Stage 1 – 2014 Edition

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.

Am I able to count an exclusion as a menu item?

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.

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 can we determine if our providers are eligible for Meaningful Use?

For questions regarding provider eligibility, we highly recommend referencing the CMS website and following up with your state Medicaid office. Evident is not permitted to discuss or recommend provider eligibility with a site.

What do we need to purchase for our system to be able to meet Stage 1 Meaningful Use?

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.

Provide a Summary of Care record for each transition of care: We have never had to change the discharge code in the past, why now?

This is needed in order to capture the denominator for this objective. Thrive uses discharge codes to calculate the number of transitions of care and referrals for which the EP was the transferring or referring provider.

Is there an online presentation we can view that explains how the Patient Portal works?

At this time there is not an online presentation for Patient Portal education. We have instructional documents that can be emailed to site contacts, and we will be happy to perform a WebEx to explain the functionality of the Patient Portal.

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 if we do not take vital signs on most visits?

According to the CMS Stage 1 Specification Sheets, an EP may be excluded from recording and charting changes in vital signs if "…[the EP] either sees no patients 2 years or older, or who believes that all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice."

For 2014 and beyond, additional exclusions will be added to the Stage 1 measure. According to the specification sheet, the 2014 exclusions may include "any EP who: a.) sees no patients 3 years or older is excluded from recording blood pressure b.) believes that all three vital signs of height, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them c.) believes that height and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure d.) believes that blood pressure is relevant to their scope of practice, but height and weight are not, is excluded from recording height and weight."

For additional information, please refer to the CMS website.

Do we need to report through the Physician Quality Reporting System (PQRS) to successfully attest to Meaningful Use, or will we be able to report Clinical Quality Measures (CQMs) through the Thrive software?

No, sites do not need to report Clinical Quality Measures (CQMs) through the Physician Quality Reporting System (PQRS) to attest for Meaningful Use. PQRS is a separate program from Meaningful Use. Running the National Quality Forum (NQF) Clinic Tables Report and electronically submitting this to CMS will meet the CQM reporting requirement.

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

To validate EP 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 EP’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.
  • 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 EP.

Why is a separate interface order needed for each AR?

Interfaces are configured on an AR basis – meaning the company, all directories/sub-directories and associated setup for the HIS functionality must be in place and then the interface configuration in Linux, in the software tables and in the Interface Management System (IMS) can be set up. Each company has an ARID and a FACID which drive the interface configuration as all HL7 messages must contain these identifiers to ensure the data in the message is routed appropriately. Interface setup/configuration/maintenance and support all starts with an order as we have to schedule and allocate the appropriate resources to make the interface work, as well as ensure documentation reflects what is set up and expected to be supported/managed with software updates and changes.

How will I attest for the Medicare and Medicaid EHR Incentive Programs?

EPs will have to demonstrate Meaningful Use through the CMS Medicare and Medicaid EHR Incentive Program Registration and Attestation System. In the Registration and Attestation System, providers will fill in numerators and denominators for the Meaningful Use objectives, indicate if they qualify for exclusions to specific objectives, and legally attest that they have successfully demonstrated Meaningful Use. Once providers have completed a successful online submission through the Attestation System, they will qualify for a Medicare EHR incentive payment. Starting no later than 2014, there will also be a batch file upload option. For the Medicaid EHR Incentive Program, providers will follow a similar process using their State's Attestation System. Sites eligible for Medicaid EHR incentives should contact their state for additional information.

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.

Will there be changes to the Stage 1 objectives following 2014 certification? If so, what are they?

Yes, there will be changes to certain Stage 1 objectives following 2014 certification. The objectives that will be changing are CPOE, Electronic Prescribing, Record and Chart Changes in Vital Signs, Electronic Exchange of Key Clinical Information, Report Clinical Quality Measures, Public Health Reporting and Electronic Copy of and Electronic Access to Health Information. Please refer to CMS for more information on the changes to these measures and objectives.

Are providers eligible for Meaningful Use if they are in a clinic that runs as a department of the hospital?

For eligibility questions and concerns, we recommend that sites reference information regarding provider eligibility on the CMS website and follow up with your state Medicaid offices.

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. The primary documentation that will be requested in all reviews is the source document(s) that the EP 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. You 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 EP (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 EP should be able to provide documentation to support each measure attested, including any exclusions.

Is there a guide that explains how each National Quality Forum (NQF) measure is calculated within the Thrive System?

At this time, there is not a guide that explains how each National Quality Forum (NQF) measure is calculated with the software. Evident programmed our NQF report in accordance with CMS requirements for the 2014 quality measures.

Evident programmed the following 2014 Clinical Quality Measures (CQMs):

• NQF 0028- Preventive Care and Screening Measure: Tobacco Use: Screening and Cessation Intervention
• NQF 0024- Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
• NQF 0069- Appropriate Treatment for Children with Upper Respiratory Infection (URI)
• NQF 0002- Appropriate Testing for Children with Pharyngitis
• NQF 0018- Controlling High Blood Pressure
• NQF 0034- Colorectal Cancer Screening
• NQF 0059- Diabetes: A1c Poor Control
• NQF 0608- Pregnant Women that had HBsAg Testing
• NQF 0036- Use of Appropriate Medications for Asthma

If you encounter an issue with patients not pulling to the NQF Clinic Tables Report, please contact Evident support via the Internet Call Management System or by calling Evident.

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.

Can EPs submit for Medicare and Medicaid in the same year?

Providers may be deemed eligible for both Medicare and Medicaid, but unlike the hospital, EPs are only eligible to attest for one incentive program per year. After a payment has been made, providers may only switch programs once before 2015.

If our EPs attest for adopt, implement or upgrade (AIU), does this count as Year 1 for Medicaid?

No, attesting to adopt, implement or upgrade (AIU) in the Medicaid EHR incentive program does not count as Meaningful Use. EPs may attest to AIU but will still need to meet two years in Stage 1. Under the Medicaid incentive program, EPs will attest for 90 consecutive days during year 1 and will attest for a full 365 days during year 2.

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.

Who can I call if I need help gathering my information from the software to submit for Meaningful Use?

For Meaningful Use related questions, please contact a Evident Support Representative by entering a situation via the Internet Call Management System or by calling Evident. If you feel your facility would benefit from a consulting service, this can be provided through TruBridge Consulting Services.

Who should I contact when my clinic decides we are ready to move forward with our plans to begin our attestation period with our EPs?

Please contact your CPSI Account Manager.

What if none of our local pharmacies will accept electronic prescriptions?

According to the CMS Stage 1 specification sheets, an EP may be excluded if "[the EP] does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period." For additional information, please refer to the CMS website.

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.

Do custom education documents count for Meaningful Use?

Yes, providers may utilize custom education documents aside from those provided through Micromedex. According to the CMS Patient-specific Education Resources objective specification sheet, "Education resources or materials do not have to be stored within or generated by the certified EHR. However, the provider should utilize certified EHR technology in a manner where the technology suggests patient-specific educational resources based on the information stored in the certified EHR technology. The provider can make a final decision on whether the education resource is useful and relevant to a specific patient."

My facility plans on meeting Meaningful Use for the first time in FFY 2014. What stage will I have to meet and how do we get started?

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.

Is the physician the only person who can enter information in the EHR in order to qualify for the Medicare and Medicaid EHR Incentive Programs?

No, CMS does not specify any requirement for who must enter information into the EHR.

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 need to have to have an installed EHR system in order to register for the Medicare and Medicaid EHR Incentive Programs?

No, you do not need to have a certified EHR in order to register for the Medicare and Medicaid EHR Incentive Programs.

How do you add custom documents?

Hospital administrators are educated on the process for adding custom education documents to the Thrive System during the implementation of hospital applications. We recommend that clinic staff follow up with the hospital administrator on any requests to add customized education documents within the Thrive System.

Are physicians who practice in hospital-based ambulatory clinics eligible to receive Medicare or Medicaid incentive payments?

According to CMS, a hospital-based EP is defined as an EP who furnishes more than 90% of their services in either an inpatient or emergency department of a hospital and does not qualify for Medicare or Medicaid EHR incentive payments.

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.

Do edited education documents count for Meaningful Use?

The current functionality of the Thrive Provider EHR software does include education documents within the numerator when the "Edit" option is selected. The document will open as a Word document. After printing or reviewing the education document with a patient, users must select to save and exit the document in order for that unique patient to be counted within the numerator, for the Patient Specific Education Resources objective.

Is there a website I can go to see if my facility will meet the objectives required for Stage 1?

Yes, this online tool assists providers and hospitals to test whether or not they would successfully demonstrate Meaningful Use for the EHR Incentive Programs.

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.

If an EP is unable to meet the measure of a Meaningful Use objective because it is outside of the scope of their practice, will the EP be excluded from meeting the measure of that objective under the Medicare and Medicaid EHR Incentive Programs?

Some Meaningful Use objectives provide exclusions and others do not. Exclusions are available only when CMS regulations specifically provide for an exclusion. EPs may be excluded from meeting an objective if they meet the circumstances of the exclusion. The statistics report will still calculate a percentage, but when the provider attests online there will be an area to include the exclusion. We recommend that sites refer to the CMS website for more information regarding these exclusions.

If an EP is unable to meet a Meaningful Use objective for which no exclusion is available, then that EP would not be able to successfully demonstrate Meaningful Use and would not receive incentive payments under the Medicare and Medicaid EHR Incentive Programs.

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

Your facility will need to contact CMS for payment information.

How should EPs select menu objectives for the Medicare and Medicaid EHR Incentive Programs?

EPs participating in Stage 1 of the EHR Incentive Programs are required to report on a total of five Meaningful Use objectives from the menu set of 10. When selecting their five objectives, EPs must choose at least one option from the public health menu set. If an EP is able to meet the measure of one of the public health menu objectives but can be excluded from the other, the EP should select and report on the public health menu objective they are able to meet. If an EP can be excluded from both public health menu objectives, the EP should claim an exclusion. Starting in 2014, meeting the exclusion criteria will no longer count as reporting a Meaningful Use objective from the menu set. An EP must meet the measure criteria for five objectives in Stage 1, or report on all of the menu set objectives through a combination of meeting exclusions and meeting the measures.

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.

If the denominators for all three of the Stage 1 core clinical quality measures are zero, do I have to report on the additional clinical quality measures for EPs under the Medicare and Medicaid EHR Incentive Programs?

If the denominator value for all three of the core clinical quality measures is zero, an EP must report a zero denominator for all such core measures, and then must also report on all 3 alternate core clinical quality measures. If the denominator values for all three of the alternate core clinical quality measures is also zero, an EP still needs to report on three additional clinical quality measures. Zero is an acceptable denominator provided that this value was produced by certified EHR technology.

How do we receive credit for the Visit Reminders measure?

Preventative has to be "completed." The user will need to select "Complete" for a preventative once a patient has been reminded to schedule their visit.

How are immunizations sent to the state registry? Is this interface performed automatically, or does the staff need to select a certain option when charting?

Transmission depends on the public health agency. Some states utilize Public Health Information Network Messaging System (PHIN-MS), File Trasnfer Protocol (FTP) or batch transmissions and others that require real-time updates – all via an HL7 v2.5.1 message. For immunization reporting, the software is designed with logic that automatically generates a message in the background so charting of immunizations is all that the staff need to do to initiate. There is setup in the software at the item level to ensure administration charting includes lot number and expiration date.

How should I help my physicians select menu objectives for the Meaningful Use Incentive Programs?

EPs are required to report on a total of five Meaningful Use objectives from the menu set. Of the five menu objectives, EPs must choose at least one option from the public health menu set. The general recommendation is that if an EP is able to meet the measure of one of the public health menu objectives but can be excluded from the other, the EP should select and report on the public health menu objective they are able to meet. CMS further clarifies with the following statement:

"If an EP can be excluded from both public health menu objectives, the EP should claim an exclusion from only one public health objective and report on four additional menu objectives from outside the public health menu set."

Will we be able to send controlled substances electronically?

No, sending controlled substances electronically is not a requirement for Meaningful Use and cannot be done at this time.

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.

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).

If the immunization registry that I am required to submit information to only accepts transmissions using the HL7 2.3.1 standard, will I qualify for an exclusion since Evident was certified using HL7 2.5.1 standard?

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)."

Do I have to purchase a separate interface for immunizations if the clinic runs as a department of the hospital?

No, clinics that are considered to be departments of the hospital (housed within the hospital AR) are not required to purchase an additional immunization interface. Separate interface orders are needed for each additional clinic AR.

Where can I find a list of public health agencies and immunization registries to submit my data as required by the public health objectives for the Medicare and Medicaid EHR Incentive Programs?

For information and/or instructions on where to submit your public health-related data, please contact your local or state public health agencies and immunization registries.

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 EP will receive an Audit Determination Letter from the audit contractor. This letter will inform the EP whether they were successful in meeting Meaningful Use of electronic health records. If, based on the audit, an EP is found not to be eligible for an EHR incentive payment, the payment will be recouped. CMS may also pursue additional measures against EPs who attest fraudulently to receive an EHR incentive payment. Punishment may involve imprisonment, significant fines or both. 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.

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.

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.

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.

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.

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.

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.

Is the attestation period different for 2014?

Yes. For 2014 only, all providers are only required to demonstrate Meaningful Use for a 3-month EHR reporting period, regardless of their stage. For Medicare providers, this 3-month reporting period is fixed to the quarter of the calendar year in order to align with existing CMS quality measurement programs, such as the Physician Quality Reporting System (PQRS). The 3-month reporting period is not fixed for Medicaid EPs that are only eligible to receive Medicaid EHR incentives, where providers do not have the same alignment needs. CMS is permitting this one-time, 3-month reporting period in 2014 only so that all providers who must upgrade to 2014 certified EHR technology will have adequate time to implement their new, certified EHR systems.

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.

Our state requires our EPs to supply the number of patients seen during the given reporting period and the number of these accounts that utilized the EHR. How do you recommend I generate this information?

This information can be gathered via the RHC Encounters Report.

The path for the report is as follows: Clinic Base Menu > Print Reports > Medical Records > Page 2 > RHC Encounters Report. (This is the last option in the JCAHO/Agency Reports section located in the center column.) Enter the date range you are reporting for and generate the report.

As long as all of the patients seen are entered into the Thrive system and marked as an encounter on the visit screen, they will be counted in this report.

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.

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.

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 is the attestation deadline for reporting any quarter of meaningful use for an Eligible Professional for reporting year 2014?

According to CMS, the attestation deadline for Medicare Eligible Professionals is Feb. 28, 2015. All Medicaid deadlines are regulated by the individual states.  However, most of the time the states honor the same deadlines set by CMS for Medicare.

Our state requires our EPs to supply the number of patients seen during the given reporting period and the number of these accounts that utilized the EHR. How do you recommend I generate this information?

This information can be gathered via the RHC Encounters Report.

The path for the report is as follows: Clinic Base Menu > Print Reports > Medical Records > Page 2 > RHC Encounters Report. (This is the last option in the JCAHO/Agency Reports section located in the center column.) Enter the date range you are reporting for and generate the report.

As long as all of the patients seen are entered into the Thrive system and marked as an encounter on the visit screen, they will be counted in this report. This document will need to be retained for audit purposes.

Does my facility still have to perform the Key Clinical Information Exchange in 2014?

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.

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

Can we keep screen shots in our records to prove we were able to attest to certain objectives in case of audits?

Yes, we recommend that you take screen shots of all objectives met through attestation in case of future audits.

Why do we have to purchase Patient Portal if we aren’t using that menu objective to meet Meaningful Use?

Thrive is certified as a complete EHR and Patient Portal is part of possessing Evident's complete EHR. Sites must purchase Patient Portal even if not attesting to the Stage 1 Timely Access menu objective. Sites may choose not to purchase the Patient Portal, but if they attest for Meaningful Use and are audited, Evident is not liable for any penalties they may incur.

Do states need to verify the "installation" or "a signed contract" for adopt, implement or upgrade (AIU) in the Medicaid EHR Incentive Program?

States should make clear to providers when they attest for adopt, implement or upgrade (AIU) what documentation they must maintain, and for how long, in case of audit. If states determine that certain provider types are a high risk for potential fraud/abuse for AIU, then they can ask for some verification of adopting, implementation or upgrading. However, CMS encourages that this be done in a targeted manner, with the most electronic and simple means possible and not in such a way that would be burdensome to providers. For AIU, a provider does not have to have installed certified EHR technology. The definition of AIU in 42 CFR 495.302 allows the provider to demonstrate AIU through any of the following:
(a) acquiring, purchasing or securing access to certified EHR technology capable of meeting Meaningful Use.
(b) installing or commencing utilization of certified EHR technology capable of meeting Meaningful Use requirements.
(c) expanding the available functionality of certified EHR technology capable of meeting Meaningful Use requirements at the practice site, including staffing, maintenance and training, or upgrade from existing EHR technology to certified EHR technology per the EHR certification criteria published by the Office of the National Coordinator of Health Information Technology (ONC).
Thus, a signed contract indicating that the provider has adopted or upgraded would be sufficient.