This document provides New Hampshire Medicaid Office guidelines for Medicaid EHR Incentive Program screenshots and reports that are included as supporting documentation for Meaningful Use (MU), and Clinical Quality Measure (CQM), attestations: Section 1: Links to 2016 CMS Specification Sheets Section 2: General Guidelines for MU and CQM Supporting Documentation; and Section 3: Modified Stage 2 Meaningful Use Objective specific Requirements for 2016 SECTION 1: CMS 2016 SPECIFICATION SHEETS FOR MODIFIED STAGE 2 MEANINGFUL USE OBJECTIVE 1 Protect Patient Health Information 2 Clinical Decision Support LINK Guidance/Legislation/EHRIncentivePrograms/Downloads/2016EP_1ProtectPatientHealthInfoObjectiv e.pdf Guidance/Legislation/EHRIncentivePrograms/Downloads/2016EP_2ClinicalDecisionSupportObjective.pdf 3 Computerized Provider Order Entry Guidance/Legislation/EHRIncentivePrograms/Downloads/2016EP_3CPOEObjective.pdf 4 Electronic Prescribing Guidance/Legislation/EHRIncentivePrograms/Downloads/2016EP_4ePrescribingObjective.pdf 5 Health Information Exchange Guidance/Legislation/EHRIncentivePrograms/Downloads/2016EP_5HealthInformationExchangeObjective.pdf 6 Patient Specific Education Guidance/Legislation/EHRIncentivePrograms/Downloads/2015EP_6PatientSpecificEducationObjective.pdf 7 Medication Reconciliation Guidance/Legislation/EHRIncentivePrograms/Downloads/2016EP_7MedicationReconciliationObjective.pdf 8 Patient Electronic Access 9 Secure Electronic Messaging Guidance/Legislation/EHRIncentivePrograms/Downloads/2016EP_8PatientElectronicAccessObjective.pdf Guidance/Legislation/EHRIncentivePrograms/Downloads/2016EP_9SecureElectronicMessagingObjective.p 10 Public Health Reporting Guidance/Legislation/EHRIncentivePrograms/Downloads/2016EP_10PublicHealthObjective.pdf December 2016 1
SECTION 2: GENERAL GUIDELINES MU and CQM SUPPORTING DOCUMENTATION Screenshots Must: 1. Be generated from Certified EHR Technology (CEHRT). 2. Display dates that are WITHIN the MU reporting period. Reports/Screenshots dated outside of the reporting period will not be accepted as supporting documentation. Vendor verification of functionality will be required. 3. Display: a. An Eligible Professional s (or, where appropriate, an Administrator s) first and last name; b. The facility/organization name and address (or other identifying information that would tie the documentation to the attesting EP. 4. Display the name of the objective. 5. Display the appropriate Document Type on epip (with corresponding File Name and Memo that clearly describe the content of the document). 6. Not include HIPAA data. If patient data has been redacted, it must not be legible. 7. Be uploaded in sequential order. Best practice: upload one document containing screenshots for each report category, i.e., one report with all MU measures and one report with all CQMs. Acceptable (but not preferable): upload individual screenshots; if this option is used, the objective name and identification number must be included in the epip Memo field. 8. Be submitted even for EPs that are excluded from a measure because they have no patients in the numerator and denominator. If an EP is not listed on a report because he/she is claiming exclusion, handwrite the EP s name on the report with an explanation (example: Dr. Smith was excluded from this measure ), and sign and date. December 2016 2
1. Objective #1 (Protect Patient Health Information) A security risk analysis must be conducted, or reviewed, at least once each calendar year This analysis must occur no earlier than the start of the EHR reporting year and prior to the attestation date for that EHR reporting period. 2. Objective #2 (Clinical Decision Support) screenshots must: Display dates within the MU reporting period Be uploaded for each Clinical Decision Support rule and Drug Drug and Drug Allergy interaction (Drug Drug and Drug Allergy interaction alerts are separate from clinical decision support rule interventions and do not count toward the clinical decision support rules required for this first measure); Display an Eligible Professional s, or Administrator s, first and last name; Display the facility/organization name and address (or other identifying information) that would tie the documentation to the attesting EP. Reflect only data that was captured during the MU reporting report (Clinical Decision Support Rules) Demonstrate that the EHR automatically triggers interventions based on a specialty or high priority health condition (for example: a problem list; medication; or laboratory test) (Drug/Drug and Drug/Allergy interactions) Demonstrate that the functionality was enabled on the EHR (for example: a color coded warning for the provider) Be easily understandable; include additional explanation or documentation as needed 3. Objective #3 (Computerized Provider Order Entry): if scheduled to be in Stage 1 and claiming Alternate Exclusion to Measure 2 or 3, EPs will be required to: Enter the number of laboratory or radiology orders during the EHR reporting period wrote fewer than 100 medication/laboratory/radiology orders during the EHR reporting period ), and sign and date 4. Objective #4 (Electronic Prescribing): if claiming exclusion that the EP writes fewer than 100 prescriptions, EPs will be required to: Enter the number of permissible prescription written during the EHR reporting period wrote fewer than 100 permissible prescriptions during the EHR reporting period ), and sign and date 5. Objective #5 (Health Information Exchange): if claiming exclusion, EPs will be required to: Enter the number of times that they transfer a patient to another setting or refer a patient to another provider during the EHR reporting period didn t transfer patients to any other setting of care during the EHR reporting period ), and sign and date ** CONTINUED ON NEXT PAGE ** December 2016 3
6. Objective #6 (Patient Specific Education): measure because she didn t have any office visits during the EHR reporting period ), and sign and date 7. Objective #7 (Medication Reconciliation): measure because she did not have any transitions of care during the EHR reporting period ), and sign and date 8. Objective #8 (Patient Electronic Access): If claiming exclusion because 50 percent or more of patient encounters were in a county that did not have 50 percent of more of its housing units with 4 Mbps broadband availability, EPs will be required to enter the county in which these patient encounters were conducted did not order or create any of the information listed for inclusion in this measure and/or conducted 50 percent or more of his/her patient encounters in a county that did not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period ), and sign and date 9. Objective #9 (Secure Messaging): Change from 2015: in 2016, requires that at least one secure message is sent; in lieu of yes/no response, 2016 attestation requires a numerator and denominator If claiming the second half of the exclusion, EPs will be required to enter the county at which 50 percent or more of patient encounters are conducted measure because she did not have any office visits and/or conducted 50 percent or more of his/her patient encounters in a county that did not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period ), and sign and date ** CONTINUED ON NEXT PAGE ** December 2016 4
Objective #10 (Public Health Reporting): EPs scheduled to be in Stage 1 or Stage 2 MU in 2016 must attest, or claim Exclusion or Alternate Exclusion, to all three Objective 10 measures. To do this, an EP has two options: Option 1: the State of New Hampshire is not accepting data from EPs for Measure 1 (Immunization Registry) or Measure 2 (Syndromic Surveillance) o The EP may claim one of the Exclusion options offered (as applicable) for Measure 1 and Measure 2 and upload a copy of the New Hampshire Division of Public Health Services 2016 readiness letter (located on the Department s website at http://www.dhhs.nh.gov/dphs/bphsi/meaningful use.htm) onto epip as supporting documentation o Then the EP must attest, or claim Exclusion or Alternate Exclusion, for Measure 3 (Specialized Registry Reporting) Option 2: by federal statute, EPs may claim Alternate Exclusion for Measure 2 (Syndromic Surveillance) and/or Measure 3 (Specialized Registry Reporting) o The EP must attest, or claim one of the Exclusion options offered (as applicable) for Measure 1 (Immunization Registry) and upload a copy of the New Hampshire Division of Public Health Services 2016 readiness letter (located on the Department s website at http://www.dhhs.nh.gov/dphs/bphsi/meaningful use.htm) onto epip as supporting documentation o Then the EP may claim Alternate Exclusion for Measure 2 and Measure 3 IMPORTANT: an EP may not claim Exclusion AND Alternate Exclusion for the same measure. It has to be one or the other. For EPs that attest for Measure 3 (Specialized Registry Reporting): EPs must demonstrate that they are in active engagement to submit data to a specialized registry. Active engagement means that the provider is in the process of moving towards sending "production data" to a public health agency or clinical data registry, or is sending production data to a public health agency or clinical data registry. SUPPORTING DOCUMENTATION FOR MEASURE 3 EPs that attest to being in active engagement to submit data to a specialized registry must provide a signed, dated letter from that registry that verifies that the EP demonstrated active engagement during the EHR reporting period as well as the active engagement option (i.e., Level 1, 2, or 3). EPs claiming Exclusion (NOT Alternate Exclusion) to Measure 3 must document (and upload onto epip) all steps demonstrating due diligence for an Exclusion including email communications to specialty societies, screen shots of webpages, etc. END OF DOCUMENT December 2016 5