Stage 2 – 2014 Edition

What information should be retained if I find myself in an audit?

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.

How long should I retain documentation for Meaningful Use Attestation?

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.

I have an engine that is owned and maintained by my IT staff. Can I configure the interfaces required for Meaningful Use or do I have to purchase an Evident-configured interface?

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.

How far in advance do I need to place orders for required 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.

What type of documentation is required for non-percentage-based measures?

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.
• 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.

My facility utilizes a separate product for patient access to our website for accounting needs and well-being instructions. Can the Thrive Patient Portal be linked to this portal product for the View/Download/Transmit objective that Evident plans to implement through the portal?

No, the email triggers, statistic tracking, etc. require use of the Thrive Patient Portal to meet the View, Download & Transmit objective.

What type of documentation is required for percentage-based measures?

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.

If my public health agency is unable to accept the reporting data in an HL7 v2.5.1 message, or requires validation of multiple transmissions before allowing my facility to move to a production status, can Evident provide a letter of exclusion for that objective?

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.

Who performs the Medicare EHR incentive programs auditing?

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.

We participate in a Regional Health Information Organization (RHIO) and they have the ability to submit public health reporting data for the RHIO participants. Can I use the interface to the RHIO to satisfy all the public health reporting objectives?

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.

How will I know if I am being audited by CMS?

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.

Do I have to have an interface for Quality Measures in Stage 2 of Meaningful Use?

No – Initially, CMS indicated plans to require electronic submissions for Clinical Quality Measure (CQM) data but no specifications were provided and the electronic submission requirement was later retracted. The current process for submitting Quality Measures remains acceptable. More information is available on the CMS website.

I read that my lab results must be in a discrete structured format. How can I confirm the format if I do not have access to the interface messages? With this requirement, do you anticipate any changes in the way reference labs deliver results? For example we receive a lot of results as HL7 "comments" or “blurbs of text” – is there set criteria to determine how structured "structured data" really is?

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.

How can I make sure the Syndromic Surveillance interface includes all the required data for public health reporting?

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.

Who should our hospital contact when we are ready to proceed with Meaningful Use Stage 2?

Please contact your Evident Sales Account Manager. They will review the sales matrix with each site to ensure that each required application or interface has been purchased. Once this is reviewed, and all items are purchased, your facility will be assigned to a Meaningful Use Representative for further direction and discussion.

Can lab results be scanned into the EHR and be acceptable for structured data and submission for public health reporting (ELR)?

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. 

Do third party vendors that send data to the Thrive System have to be Meaningful Use certified?

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.

I have a Microbiology analyzer in my lab. Is there anything I need to do to be sure these results are in a discrete format?

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.

I have a third party vendor that sends data to Evident in HL7 v2.3 and this data will be included in what is transmitted for public health reporting. Does that vendor have to start sending the data in HL7 v2.5.1 or can we up-convert the current data stream to meet the criteria that requires HL7 v2.5.1 for 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.

How long after I attest should my Medicare incentive payment arrive?

Your facility will need to contact CMS for payment information.

Can I be audited prior to receiving a payment?

Yes, CMS conducts random pre-payment audits to validate submitted attestation as well as post-payment audits.

Do all of my “public health” interfaces have to be successful ongoing submissions to my public health agency for Meaningful Use Stage 2?

Yes, all public health interfaces must be successful ongoing submissions from the certified EHR to the registry for the entire reporting period. (Note: some exclusions apply). If your state is exempt, your state will need to provide your facility with a letter of exemption.

Can I create a hyperlink in the Thrive ChartLink application to a third party PACS system and use that to meet the menu objective for accessing the image from the EHR?

No, the criteria for this objective specifies access to the patient and associated diagnostic test(s) which requires the implementation of a URL interface to allow the launch point at the order.

My facility does not perform many immunizations. Do we still have to report this data?

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).

With the increased demand for EHR integration, what is Evident doing to facilitate this process between third party systems and the Thrive system?

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.

Can I be audited for Medicaid incentive payments?

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.

What happens if I fail the audit?

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.

Can I appeal the results of an audit?

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.

Does my facility have to perform a security risk analysis for Meaningful Use Stage 2?

As with Meaningful Use Stage 1, each facility will have to review or conduct a security risk analysis of the certified EHR prior to the end of the reporting period. A new review must occur for each subsequent reporting period. Parameters of the risk analysis are defined in 45 CFR 164.308(a)(1) created by the HIPAA Security Rule.

I see there are multiple objectives that are not listed for Meaningful Use Stage 2, that were required with Meaningful Use Stage 1. Does my facility have to continue the Stage 1 objectives?

Yes, there are some Meaningful Use Stage 1 objectives that have been incorporated into Meaningful Use Stage 2 objectives. In order to meet the new Stage 2 objectives, the previous Stage 1 objectives must be met.

Where will the Meaningful Use Stage 1 and Stage 2 Statistics Report be located?

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.

For Stage 2, can Drug-Drug and Drug-Allergy interaction checks count toward the five required clinical decision support interventions?

No. The final rule states that in order to meet the Clinical Decision Support objective, Drug-Drug and Drug-Allergy interactions have to be turned on for the entire reporting period in addition to four clinical support interventions related to four or more clinical quality measures.

The Imaging menu object reads as follows: “Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through Certified EHR Technology.” What does “accessible through Certified EHR Technology” mean?

According to CMS, “accessible through Certified EHR Technology” is defined as either incorporation of the image and accompanying information into Certified EHR Technology, or as an indication in Certified EHR Technology that the image and accompanying information are available for a given patient in another technology with a link to that image and accompanying information.

For the menu objective “Lab Results to Ambulatory Providers,” are all ambulatory lab orders included in the denominator or just those that were sent electronically?

Only the electronically received ambulatory lab orders are to be included in the denominator.

What if my facility does not pass an audit, can my facility/provider appeal?

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.

CMS Appeals Information

What if my hospital/provider does not agree with the amount of EHR incentive funds we have received?

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.

What version of the Thrive software should our hospital be running to attest for Meaningful Use in 2014?

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.

Since the Thrive system has certified as a “Complete EHR”, does this mean that our hospital must possess all applications Evident used to certify for 2014 Meaningful Use?

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.

For the objective Record Demographics, is the final cause of death needed to meet this objective?

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.

What is the timeline for Meaningful Use in 2014?

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.

Now that CMS has released the Modified Stage 2 final ruling (2015-2017) and Meaningful Use Stage 3 final ruling, what does this mean with regards to 2015 reporting period, attestation and subsequent reporting/attestation periods?

The Modified Stage 2 (2015-2017) final ruling that was released made changes to a few things for 2015-2017. Listed below are some of the high points:

• 2015 only: will now become a continuous 90-day reporting period that can range from Oct 1 2014  -Dec 31 2015.
• For hospitals, their reporting period has now been moved to a calendar year instead of a fiscal year.
• Actual attestation for 2015 cannot take place until Jan. 4, 2016 and will run through Feb. 29, 2016.
• 2016: the reporting period will be a 365-day calendar year and attestation will not take place until January - February 2017.
• 2017: the reporting period for modified Stage 2 will be a 365 day calendar year and attestation will not take place until January - February 2018.
• Stage 3 will not be mandatory until 2018.

Please note: There will no longer be core vs menu objectives or stages. All facilities will align into reporting the same objectives.

We are a critical access hospital with a psychiatric unit that bills under POS code 21 but are excluded from the IPPS. Should these patients be included in the denominator for the Meaningful Use measures?

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.

If my interface for public health reporting is ‘on hold’ or ‘in the queue’ with the state agency, what exclusion option do I select for my Stage 2 attestation?

You should only select an exclusion option if your state agency has provided your facility with a letter of exclusion/exemption. If your facility has completed the state-required registration/onboarding and are waiting to begin implementation, you should select ‘Yes’ to attest. Keep in mind that the attestation requirements included with the public health reporting objectives include registration with intent to initiate ongoing submissions within 60 days of the start of the reporting period as well as the full/ongoing submissions.

I hear there is a new timeline for Meaningful Use. Does this change anything with Stage 2?

Per Centers for Medicare and Medicaid Services (CMS), there will be a new, revised timeline for Stage 2. This will be extended through 2016, and Stage 3 will begin in 2017 for those hospitals and providers that have completed at least two years in Stage 2. For those that are to start Stage 2 in 2014, this does not change when you start Stage 2, only that you will now be at Stage 2 for three years, instead of two. In the fall of 2014, it is expected that CMS will release a notice of proposed Stage 3 Rulemaking and corresponding ONC Standards will be released in the fall of 2014. The final rule for Stage 2 would then follow in 2015.

What costs can be included in the Medicare EHR Incentive Payment for CAHs?

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.

For outside reference labs that do the reportable lab results, what is the hospital’s obligation to make sure that the reference lab is capable of doing this and is actually doing it? Our reference lab was not at all clear whether or not they can do this, or if they even have plans to do so.

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.

I listened to a webinar recently on Meaningful Use which I did not understand as it related to missing a year of attesting. For example, if a hospital for some reason was not able to attest to Meaningful Use say in 2014, but they got right back in the next year, would that mean the 3 month attesting is gone now and they would need to do a complete year from Oct. 1, 2014 to Sept. 30 2015? And how would this effect their payments?

Each year after the first attestation year requires full year of attestation (exception currently one quarter for 2014 only); therefore, if you miss 2014, 2015 should be a full year of attestation required. If the payment is For Acute PPS, the missed year would result in the 25% reduction associated with the missed year of the four potential incentive payment years. If CAH, the reduction would be related to missed Reasonable costs as calculated. Overall, there are four potential years of incentive payments for hospitals for those starting early, any missed year will also result in Medicare payment adjustments starting in 2015 for previous years.

What elements should our facility be documenting on the summary of care for Meaningful Use?

Recently, we have been provided with the following correspondence from CMS. While problems, medication list  and medication allergy list are the key components to populate the numerator of the summary of care measure, CMS now states they will be looking for the CCD to have all of the below elements populated below, if known.  If your facility has attested, Evident recommends that your facility reviews all of the patients in your attestation period contained in the numerator, and make sure the data elements below are documented If known, since this information has recently been made available to us.

We apologize for any inconvenience this FAQ has caused but want to make sure you are aware of recent CMS information. Please also note that any FAQs that are released after the final rule are regarded as “sub-regulatory guidance” by CMS and must be followed within a reasonable amount of time. CMS also communicates the updated FAQs to auditors who utilize the information for  Meaningful Use audits.

FAQ response from CMS: 

Thank you for your recent inquiry. Below is the information you requested regarding the meaningful measures for transitions of care. Our response focuses on the measure for eligible hospitals (EHs), but the eligible professional (EP) measure is essentially the same.

As adopted by CMS, the Stage 1 and Stage 2 objectives require hospitals that transition their patient to another setting of care or provider of care or refer their patients to another provider of care (including long-term care) to provide a summary care record for more than 50 Percent or transitions of care and referrals.

For the Stage 1 measure, CMS did not specify the contents of the summary of care record. While the hospital can send an electronic or paper copy of the summary care record directly to the next provider or can provide it to the patient to deliver to the next provider, if the patient can reasonably expected to do so. However, beyond the CMS requirements, in order to meet this objective and its measures, the hospital must use the capabilities and standards of certified EHR technology (CEHRT) established by the Office of National Coordinator for Health IT (ONC), specifically, the standards found at 45 CFR 170. 205(a)(1) and (2). The ONC has defined the content of a summary of care record to include at a minimum, diagnostic results, problem list, medication list, medication allergy list, and procedures.

For the Stage 2 measure, CMS specifies that the summary of care record must include the following elements:
* Patient name.
* Referring or transitioning provider's name and office contact information (EP only).
* Procedures.
* Encounter diagnosis
* Immunizations.
* Laboratory test results.
* Vital signs (height, weight, blood pressure, BMI).
* Smoking status.
* Functional status, including activities of daily living, cognitive and disability status
* Demographic information (preferred language, sex, race, ethnicity, date of birth).
* Care plan field, including goals and instructions.
* Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider.
* Discharge instructions
* Current problem list (Hospitals may also include historical problems at their discretion).
* Current medication list, and
* Current medication allergy list.

If the provider does not have the information available to populate one or more of the fields listed, either because they can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the provider may leave the field(s) blank. The only exception to this is the problem list, medication list, and medication allergy list. In the event that there are no current or active diagnoses for a patient, the patient is not currently taking any medications, or the patient has no known medication allergies, confirmation of no problems, no medications, or no medication allergies would satisfy the measure of this objective. In circumstances where there is no information available to populate one or more of the fields listed previously, either because the eligible hospital or CAH can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the eligible hospital or CAH may leave the field(s) blank and still meet the objective and its associated measure.

Beyond the CMS requirements, in order to meet the Stage 2 objective and its three measures, the hospital must use the capabilities and standards of certified EHR technology (CEHRT) established by the Office of National Coordinator for Health IT (ONC), specifically, the standards found at 45 CFR 170.314(b)(2), (g)(1), (g)(2). The ONC has defined the content of a summary of care record to include “at a minimum, the Common MU Data Set and the following data expressed, where applicable, according to the specified standard(s):
(A) Encounter diagnoses. The standard specified in § 170.207(i) or, at a minimum, the version of the standard specified § 170.207(a)(3);
(B) Immunizations. The standard specified in § 170.207(e)(2);
(C) Cognitive status;
(D) Functional status; and
(E) Ambulatory setting only. The reason for referral; and referring or transitioning provider’s name and office contact information.
(F) Inpatient setting only. Discharge instructions.”

For further information regarding the certification and standards criteria, you should contact the ONC at: 
• (202) 690-7385;
• E-mail: onc.request@hhs.gov; or
• Visit its Web site at http://healthit.hhs.gov.

The purpose of providing the summary of care records is to assure that the provider to whom the patient is transferred or referred obtains the  most recent information on the patient that may be crucial to his/her care.  A summary of care record that does not include the required contents as defined by the ONC could not be counted in the numerator of the measure.

The tracking number for this inquiry is 330002. If you have further questions, please visit the CMS Medicare & Medicaid EHR Incentive Programs Website located at http://cms.gov/EHRIncentivePrograms/. You will find accurate and up-to-date information about the programs, including eligibility, payment amounts, requirements, upcoming events and more. Bookmark the above link and check back often to learn more about these programs, or contact the EHR Information Center at (888) 734-6433.

The Medicare and Medicaid EHR Incentive Programs listserv provides timely, authoritative information about the programs, including registration and attestation updates and details about the payment process. The listserv messages are another CMS resource to provide you with the latest news about the Incentive Programs. On average, two messages are sent per week. Information on how to join the listserv can be found at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentiveProg....

Thank you,

The EHR Information Center

My hospital has an interface with a third party clinic vendor where orders are sent to the hospital and the results are returned to the physician’s clinic. We plan to use this for the ‘Incorporate Clinical Lab Tests’ objective. Does the physician in the clinic have to sign the orders in Thrive for these orders to meet Meaningful Use requirements and/or legal signature requirements on orders?

No, the Meaningful Use criteria surrounding this objective do not specify inclusion of the physician signature in the order message. Additionally, 42 CFR 410 indicates documentation by the treating physician (i.e.: in the summary of care/progress note) that he/she intended for the test to be performed will satisfy the authorization requirement without the need for the signature of the ordering physician. The industry standard on electronic orders is to include the ordering physician in the HL7 transaction as acceptable authorization for the test to be performed.

If our hospital “aims” to meet Meaningful Use in one quarter, but we don’t succeed, can our facility attest in a different quarter?

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.

Should swing bed patients be counted in the denominators of Meaningful Use measures for the hospital?

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.

Who can enter in medication orders to meet the measure for CPOE?

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.

If our facility or provider is audited, who will the initial audit letters come to?

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.

My facility does not test any reportable conditions in house – all testing is done by a reference lab. Our state requires that both the performing lab and the ordering facility report results with reportable conditions. Since the reference lab we use is a commercial reference lab and does not have a certified product, they cannot submit on our behalf; and we don’t have an interface that includes all the fields that Meaningful Use requires. How can my facility meet Meaningful Use?

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. 

If I choose the menu item Electronic Notes, does that mean we have to have to use an electronic progress note through Physician Documentation to meet the objective?

Yes, CMS has recorded this measure as the following: "Enter at least one electronic progress note created, edited and signed by an authorized provider of eligible hospital’s or CAH IP/ED (POS 21 or 23) for more than 30% of unique patients admitted to the hospital/CAH’s IP/ED during the EHR reporting period. The text of the electronic note must be text searchable and may contain drawings and other content." CMS further defines an “electronic note” as an electronic progress note. Therefore, Evident interprets this as a progress note and our statistics will be looking for this specific document to be populated through the Physician Documentation application in order to meet this objective.

What patient types are to be included for Meaningful Use?

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.

Is there somewhere I can review documentation on how my Medicare Incentive Payment will be calculated?

Yes, CMS created tip sheets for EPs, EHs and CAHs to assist with explaining Medicare reimbursement.

Are nursery days and discharges (for newborns) to be included as acute-inpatients in the calculation of hospital statistics?

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.

Who should I be expecting to contact me if my facility/provider is in an EHR Incentive Audit?

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.

My facility uses a reference laboratory for a portion of our microbiology testing and the results from this reference lab are not compliant with Meaningful Use. If state law requires that all reportable lab results performed by my hospital or received from my reference lab must be reported, does that mean that my facility has to report all the results to meet Meaningful Use?

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.

How will my hospital meet the measure that requires 5% of the patients to View, Download & Transmit when that is out of our control?

The View, Download & Transmit objective has two measures that must be met for Meaningful Use Stage 2. They are as follows: • Provide patients the ability to view online, download and transmit their health information within 36 hours after discharge from the hospital.
• More than 5% of patients admitted to IP/ED (POS 21 or 23) of the eligible hospital must view, download or transmit to a 3rd party their health information.

Patient education is going to be a vital part to successfully achieving this portion of the objective. There are a number of ways we have heard hospitals are going to help educate their patients on this objective. Here are some examples:
• Via Patient Education Documents entailing the process of View, Download, & Transmit.
• Host hospital luncheons, bingo games, and education sessions at the hospital and have patients log in to the Patient Portal.
• Have a hospital kiosk where patients can log in to the Patient Portal to retrieve their information.

If my facility/provider is in an audit, what information should I gather to present?

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.

When a patient is registered in Thrive and upon inquiry they respond that they have not received any immunizations since their last visit, should I document that no vaccine was administered in the immunizations menu?

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.

What is a “unique” patient?

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.”

How can I change my attestation information after I have attested and/or received an incentive payment?

Your facility would have to contact CMS to determine the error and re-attest with the correct information.

When will the Meaningful Use payment adjustments start?

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.

If my hospital can only participate in the Medicaid EHR incentive program, are we excluded from the payment adjustments starting in FFY 2015?

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.

Transition of Care: When a patient moves from say ER to Inpatient to Skilled all in-house with all areas having full access to the EHR, do we need to create a Patient Summary with each?

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.