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What to Expect When You re Attesting: A Survival Guide to Meaningful Use Attestation
Introductions Lindsey Lanning Healthcare Compliance Consultant Cindi Kincade Vice President, Consulting Solutions
What to Expect When You re Attesting: A Survival Guide to Meaningful Use Attestation
Today s Webinar What You Need to Know for 2016 Reporting Getting Started Meaningful Use Objectives Clinical Quality Measures Submission Attestation Recommendations
2016 Reporting Deadlines Meaningful Use Reporting: The EHR Incentive Programs attestation system will be open from January 3 - February 28, 2017. Providers must attest by the attestation deadline (2/28/2017) to avoid a 2018 payment adjustment. PQRS EHR Reporting: (aka Aligned Reporting) February 24, 2017 NextGen Healthcare deadline for clients to have their QRDA files approved and ready for submission to CMS February 28, 2017, 8:00pm CMS Deadline for NextGen Healthcare to submit client-approved QRDA files submitted to CMS PQRS Qualified Registry Reporting: March 10, 2017 NextGen Healthcare deadline for clients to have their XML file(s) approved and ready for submission to CMS. March 31, 2017, 8:00pm CMS Deadline for NextGen Healthcare to submit client-approved XML files submitted to CMS
What You Need to Know All providers are required to attest to a single set of objectives and measures For eligible professionals (EPs), there are 10 objectives In 2016, all providers must attest to objectives and measures using EHR technology certified to the 2014 Edition For all participants, the EHR reporting period will be a minimum of any continuous 90-day period between January 1, 2016 and December 31, 2016 For all EPs that choose to report CQMs by attestation in 2016, the reporting period will also be 90-days
2016 Changes Secure Electronic Messaging (EPs only) An EP must send a secure message using their CEHRT's electronic messaging function to at least one patient the EP sees during the EHR reporting period Public Health Reporting In 2016, all EPs must meet two measures, and eligible hospitals and CAHs must meet three measures or claim alternate exclusions
Alternate Exclusions Objective 3, Computerized Provider Order Entry (CPOE): There are alternate exclusions for measure 2 and measure 3. Providers scheduled to be in Stage 1 in 2016 may claim an exclusion for measure 2 (laboratory orders) and/or measure 3 (radiology orders) of the Stage 2 CPOE objective for an EHR reporting period in 2016. Objective 10, Public Health Reporting: EPs scheduled to be in Stage 1 and Stage 2 in 2016 must attest to at least two measures from the Public Health Reporting measures 1 3. However, EPs may claim an alternate exclusion for measure 2 (syndromic surveillance) and Measure 3 (specialized registry reporting) as these measures might require the acquisition of additional technologies eligible hospitals/cahs did not previously have or did not previously intend to include in their activities of meaningful use. An alternate exclusion may only be claimed for up to two measures, then the provider must either attest to or meet the exclusion requirements for the remaining measure.
Medicaid MU Some states have not yet opened their Medicaid EHR Incentive Programs, Eligible Professionals will not be able to register for a Medicaid EHR Incentive Program until their state's program has launched and that state's site has opened. Medicaid State Information Page
Attestation Acronyms CCN CMS CQM EH EHR EIN EP I&A NPI PECOS TIN CMS Certification Number Centers for Medicare & Medicaid Services Clinical Quality Measures Eligible Hospital Electronic Health Record Employer s Identification Number Eligible Professional Identification & Authentication System National Provider Identifier Provider Enrollment, Chain and Ownership System Tax Identification Number
Getting Started
Page Navigation Enter the EHR Incentive Program URL https://ehrincentives.cms.gov
To determine your eligibility, click on the CMS website For a list of Eligible Professional Types (EPs), click on Eligible Professionals (EPs) link
Statement Acknowledgement Please read the statements on the page and check the box to indicate that you acknowledge that you are aware of the statements Click Continue
Login Enter your National Plan and Provider Enumeration System (NPPES) web user account, user ID and password to log into the attestation system Users working on behalf of an Eligible Professional(s) must have an Identity and Access Management system (I&A) web user account (User ID/Password)
Login on Behalf of Provider CMS allows an eligible professional to designate a third party to register and attest on his or her behalf. To do so, users working on behalf of an eligible professional must have an Identity and Access Management System (I&A) web user account (User ID/Password), and be associated to the eligible professional's National Provider Identifier (NPI).
Creating an I&A Account Enter the email address associated with your account Once you enter your email address, you will receive an email with a PIN number to verify your account
Creating an I&A Account Follow all of the steps to creating a new account and verifying your identity
Successful Registration Once you have entered all your information, you will receive a confirmation email and see a screen notifying you that you have been successfully registered. Note: Participants CANNOT register and attest on the same date
Update I&A Profile To finish registering, you will need to enter your personal information in the My Profile tab. If you would like to add an employer, you can do so at the bottom of the page. To add an employer, enter the organization information including the NPI number.
Adding Employer Select your employer from the search results. If your provider is not listed, click Add Employer Not in List Select Delegated Official as the role you are requesting for the provider
Confirmation of Added Employer Once you have added your employer, verify the information in your profile is correct As the Delegated Official, you will need to have the Authorized Official confirm your request to be the Delegated Official
Confirming Delegate Request When your employer logs in to the Identity & Access Management System and reviews their Home tab, they will see any pending requests to connect There they can click Approve or Reject, or quickly add a connection, staff member, or other employer
Connections Status In the My Connections tab you can view the details and status of each of your connections Once your account is connected with the eligible professional or organization you are working with, you will be able to begin the registration and attestation process
Welcome Screen Welcome screen consists of four tabs to navigate through the registration and attestation process 1. Home 2. Registration 3. Attestation 4. Status
Attestation Instructions After reading the attestation instructions, depending on the current state of your Medicare attestation you would select an action such as: Attest Modify Cancel Resubmit Reactivate View
Only one action can be performed at a time on this page Resubmit, Modify, Cancel and Reactivate are the available Action web links for returning users To begin attestation, select attest in the action column Action Selection
Attestation Topics The data required is grouped into three topics for Attestation: Attestation Meaningful Use Objectives Clinical Quality Measures The topics will only be marked as completed once all the information has been entered and saved When all topics are checked completed or N/A user can select Continue with Attestation Click on Topic Attestation Information to begin the attestation process
Attestation Information Enter your CMS EHR Certification Number Note: The EHR reporting period is a minimum of any continuous 90-day period between January 1, 2016 and December 31, 2016. Enter the period start and end date of the reporting period you are attesting for
How to get your EHR Certification ID To get your EHR certification ID you need to: Go on their website (http://oncchpl.force.com/ehrcert) and search the comprehensive list of certified health information technology for NextGen. Make sure you know what version(s) you used during the reporting period and that you add any other 3 rd party products to your cart as well. After you select your EHR and 3 rd party products click View Progress and then Get Certification ID which you will then want to email to yourself.
Meaningful Use Objectives
Overview Choose 2 of the 3 public health measure options. Eligible Professionals scheduled to be in Stage 2 must attest to at least 2 measures from the Public Health Reporting Objective Measures 1-3. You may claim an alternative exclusion for Public Health Measures: Syndromic Surveillance Reporting Specialized Registry Reporting
Objective 1:Protect PHI (aka SRA) Read the objective and measure and respond by selecting yes or no No change from last year Security Risk Analysis (SRA) needs to be updated annually
Objective 2: Clinical Decision Support Answer Yes or No to the Exclusion If the exclusion does not apply to you, answer Yes or No to the measure No change from last year Yes/No attestation usually requires screenshots from your EHR to include in your audit binder Helpful hint: Ensure the provider has 5 CDS interventions in addition to drug-drug and drugallergy interactions enabled for the entire reporting period
Objective 3A: CPOE Meds Select the appropriate option under Patient Records Answer Yes or No to the Exclusion If you click No, the screen will expand and you must enter the numerator and denominator for the measure The numerator and denominator will only contain data that was done during the reporting period Items done outside of the reporting period do NOT increment the numerator or denominator
Objective 3B: CPOE Labs EPs, eligible hospitals and CAHs that were scheduled to be in Stage 1 in 2016 may claim an alternate exclusion for Objective 3: Computerized Provider Order Entry, Measures 2 and 3 (lab and radiology orders), or choose the modified Stage 2 objective and measures.
Objective 3C: CPOE Radiology The Medicare and Medicaid EHR Incentive Programs registration and attestation system will automatically identify those providers who are eligible for alternate exclusions. Upon attestation, these providers will be offered the option to attest to the objective and measure, and the option to attest to the alternate exclusion, if applicable. The provider may independently select the option available to them for each measure for which an alternate exclusion may apply.
Objective 4: E-prescribing No change from previous reporting year Numerators and Denominators must be whole numbers Numbers come from the MU 2 Objective Summary Report in the HQM Please make sure the reporting period is correct on the report
No change from previous reporting year NextGen Share is utilized for electronically sending a Summary of Care record Helpful hint: In order to exclude referral orders to providers within the same practice or enterprise the internal referral checkbox must be selected when the order is placed Objective 5: HIE
Objective 6: Patient Education No change from previous reporting year Patient Education is an integrated feature that provides easy access to patient instructions related to each clinical encounters and diagnoses You can access Patient Education from various points in NextGen which includes: HealthWise Health promotion plan Medline Plus
Objective 7: Medication Reconciliation No change from previous reporting year Medication reconciliation is a formal process of obtaining and verifying a patient s current medicines following a transfer of care to your office. After you have confirmed with a patient that medications on the Active Medications list are accurate and up to date, you would check medications reconciled in the Medication Reconciliation module
Objective 8A: Patient Electronic Access For an EP to successfully attest for Objective 8, they need to invite more than 50% of patients to the patient portal. Patients who are given a token and register can view their problems, allergies, medications, lab results and vital signs. They can also manage their accounts and message their providers.
Objective 8B: Patient Electronic Access Patient portal objective Part 1: Issue the token Part 2: View, Download, Transmit Threshold is still 1 patient Decrease patient participation measures
Objective 9: Secure Messaging **Threshold Increase: 2016 requires 1 patient not just enabled For at least 1 patient seen by the Eligible Professional (EP) during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient or in response to a secure message sent by the patient during the EHR reporting period. Send a message through the portal
Objective 10A: Immunization Note: If you did not select this public health measure option at the beginning of attestation, you will not see this screen. You will only see the screen for the public health options you chose. Answer Yes or No to the Exclusion If the exclusion does not apply to you, answer Yes or No to the measure.
Objective 10B: Syndromic Surveillance Providers scheduled to be in Stage 1 and Stage 2 in 2016 may claim an alternate exclusion for the Public Health Reporting measure(s) that might require acquisition of additional technologies that they did not previously have or did not previously intend to include in their activities for meaningful use. EPs may claim an alternate exclusion for measure 2 (syndromic surveillance) and measure 3 (specialized registry reporting).
Objective 10C: Specialized Registry EPs may report to more than one specialized registry and count more than once Helpful hint: We recommend that any documentation that is received as part of your communication or verification of registry participation is placed in your audit binder Emails with registry Screenshot of a website stating a registry is not ready
Clinical Quality Measures
CQM Refresher Clinical quality measures, or CQMs, are tools that help measure and track the quality of healthcare services provided by eligible professionals, eligible hospitals and critical access hospitals (CAHs) within our healthcare system. These measures use data associated with providers ability to deliver high-quality care or relate to long term goals for quality healthcare. CQMs measure many aspects of patient care. To participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs and receive an incentive payment, providers are required to submit CQM data from certified EHR technology.
On the Clinical Quality Measure homepage, the user must select between 2 options before moving forward If you choose Option 1, you must electronically report using the Medicare EHR Incentive ereporting option OR submit CQM data using the Comprehensive Primary Care (CPC) attestation module If you choose Option 2, you may enter the CQMs manually to complete your attestation Reporting CQMs
CQM Selection After choosing option 2, the user will be taken to this page containing instructions for selecting CQMs You are required to select a minimum of 9 Clinical Quality Measures from the list Your selection must include at least 3 of the 6 HHS National Quality Strategy domains
CQM Questionnaire Once you have made your selections, you will be prompted to enter Numerator(s), Denominator(s), Performance Rates, and Exclusion(s), if applicable, for selected Clinical Quality Measures Do this for all 9 measures NextGen Users: This data can be found on your CQM Summary Report from the HQM Helpful hint: Make sure you confirm the correct measure, version, title, and description before submitting
Submission
Attestation Progress When all topics are marked as completed or N/A, you may proceed with Attestation You will be able to view your entries before the final submission Click Continue with Attestation to complete the Attestation process
Attestation Statements Check the box next to each statement to attest Notice these statements have been expanded on to address information blocking To complete your attestation, click agree Select the Disagree button to go to the Home Page (your attestation will not be submitted)
Attestation Disclaimer Read the disclaimer and click on Agree or Disagree If Agree is chosen and you have met all meaningful use objectives and measures you will see the Accepted Attestation page CMS recommends you review all of your attestation information before submitting
Accepted Attestation If your submission is accepted you will see the Accepted Attestation submission receipt which contains attestation tracking information This concludes the Attestation Process Click on Review Results to view the Summary and Detail of the Objectives, Measures, and Clinical Quality Measures Please print this receipt for your records and a confirmation email will also be sent
Rejected Attestation If your attestation was rejected you will see the below message. This means you did not meet one or more of the meaningful use minimum standards. You will need to reassess/modify your data so that you can meet the measure(s) The EP did not demonstrate meaningful Use of certified EHR technology because one or more objectives were not met as indicated by non-compliant measures. One or more meaningful use objective measures calculation did not meet meaningful use minimum standards.
Review Summary Once you click Review Results, you can review your documentation to ensure the correct information was entered at attestation for each of the objectives and their associated measures If an error is found, you may make the correction and resubmit your attestation for this same reporting period
Resubmitting Attestation Select Resubmit under the Action column When you click on a measures list, you will navigate to the first page of the chosen measures. Click Save and Continue until you get to the appropriate measure for editing Click Save and Continue through the remaining measures to the Topics for this Attestation page If all of the topics show complete you can resubmit
Review Status When you have finished attestation and received an accepted attestation receipt, click on the Status tab to see your progress You can then click on the appropriate tab to see your registration, attestation, and payment status
Attestation Recommendations
Best Practices Collect documentation you will use to submit your Meaningful Use data: Printed Meaningful Use Summary Report and CQM Summary Report Documentation that verifies any actions completed outside of the EHR Screenshots and SRA Documentation to support any applicable exclusions Screenshots and summary report data Be aware of attestation resources Itentive CMS NextGen
Attestation Worksheet Fill out your attestation worksheet prior to attesting Use your attestation worksheet while you are attesting
NG HQM Summary Report Print/Save your HQM MU 2 Objective Summary report and use while you are attesting This is the report your numerator and denominator data will come from Check the reporting date range
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Questions Lindsey Lanning Healthcare Informatics Coordinator llanning@itentive.com 224-220-5621 Cindi Kincade Vice President, Client Solutions ckincade@itentive.com 224-220-5575
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