Transforming Data to Knowledge Guide to Preparing for Meaningful Use Stage 1 Bill Presley September 27, 2013
Hospital Attestation Process A successful and active Registration in the CMS website. https://ehrincentives.cms.gov Completed the appropriate reporting period and met measures Obtain EHR Certification Identification Number Attest online!
Registration and Attestation System Registration User Guide Step-by-Step guide for EH's. https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/dow nloads/ehrhospital_registrationuserguide.pdf
Registration and Attestation System Attestation User Guide Step-by-Step guide for EH's. https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/do wnloads/hospattestationuserguide.pdf
Registration and Attestation System Timelines http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downl oads/hit-programs-timeline-2012-.pdf
EHR Certification Identification Number CMS EHR Certification Identification Number is a number generated by the Certified Health IT Product List (CHPL) used for reporting to CMS for Meaningful Use attestation. It represents a product or combination of products in the CHPL.
EHR Certification Identification Number (Cont.) Warning!!! Do not use the vendor product certification number.
EHR Certification Identification Number (Cont.) Each Hospital must obtain their your own unique CMS HER Certification ID from the Certified Health IT Product List website cart.
Steps to obtaining CMS EHR Certification ID Number Visit Certified Health IT Product List website at http://oncchpl.force.com/ehrcert. Select which edition of ONC HIT EHR Certification are you attesting? Select the practice type by selecting the Ambulatory or Inpatient buttons.
Steps to obtaining CMS EHR Certification ID Number (Cont.) Search for the Certified EHR Products being used. There is the option of browsing all products, searching by product name, number, vendor, or searching by criteria met.
Steps to obtaining CMS EHR Certification ID Number (Cont.) Add product(s) to the cart to determine if your product(s) meet 100% of the required criteria.
Steps to obtaining CMS EHR Certification ID Number (Cont.) Request a CMS EHR Certification ID for CMS registration or attestation from your cart page
CMS Attestation Website changes for 2013. Contents: CPOE (CM-1) Alternate Measure Available Vitals (CM-7) Alternate Measure Available Clinical Quality Measures (CM-9) Deleted Electronic Exchange of Key Clinical Information (CM- 13) Deleted ALL Clinical Quality Measures - Minimum Case Threshold Exemption
CPOE (CM-1) Alternate Measure Available Beginning in 2013, CMS is adding an optional alternate measure to the objective for CPOE. The current measure for CPOE is based on the number of unique patients with a medication in their medication list that was entered using CPOE. The new, alternate measure is based on the total number of medication orders created during the EHR reporting period. An EP, eligible hospital, or CAH may select either measure for this objective in Stage 1 in order to achieve meaningful use. Optional in 2013 but will be required in 2014 and beyond. Optional alternate method of reporting CM-1
Vitals (CM-7) Alternate Measure Available Beginning in 2013, CMS is changing the measure of the objective for recording and charting changes in vital signs for EPs, eligible hospitals, and CAHs. The new measure amends that age limit to recording blood pressure for patients ages 3 and over and height and weight for patients of all ages. Optional in 2013 but will be required in 2014 and beyond. Optional alternate method of reporting CM-7
Clinical Quality Measures (CM-9) Deleted Beginning in 2014, there will no longer be a separate objective for reporting ambulatory or hospital clinical quality measures as a part of meaningful use. CMS is simply removing the standalone objective in 2013 that requires providers to attest that they plan to report on clinical quality measures because it is redundant.
Electronic Exchange of Key Clinical Information (CM-13) Deleted Beginning in 2013, the objective for electronic exchange of key clinical information will no longer be required for Stage 1. In Stage 2, this objective is part of providing a summary of care record following a transition of care or referral.
ALL Clinical Quality Measures Minimum Case Threshold Exemption The revisions to the Stage 2 EHR incentive program final rule adopted a minimum case number threshold exemption for quality measure reporting for eligible hospitals and CAHs available in fiscal year 2013. As a result of this change, eligible hospitals and CAHs with five or fewer inpatient discharges in their 90-day period of Meaningful Use, or 20 or fewer inpatient discharges per year if reporting a full year of Meaningful Use, in a given clinical quality measure (CQM) denominator population will be exempted from reporting on that individual CQM. The threshold that you have to meet is defined by the CQM s denominator population, so those discharges have to apply for the population that is being captured in the denominator, and it applies on the CQM-by-CQM basis. So just because you meet the threshold for one CQM doesn t mean you re automatically excluded from others.
Minimum Case Threshold Exemption (Cont.) Example: For example, if the hospital submitted aggregate population and sample size data reflecting 4 stroke patients discharged in FY 2013, then the hospital would be exempt from reporting the CQMs that include stroke patients as part of the denominator population (that is, the 7 stroke CQMs out of the total 15 CQMs). Therefore, this hospital would successfully meet the CQM reporting requirements in FY 2013 if they submit the 8 remaining CQMs. If a hospital does not reach the case threshold for all 15 CQMs, the hospital would be exempt from reporting all CQMs. To be eligible for the exemption, Medicare-eligible hospitals and CAHs must use the same process outlined in the Stage 2 final rule (see 77 FR 54080), including submitting aggregate population and sample size counts for Medicare and non-medicare discharges as defined by the CQM's denominator population for the EHR reporting period no later than November 30 after the end of the fiscal year containing the EHR reporting period (for example, November 30, 2013 for the hospital's EHR reporting period that occurs in FY 2013). Medicaid-only hospitals, including children's hospitals, must report this same information to the state to which they attest, in a manner specified by that state. Sample size data are not required for electronically submitted CQMs. http://www.gpo.gov/fdsys/pkg/fr-2012-12-07/html/2012-29607.htm
Attestation with OneView Start an Attestation under the Attestation section Select appropriate reporting period Everything should have green checks Lock it when hospital is ready to attest
Attestation Locked View Attestation Data Report
Audit Preparation with Supporting Documentation Relevant supporting documentation associated with a CQM, CM, or MSM Measure MEDITECH screenshots Payment calculations ONC EHR licensing documentation OneView Invoices