4) Organization NPI (Can be retrieved from the NPPES NPI Registry here:

Transcription

1 Mass HIway Connection Requirement Attestation Form Year 2 Atestation Mass HIway Form Connection Year 1 Requirement Mass HIway Connection Requirement Purpose: This Attestation Form shall be completed by Provider Organizations in order to report compliance with the second year of the statutory requirement that Provider Organizations implement fully interoperable electronic health record (EHR) systems that connect to the Mass HIway in accordance with the Mass HIway Regulations (101 CMR 20). The Mass HIway is the Commonwealth's statewide, state-sponsored health information exchange. Instructions for this form appear as endnotes on pages 7 to 8 of this document. An authorized individual at the applicable Provider Organization should complete and submit this Attestation Form by the date specified in the instructions. 1 Contact MassHIwayAttestation@state.ma.us if you need assistance completing this Attestation Form or meeting the connection requirement. Section A: Provider Organization Information: 1) Legal name of the Provider Organization (Example: George Washington Hospital): 2) Street Address (Please include the address for the Provider Organization, not for the administrative or billing office if these are different): Questions 3-5 are required in order to help identify the Provider Organization that is completing the Attestation Form. 3) Massachusetts Tax ID (TIN): 4) Organization NPI (Can be retrieved from the NPPES NPI Registry here: 5) Provider Organization s Direct address domain(s) 2 : 6) Name of parent company or organization (if applicable): Question 7 applies to a parent company or organization subject to the regulations that may include suborganizations or legal entities that are also subject to the regulations based on the definition of Provider Organization in Section of the Mass HIway Regulations. 7) Name all of the sub-organizations or legal entities that are subject to the Year 1 Connection Requirement AND use the same implementation of an EHR and domain as the parent company or organization. A single Attestation Form from the parent organization may be sufficient to cover the attestation requirement for all Provider Organizations subject to the Mass HIway Regulations that use the same implementation of and EHR and domain. The Mass HIway may require separate Attestation Forms as it deems necessary. If the sub-organizations or legal entities are using a different EHR system and domain than the parent organization, separate Attestation Forms are required. Contact MassHIwayAttestation@state.ma.us if you need clarification or assistance in completing Question 7. 1

2 Section B. Documentation of the Use Case: The following questions document the Use Case implemented by the Provider Organization to meet the Year 2 connection requirement. A Use Case involves a Provider Organization sending, receiving, or sending and receiving a HIway Direct Message. Sending or receiving a HIway Direct Message is also referred to as a transaction. Although the Provider Organization may have multiple Use Cases utilizing the Mass HIway, only a single Use Case should be reported in Section B. ALL QUESTIONS ARE REQUIRED 8) Descriptive name for the Use Case (Example: Transmission of hospital discharge summaries to selected primary care provider practices): 9) Approximate date that the Use Case was implemented (MM/YYYY): 10) Category that the Use Case falls within (Note that the Year 2 requirement is met by Provider Organizations sending and/or receiving HIway Direct Messages for at leaast one Use Case that is within the Provider to Provider Communications Category of Use Cases. No other Use Cases qualify to meet the Year 2 requirement.) 3 Provider to Provider Communications 11) Does this Use Case involve the Provider Organization sending a HIway Direct Message, or receiving a HIway Direct Message, or both? (Select only one of the three following options) The Use Case involves the Provider Organization sending, but not receiving a HIway Direct Message. The Use Case involves the Provider Organization receiving, but not sending a HIway Direct Message. The Use Case involves the Provider Organization both sending and receiving a HIway Direct Message. 12) Name(s) of the other entity (or entities) participating in the Provider to Provider exchange of information for the Use Case (Example: Abraham Lincoln Primary Care Practice or Massachusetts Department of Public Health. Entities should include Provider Organizations involved in healthcare delivery for a Provider to Provider Use Case): 2

3 13) Specify the type of entity (or entities) identified in question 12 that are participating in the Provider to Provider exchange of information for the Use Case (select all that apply) 4 Ambulance and emergency response Ambulatory surgery center Home health, LTSS Large ambulatory practice (50+*) Large behavioral health (10+*) Large community health center (10+*) Large Federally Qualified Health Center (10+*) Large hospital/health system Large long-term care facility (500+ beds) Medium ambulatory practice (10-49*) Skilled nursing facility Small ambulatory practice (3-9*) Small behavioral health (<10*) Small Community health center (< 10*) Small Federally qualified health center (<10*) Small hospital Small long-term care facility (< 500 beds) Very small ambulatory practice (1-2*) Other (please specify) * Notes the number of licensed providers. The term provider includes medical doctors, doctors of osteopathy, nurse practitioners, or physician assistants. 13a) If you are the sending Organization in this Use Case, please check the box below, to confirm that you have coordinated with the other entity (or entities) for this Use Case The Provider Organization submitting this form attests that the work flow or process for this Use Case has been coordinated with the other entity (or entities) listed in question 12, and that the other entity (or entities) are receiving and able to use the transmission. 13b) If you are the receiving Organization in this Use Case, please check the box below to confirm that you are able to use the information received in the transmission: The Provider Organization submitting this form attests that the work flow or process for this Use Case has been coordinated with the other entity (or entities) listed in question 12 and that the Provider Organization is receiving and able to use the information being received in the transmission for this Use Case to coordinate patient care. 14) Specify the type of information sent and/or received as a part of the Use Case (select all that apply): Discharge Summary Admission, Discharge, Transfer (ADT) Referral summary Summary of care General assessment Other (please specify) 3

4 15) Specify the format of information sent and/or received as a part of the Use Case: CCD C-CCDA/CCDA Secure message PDF Other (please specify): 16) Please estimate the percent of Direct Messages that are sent and/or received via the Mass HIway as a part of the Use Case. It may be the case that 75% of all transactions that are a part of this Use Case are sent or received using the Mass HIway, and the other 25% of transactions are sent or received via a supplemental method, like fax or US Mail. 5 Less than 25% of Direct Messages for the Use Case are sent and/or received via the Mass HIway Between 25-99% of Direct Messages for the Use Case are sent and/or received via the Mass HIway 100% of Direct Messages for the Use Case are sent and/or received via the Mass HIway; we do not use supplemental methods. 17) Please estimate the number of transactions sent and/or received per month as a part of the Use Case: Less than 100 Direct Messages Between 100 to 1,000 Direct Messages Over 1,000 Direct Messages 4

5 Section C. EMR / EHR System Information 18) Is your Provider Organization using an Electronic Medical Record (EMR) or an Electronic Health Record (EHR) system for the Use Case described in this Attestation? (yes / no): If the answer to question 18 is "yes", then answer questions 19 through 22. If the answer to question 18 is "no", then go to question 23: 19) Name of the EMR / EHR system: 20) Version of the EMR / EHR system: 21) How is the EMR / EHR system connecting to the Mass HIway (please select only one): directly to the Mass HIway via a HISP other than the Mass HIway 22) Is the EMR / EHR system an ONC Certified Health IT Product (All ONC certified health IT products are listed on this webpage: (yes / no): 23) How is your Provider Organization connecting to the Mass HIway (please select all that apply): via Mass HIway Webmail via some other method (please specify): Section D. Contact information Please enter contact information for the person(s) at the Provider Organization if the Mass HIway has technical or operational questions regarding the information submitted in this Attestation Form: 6 a) First/Last Name and Title: Phone: address: Role in relation to the Mass HIway: Technical contact Business contact Access Administrator Other (please specify): b) First/Last Name and Title: Phone: address: Role in relation to the Mass HIway: Technical contact Business contact Access Administrator Other (please specify): c) First/Last Name and Title: Phone: address: Role in relation to the Mass HIway: Technical contact Business contact Access Administrator Other (please specify): 5

6 Section E. Signature As an authorized representative of the Provider Organization listed in Question #1, above, I attest that I am authorized to complete and submit this Attestation Form, that I have read the questions, and that the information submitted is true and correct. a) Signature: b) First and Last Name: c) Title: d) Date signed: Month: Day: Year: e) Work phone #: f) address: 6

7 Supplemental Instructions for the Attestation Form for Year 2 Mass HIway Connection Requirement Purpose: These are instructions for completing the Attestation Form for the Year 2 Mass HIway Connection Requirement. Numbers refer to references that appear on the Attestation Form. Background The Year 2 Connection Requirement: Under Mass HIway Regulations Section101 CMR 20.08(3), the statutory requirement from M.G.L. Ch. 118I that Provider Organizations connect to the Mass HIway follows a 4 year phased-in timeline. The Year 2 connection requirement for applicable Provider Organizations is that the Provider Organization shall send or receive HIway Direct Messages for at least one Use Case that is within the Provider to Provider Communications category of Use Cases. Use Case: The Mass HIway Regulations (101 CMR 20.04) define a Use Case as follows: A narrative that describes how to accomplish a business goal and sets forth the functional requirements including scope of the activity, people and organizations involved, expected inputs and data, processing steps, and anticipated results. The use case informs the technical and process planning for development of a solution, and can be implemented between two provider organizations or multiple provider organizations based on the business need, clinical workflows, and technical and operational readiness. Categories of use cases will be detailed in the Mass HIway Policies and Procedures as updated from time to time, and may include, but not be limited to, the following categories: (a) Provider to Provider Communications (b) Payer Case Management (c) Quality Reporting (d) Public Health Reporting More information on Use Cases can be found in Section 5.4 of the Mass HIway Policies and Procedures. 1 Dates and method for submitting the Attestation Form: The following table provides the dates and methods by which Provider Organizations must submit to EOHHS the Attestation Form in order to comply with the statutory requirement that Provider Organizations connect to the Mass HIway. The online version of this form is expected to be made available March 1, The Mass HIway prefers the online method of submitting this form over the paper version of this form. However, Provider Organizations that are required to connect by January 1, 2018 and prefer to attest prior to March 1, 2018 may complete this form, print, sign, and it to MassHIwayAttestation@state.ma.us. Provider Organization Date of the "Year 2" connection requirement Due Date for this Attestation form How to submit this Attestation Form Acute Care Hospitals January 1, 2018 July 1, 2018 If submitting prior to March 1, 2018, complete this form and to Masshiway@state.ma.us. If submitting on March 1, 2018 or after, submit via on-line submission form 7

8 2 Provider Organization s Direct Address Domain. This is the part of the Direct address to the right of sign, such as "direct.orgname.masshiway.net" or "1234.direct.hispname.com"). Either a Mass HIway or HISP address is acceptable. Please send all domain names currently in use by the Provider Organization. 3 Category of Use Case. The following provides a brief description of the Provider to Provider Communications category of Use Case. Please refer to the Mass HIway Policies and Procedures Section 5.4 for more information on Use Cases. Note that the Year 2 requirement is met by Provider Organizations sending or receiving HIway Direct Messages for at least one Use Case that is within the Provider to Provider Communications Category of Use Cases. No other Use Cases qualify to meet the Year 2 requirement. Provider to Provider Communications - sending and receiving patient information between provider organizations 4 Specify the type of entity (or entities) that are participating in the exchange of information for the Use Case. This list includes all Provider Organization types listed in the Mass HIway Rate Card ( as well as Provider Organizations that are subject to the Mass HIway Regulations. Note that as a part of this question, the Provider Organization must attest that certain advanced coordination and operational steps were taken as a sending and/or receiving Organization. 5 Estimate the percent of transactions that are sent and/or received via the Mass HIway as a part of the Use Case. Note that the Mass HIway is using the information to understand the scope of how the Mass HIway or another HISP is used statewide in lieu of traditional methods. Note that sending 100% of all transactions related to the Use Case over the Mass HIway is not required. 6 Contact information for the person(s) at the Provider Organization if the Mass HIway has technical or operational questions regarding this Attestation Form. Examples of Business contacts would be Head legal counsel or practice manager or Access Administrator. See section 7 of the Mass HIway Policies and Procedures for a description of the Access Administrator role. Examples of Technical contacts would be EHR Implementation Manager or Interoperability Analyst. 8