objectives
No, EHs and CAHs must record in the patient's EHR the preliminary assessment/impression of the cause of death. No further documentation is required. This measure does not require cause of death to be updated if the case is referred to the Department of Health or the coroner’s office.
- MU-EH-Stage 1-Attestation
- MU-EH-Stage 2-Attestation
Meaningful Use in 2014 for Stage 1 and Stage 2 has a 90-day period of attestation. However, in 2014, these 90 days will have to be tied to a Fiscal Year Quarter. The CMS-defined Fiscal year is Oct. 1 - Sept. 30. The quarters are as follows:
• Oct. 1 - Dec. 31, 2013
• Jan. 1 - March 31, 2014
• April 1 - June 30, 2014
• July 1 - Sept. 30, 2014
View the CMS timeline.
- MU-EH-Stage 1-Attestation
- MU-EH-Stage 1-Misc.
- MU-EH-Stage 2-Attestation
- MU-EH-Stage 2-Misc
No. According to the final rule, the definition of hospital used for Meaningful Use measures does not apply to hospitals excluded from the inpatient prospective payment system (IPPS), such as psychiatric or rehabilitation units. If patients treated in the psychiatric unit are also admitted to areas of the inpatient department that are not excluded from IPPS, then they should be counted in the denominator (and numerator) for Meaningful Use measures.
For more information, see the CMS FAQ on this topic.
- MU-EH-Stage 1-Objectives
Yes, if your facility is attesting for year 2 of Stage 1 in 2014, your facility will have to meet measure A of View, Download & Transmit. This objective will replace the previous Stage 1 objectives of Provide patients with an electronic copy of their health information, upon request and Provide patients with an electronic copy of their discharge instructions at the time of discharge, upon request. The new objective is: Provide patients the ability to view online, download and transmit information about a hospital admission.
The new measure is: More than 50% of all patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an EH or CAH have their information available online within 36 hours of discharge.
In Stage 2, an additional measure will be added. This states that more than 5% of all patients (or authorized representatives) who are discharged from the IP/ED (POS 21 or 23) of an EH/CAH view, download or transmit to a 3rd party their information during the EHR reporting period.
- MU-EH-Stage 1-Objectives
In 2014, there will be an optional alternate measure to the objective for CPOE. The current measure for CPOE is based on the number of unique patients with a medication in their medication list that was entered using CPOE. The new, alternate measure is based on the total number of medication orders created during the EHR reporting period. An EP, EH or CAH may select either measure for this objective in Stage 1 in order to achieve Meaningful Use. (Note that this alternative measure will be required for all providers in Stage 2.) Alternate Measure:
More than 30 percent of medication orders created by the EP or authorized providers of the EH's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE.
- MU-EH-Stage 1-Attestation
- MU-EH-Stage 2-Attestation
The EHR incentive payment shall only include reasonable costs for the purchase of certified EHR technology to which purchase depreciation would apply. This would include the computers, and associated hardware and software, necessary to administer certified EHR technology. If the cost cannot be included as a depreciable asset under normal Medicare cost reporting principles, it cannot be included in the EHR incentive payment. However, the CAH may continue to report all other costs on the Medicare Cost Report, and be reimbursed under reasonable costs principles.
Since the reasonable costs of the depreciable assets being included in the EHR incentive payment are allowed to be expensed in their entirety in the year incurred, the CAH must ensure that the resulting depreciation on those assets is not included in subsequent cost reports.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
The public health agency should provide documentation either on their website or as part of your onboarding documentation as to whether they require dual or singular reporting. Agencies that require dual reporting expect both the ordering and performing facilities to submit reportable results. Agencies that require reporting from the performing lab only will establish the required transmission protocols with the reference lab(s) as reportable results is already a requirement for performing labs. Therefore, no further follow-up is required on your part. However, it is Evident’s recommendation that you keep a copy of the agency’s expectations for reporting (screenshot, specifications, email notification) in your Meaningful Use audit folder. Additionally, please keep in mind that any tests performed in-house that include reportable results must be submitted by your facility; the reference lab is only responsible for reporting the reportable results for tests they perform.
- MU-EH-Stage 1-Attestation
- MU-EH-Stage 2-Attestation
Yes, attestation does not occur on the CMS website until your attestation period has been completed. Therefore, if you do not meet your numbers in one quarter, you can defer to another quarter. However, if you are to meet Meaningful Use in Federal Fiscal Year (FFY) 2014, this must be accomplished the last quarter of the Federal Fiscal Year: July 1 - Sept. 30, 2014.
- MU-EH-Stage 1-Objectives
- MU-EH-Stage 2-Objectives
Unique swing bed patients who receive inpatient care should be included in the denominator of Meaningful Use measures. However if the EH or CAH cannot readily identify and include unique swing bed patients who have received inpatient care, those patients may be excluded from the calculations for the denominators of Meaningful Use measures.
- MU-EH-Stage 1-Objectives
- MU-EH-Stage 2-Objectives
- MU-EP-Stage 1-Objectives
- MU-EP-Stage 2-Objectives
Any licensed healthcare professional can enter orders into the medical record for purposes of including the order in the numerator for the measure of the CPOE objective if they can enter the order per state, local and professional guidelines. The order must be entered by someone who could exercise clinical judgment in the case that the entry generates any alerts about possible interactions or other clinical decision support aides. This necessitates that CPOE occurs when the order first becomes part of the patient's medical record and before any action can be taken on the order. Each provider will have to evaluate on a case-by-case basis whether a given situation is entered according to state, local and professional guidelines, allows for clinical judgment before the medication is given, and is the first time the order becomes part of the patient's medical record.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
- MU-EP-Stage 1-Audits
- MU-EP-Stage 2-Audits
If your facility or provider is in an audit, an initial email will come to the person who registered on the CMS website for the attestation. If that person leaves your facility, or changes, the hospital/provider will need to go back to the CMS website and update the email address.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
First, keep in mind that on-going submissions is the goal but the objective can be met without reaching a production status with your public health agency. For Stage 1, submission of a failed test message will satisfy the objective; for Stage 2 registration and onboarding (see detailed notes below) satisfy the objective.
It is important to note that if jurisdictional (aka: state) regulations require the ordering facility to report results from their reference laboratory and your facility does not perform any lab testing for reportable conditions, then the facility that ordered the lab testing [Eligible Hospital (EH) or Critical Access Hospital (CAH)] would be required to submit reference lab performed reportable lab results to public health using CEHRT and would not be excluded.
There are four criteria for which an EH/CAH may attest to public health objectives that were established by CMS under the umbrella of ongoing submission for Stage 2:
- The EH/CAH already achieved ongoing submission for an EHR reporting period in a prior year and it has continued throughout the current EHR reporting period.
- The EH/CAH has registered intent to initiate ongoing submission with the public health agency (PHA) by the deadline (within 60 days of the start of the EHR reporting period) and ongoing submission was achieved.
- The EH/CAH has registered intent to initiate ongoing submission with the PHA by the deadline and they are engaged in testing and validation.
- The EH/CAH has registered intent to initiate ongoing submission with the PHA by the deadline and they are awaiting invitation to begin onboarding.
The only way the measure will not be met is if the provider:
- Fails to register their intent by the deadline; or
- Fails to participate in the onboarding process as demonstrated by failure to respond to the PHA written requests for action within 30 days on two separate occasions.
Therefore, your facility can meet Meaningful Use as long as you have registered your intent to initiate ongoing submission with the public health agency (by the deadline) and participate in the onboarding process as outlined by your state.
For more information, please review the ONC Options to Meet Electronic Laboratory Reporting.
- MU-EH-Stage 1-Audits
EHs can be audited for up to 6 years after attestation. It is important to retain all paperwork that was used for attestation in the event of an audit. Evident has prepared an auditing document to assist with all paperwork that needs to be kept in the event of an audit. Should you need assistance, please contact Evident.
- MU-EH-Stage 1-Objectives
- MU-EH-Stage 1-Attestation
- MU-EH-Stage 2-Objectives
- MU-EH-Stage 2-Attestation
There are two methods for calculating ED admissions for the denominators for measures associated with Stage 1 and Stage 2 of Meaningful Use objectives. EHs and CAHs must select one of the methods below for calculating ED admissions to be applied consistently to all denominators for the measures. That is, EHs and CAHs must choose either the “Observation Services method” or the “All ED Visits method” to be used with all measures.
Observation Services method: The patient is admitted to the inpatient setting (place of service (POS) 21) through the ED. The patient initially presented to the ED and is treated in the ED’s observation unit or otherwise receives observation services. Details on observation services can be found in the Medicare Benefit Policy Manual, Chapter 6, Section 20.6. Patients who receive observation services under both POS 22 and POS 23 should be included in the denominator.
All ED Visits method: An alternate method for computing admissions to the ED is to include all ED visits (POS 23 only) in the denominator for all measures requiring inclusion of ED admissions. All actions taken in the inpatient or emergency departments (POS 21 and 23) of the hospital would count for purposes of determining meaningful use.
- MU-EH-Stage 1-Attestation
- MU-EH-Stage 2-Attestation
- MU-EP-Stage 1-Attestation
- MU-EP-Stage 2-Attestation
Yes, CMS created tip sheets for EPs, EHs and CAHs to assist with explaining Medicare reimbursement.
- MU-EH-Stage 1-Attestation
- MU-EH-Stage 2-Attestation
No, nursery days and discharges are not included in inpatient bed-day or discharge counts in calculating hospital incentives. We exclude nursery days and discharges because they are not considered acute inpatient services based on the level of care provided during a normal nursery stay. In addition, nursery day patients should not be included in the denominators of Meaningful Use measures. However, if the EHs (or CAHs) certified EHR technology cannot readily identify and exclude nursery day patients, those patients may be included in the calculations for the denominators of Meaningful Use measures.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
- MU-EP-Stage 1-Audits
- MU-EP-Stage 2-Audits
Figliozzi and Company is who will be performing audits for CMS. If you are selected for an audit, you will receive a letter from them with the CMS logo attached. If you have a question regarding this, questions can be directed to Peter Figliozzi at (516) 745-6400 x302 or at pfigliozzi.com. Their website is http://www.figliozzi.com. This email and letter will come to the person that has registered as the administrator or individual that has filled out the attestation information on the CMS website.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
Technically, the intent with public health reporting is that all reportable conditions will be included. It’s important to reiterate that reporting to the public health agency (PHA) is separate from Meaningful Use. All public health reporting should comply with the state/jurisdictional requirements. To satisfy the public health reporting objectives for Meaningful Use, the data must be transmitted by a certified vendor and in the format detailed in the standards criteria associated with the objective.
Keep in mind that the Meaningful Use public health objectives do not have a percentage-based measurement. A percentage-based measure would only be applicable to those facilities, Eligible Hospitals (EH) and Critical Access Hospitals (CAH), engaged in ongoing submission. There are four different conditions to which your facility may attest to public health objectives under the umbrella of ongoing submission for Stage 2:
- The EH/CAH already achieved ongoing submission for an EHR reporting period in a prior year and it has continued throughout the current EHR reporting period.
- The EH/CAH has registered intent to initiate ongoing submission with the public health agency (PHA) by the deadline (within 60 days of the start of the EHR reporting period) and ongoing submission was achieved.
- The EH/CAH has registered intent to initiate ongoing submission with the PHA by the deadline and they are engaged in testing and validation.
- The EH/CAH has registered intent to initiate ongoing submission with the PHA by the deadline and they are awaiting invitation to begin onboarding.
CMS describes successful ongoing submission as the electronic submission of reportable data during the normal course of a provider’s operations. This is not to say all data that is reportable is sent to the PHA. A provider who is submitting any reportable data during their normal course of their operations is engaged in ongoing submission. Again, to successfully attest to Meaningful Use, a single test that is consistently submitted (when positive) as prescribed by the Meaningful Use objective, meets the measure.
It is in your facility’s best interest to work with your reference lab vendor to provide results that are Meaningful Use compliant so that all results can be reported to the PHA in the required format.
For more information, please review the ONC Options to Meet Electronic Laboratory Reporting.
- MU-EH-Stage 1-Objectives
Eligible hospitals must attest to Meaningful Use no later than April 1, 2014, to avoid the payment adjustment in Federal Fiscal Year (FFY) 2015.
- MU-EH-Stage 1-Audits
- MU-EH-Stage 2-Audits
- MU-EP-Stage 1-Audits
- MU-EP-Stage 2-Audits
To ensure you are prepared for an audit, save the electronic or paper documentation that supports all of your attestation (including any exclusions). This includes the values you have entered in the Attestation Module. Hospitals should also maintain documentation that supports their payment calculations. If based on an audit, a provider or hospital is found to not be eligible for an EHR incentive payment and has not met attestation, the payment will be recouped. Initial audit review will be conducted by the auditor at their location. Additional information may be required or needed during or after the initial review process and in some cases, an onsite review at the provider’s location could follow. A demonstration of the EHR system could be requested during the onsite-review.
Any provider or hospital that finds themselves in an audit of their EHR incentive payment, should retain the information found here.
Below are the links to the Evident Audit documentation:
Meaningful Use Audit Stage 1 - 2014 Eligible Hospitals
Meaningful Use Audit Stage 2 - 2014 Eligible Hospitals
Meaningful Use Audit Stage 1 - 2014 Eligible Professionals
Meaningful Use Audit Stage 2 - 2014 Eligible Professionals
Here is also the link to the Frequently Asked Questions regarding Auditing by CMS.
- MU-EH-Stage 1-Interfaces
- MU-EH-Stage 2-Interfaces
- MU-EP-Stage 1-Interfaces
- MU-EP-Stage 2-Interfaces
No. If the patient has not had any vaccines administered since their last visit, no new entry should be added to the immunization entry menu. Each entry made in this menu creates a record that is subsequently sent to your immunization registry via the public health interface. Each record should contain the vaccine that was received by the patient, or an explanation as to why the patient did not receive a vaccination. For example, CVX code 998 is utilized in the CPSI software to document that no vaccine was administered due to evidence of immunity. Evidence of immunity indicates that a person has plausible evidence that they have already developed immunity to a particular disease and further immunization against the disease is not likely to provide benefit. When a user selects "No vaccine administered" (CVX 998) in immunization entry, the Evidence of Immunity field should be addressed to attach an applicable SNOMED code and description to indicate that a patient is immune to a specific disease.
In summary, if the patient has not received any vaccines at any other facility since their last visit at your facility, no entry should be made in the immunization entry menu.
- MU-EH-Stage 1-Objectives
- MU-EH-Stage 2-Objectives
CMS defines a unique patient as “a patient admitted to the hospital inpatient or emergency department more than once during the EHR reporting period.” Per CMS, “for the purpose of measurement, that patient is only counted once in the denominator for the measure.”
- MU-EH-Stage 1-Attestation
- MU-EH-Stage 2-Attestation
- MU-EP-Stage 1-Attestation
- MU-EP-Stage 2-Attestation
Your facility would have to contact CMS to determine the error and re-attest with the correct information.
- MU-EH-Stage 1-Objectives
- MU-EH-Stage 2-Objectives
Payment adjustments will be applied beginning Oct. 1, 2014, for Medicare-eligible hospitals. CAHs will be applied beginning with the fiscal year 2015 cost reporting period.
- MU-EH-Stage 1-Objectives
- MU-EH-Stage 2-Objectives
Yes. If your hospital is only eligible to participate in the Medicaid Incentive program and you do not bill Medicare, you are excluded from the Federal Fiscal Year (FFY) 2015 payment adjustments.