Welcome to the MS State Level Registry Companion Guide for

Welcome to the MS State Level Registry Companion Guide for Step 3 Attestation of your EHR This companion guide will assist providers as they move through the MS State Level Registry (MS SLR) online attestation process. Screen shots and brief instructions are included throughout this guide. There are also links to additional resources available. Our Staff is available to assist you through this process. If you have a question or run into a snag or surprise along the way, please contact us. The best way to contact us is via email: MS SLR Specialists: Shakarma Green Sarah Graves shakarma.green@medicaid.ms.gov sarah.graves@medicaid.ms.gov Program inbox ms-ehr@medicaid.ms.gov Use our need help button on our website to contact us with specific SLR issues http://msehrpip.wordpress.com Many of our most common questions can be answered by looking through our web resource http://msehrpip.wordpress.com

2015 Program Requirements CMS recently released a final rule that specifies criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The final rule s provisions encompass 2015 through 2017 (Modified Stage 2) as well as Stage 3 in 2018 and beyond. Here s what you need to know about meeting EHR Incentive Programs requirements in 2015: Objectives and Measures All providers are required to attest to a single set of objectives and measures. This replaces the core and menu structure of previous stages. For EPs, there are 10 objectives, including one consolidated public health reporting objective. For eligible hospitals and CAHs, there are 9 objectives, including one consolidated public health reporting objective. o View the 2015 Specification Sheets for Eligible Professionals and Eligible Hospitals and Critical Access Hospitals. In 2015, all providers must attest to objectives and measures using EHR technology certified to the 2014 Edition. To assist providers who may have already started working on meaningful use in 2015, there are alternate exclusions and specifications within individual measures for providers who were previously scheduled to be in Stage 1 of meaningful use. These include: o Allowing providers who were previously scheduled to be in a Stage 1 EHR reporting period for 2015 to use a lower threshold for certain measures. o Allowing providers to exclude Modified Stage 2 measures in 2015 for which there is no Stage 1 equivalent. For more information, view the EHR Incentive Programs in 2015 through 2017 Objectives and Measures for Eligible Professionals and Eligible Hospitals and Critical Access Hospitals. EHR Reporting Period Starting in 2015, the EHR reporting period for all providers will be based on the calendar year. In 2015 only, the EHR reporting period for all providers will be any continuous 90-day period. EPs may select an EHR reporting period of any continuous 90 day period from January 1, 2015 through December 31, 2015.

List of Documentation that will be required in the MS State Level Registry for Meaningful Use: Meaningful Use Objective #1 - Protect Patient Health Information Security Risk Analysis Summary Report Meaningful Use Objective #3 Computerized Physician Order Entry (CPOE) Full Meaningful Use Summary Report taken from your EHR (independently for each provider Meaningful Use Objective #10 Public Health Registry Reporting Measure #1 Immunization Registry Evidence of Active Level of Engagement Letter of Acknowledgement from MS Immunization Registry Production Confirmation Notice of Exclusion (if applicable does not administer immunizations) Measure #2 Specialized Registry Reporting Evidence of Active Level of Engagement Registration Acknowledgment Letter from chosen Specialized Registy Production Confirmation Notice of Exclusion (allowable exclusions no registry available or declared readiness to receive submissions from EPs) You may download the Notice of Public Health Reporting Exclusion from our website prior to starting the online attestation process. Notice of Exclusion ( https://msehrpip.files.wordpress.com/2016/04/notice-of-exclusion-for-public-health-reporting-program-year-20151.pdf)

Meaningful Use MS State Level Registry Companion Guide Step 3 EHR Certification Please indicate that you understand that you Certified EHR Technology code is listed on the ONC Website. The MS State Level Registry validates this during the online application. We will also compare your certification number with the information on your EHR vendor contract. Please enter the Certification number for your 2014 edition EHR software. Notice in digit places three four and five these characters 14E. This indicates that the certification number references a 2014 edition. Please remember to Save and Continue at the bottom of each screen to save your work and advance you to the next screen in the online process. Enter the number of unique patients that were seen by the provider during the chosen (90-day) EHR Reporting Period from 2015. These numbers are not group numbers. These are actual, unique patients (regardless of the number of encounters). You will count each unique patient only once. These numbers will be used in various places as you continue through you Meaningful Use Attestation. You are required to include records in your EHR for at least 80% of all unique patients seen.

This is where you will include the locations where you see patients that have EHR technology. If you work in multiple locations and wish to include each of these in the aggregate report, you will need to add more locations. Steps: 1) Click the Add New Location + 2) The Numerator and Denominators should add up to equal the numbers your entered above for your unique patient count. 3) Select Yes/No under the EHR Technology column 4) Scroll back to the left side and cick the Insert button Please indicate your understanding and agreement with the following statements:

The 90-Day EHR Reporting Period is taken from any 90-day period between January 1, 2015 and December31, 2015. It can begin on any day of the month. These dates can be unique for each independent provider in your organization. We are looking for 90 days of continuous patient engagement. We understand that providers take vacations and time off. If your originally chosen EHR Reporting Period contains multiple days/weeks with no patient engagement, we will ask you to select another 90-Day period. We will verify this using our internal claims database to show continuous patient engagement over the entire reporting period. Please attach the EHR Vendor Contract between your organization and your software vendor. This contract must have evidence of your upgrade to the 2014 edition of Certified EHR Technology. We prefer a fully executed contract. Additional information about what we will look for can be found on our website. EHR Vendor Contract If the contract was dated prior to January 1, 2014, please include a Vendor Support Letter which indicates an ongoing fiscal and supportive relationship between your organization and your EHR vendor. Please use the same method to attach these supporting documents as you previously did during the Eligibility Step in online process. SLR Companion Guide Step 2

Please remember to Save and Continue at the bottom of each screen to save your work and advance you to the next screen in the online process.

Meaningful Use Objectives There is not an exclusion for this objective. This must be completed at the clinic level prior to December 31, 2015. Please upload the Security Risk Analysis Summary Report which should be dated prior to December 31, 2015. Please use the same method to attach these supporting documents as you previously did during the Eligibility Step in online process. SLR Companion Guide Step 2 For Additional Information, please follow this link Protect Patient Health Information

Steps: 1) Answer the Exclusion Criteria question No / Yes 2) Answer the Measure #1 question No / Yes 3) List the Five Clinical Decision Support Interventions you (your clinic implemented) that are connected to at least four Clinical Quality Measures, or High-Priority Health concerns. 4) Select either CQMs or High-Priority conditions 5) Use the link to select four CQMs from the pop up table (see below) 6) Click the Select Button at the bottom of the popup window. 7) Answer the Measure #2 question No / Yes

Please remember to Save and Continue at the bottom of each screen to save your work and advance you to the next screen in the online process. For additional information please follow this link Clinical Decision Support

Steps: 1) Answer the Exclusion Criteria questions No / Yes a. Medication Orders No / Yes b. Laboratory Orders No / Yes c. Radiology Orders No / Yes Note* If you created less than 100 orders in any category, you can either meet the particular Measure by taking the exclusion or reporting/entering the data using the specified minimum thresholds (see example above Measure #1) 2) Enter data extracted from the Meaningful Use Summary Report for this provider for the following applicable Measures a. Medication Orders Entered Numerator / Denominator b. Laboratory Orders Entered Numerator / Denominator c. Radiology Orders Entered Numerator / Denominator 3) Upload the complete EHR Meaningful Use Summary Report (All objectives). Your report may contain Meaningful Use Objectives that you may/may not report during the online attestation process. However, this summary report is a strong indicator that you are using your Certified EHR Technology in a Meaningful way.

For additional information, please follow this link: Computerized Physician Order Entry (CPOE)

Steps: 1) Answer the Exclusion Criteria questions N0 / Yes a. If you answer Yes you will be able to take the available exclusion b. If you answer No you will be able to report/enter data for the numerator / denominator using the required minimum threshold (More than 50%) 2) Enter data extracted from the Meaningful Use Summary Report for this provider for the Measure a. More than 50 % of permissible prescriptions written by the provider were transmitted electronically Numerator / Denominator For additional information, please follow this link: Transmit Prescriptions Electronically

Steps: 1) Answer the Exclusion Criteria questions N0 / Yes a. If you answer Yes you will be able to take the available exclusion b. If you answer No you will be able to report/enter data for the numerator / denominator using the required minimum threshold (More than 10%) 2) Enter data extracted from the Meaningful Use Summary Report for this provider for the Measure a. More than 10% of Transitions of Care or Referrals were transmitted electronically Numerator / Denominator For additional Information, please follow this link: Health Information Exchange

Steps: 1) Answer the Exclusion Criteria questions N0 / Yes a. If you answer No you will be able to take the available exclusion b. If you answer Yes you will be able to report/enter data for the numerator / denominator using the required minimum threshold (More than 10%) 2) Enter data extracted from the Meaningful Use Summary Report for this provider for the Measure a. Your EHR triggered a prompt to give specific patient information to more than 10% of unique patients Numerator / Denominator For additional Information, Please follow this link: Patient Specific Information

Steps: 1) Answer the Exclusion Criteria questions N0 / Yes a. If you answer No you will be able to meet this measure by taking an allowable exclusion. b. If you answer Yes you will need to meet the minimum threshold. You will pull data from your Meaningful Use Summary report that shows that More than 50% of (incoming) referrals had a Medication Reconciliation completed in the EHR. 2) Use the data from your EHR Meaningful Use Summary Report for this provider to report/enter the numerators and denominators for this measure. Numerator / Denominator For additional information, please follow this link: Medication Reconciliation

Steps: 1) Answer Exclusion Criteria questions for Measure # 1 and Measure #2 a. Measure #1 means that you gave some instructions to your patients if they wanted to access their electronic health records. Instructions could be emailed, printed on a sheet of paper, business card or even an office invoice or patient bill. This does not mean that patients actually accessed their electronic health record; it just means that you gave them instructions.

b. Measure #2 implies that you actually have a patient portal that can be accessed by patients through the internet. For this Measure, the current requirement is that at least one patient, seen by the provider actually accessed their electronic health record through your patient portal. The Exclusion question that refers to conducting 50% or more of patient encounters in a county or area with limited broadband internet access will need to be supported by a current FCC Broadband map which indicates limited internet access. Note: If you choose to use this exclusion criterion, please obtain and keep a copy of the FCC Broadband Internet map that covered the particular EHR Reporting Period (in the event of a future audit). 2) Use the data from your EHR Meaningful Use Summary Report for this provider to report/enter the numerators and denominators for measure # 1 (more than 50% of patients were given instructions as to how to request access to their electronic health record(s). Numerator / Denominator 3) Use Patient Portal access logs to gather data numbers for Measure #2. Enter the number of unique patients seen by the provider in the Denominator Field. Enter the number of patients that actually accessed their electronic health record online via your patient portal (at least one patient accessed the electronic health record). Note: There is not a required attachment for this Objective. However, you are encouraged to upload a copy of a supporting FCC Broadband Internet Map, or a screen shot of your patient portal login screen. These are not required at this time, but will be very helpful in the event of a future post-payment audit. For additional information, please follow this link: Patients View, Download and Transmit their health information

Steps: 1) Answer both Exclusion Criteria questions No / Yes 2) Use the data from your EHR Meaningful Use Summary Report to answer the Measure question Did you have the capacity or did you enable the Secure Messaging feature in your EHR during the entire EHR Reporting Period? No / Yes 3) List the Secure Messaging method used. If unknown, pleas enter unknown

All providers in the EHR Incentive program are considered to be Modified Stage 2 participants. Providers that are scheduled to demonstrate Old Stage 1 (Meaningful Use year 1 or Meaningful Use Year2) are required to respond to one Measure under the Public Health Reporting Objective. Providers that are scheduled to demonstrate Old Stage 2 (Meaningful Use year 3 or Meaningful Use Year4) are required to respond to two Measures under the Public Health Reporting Objective. Recommendations for Public Health Reporting options for program year 2015 - Modified Stage 2 (MU3 or MU4): 1) We encourage all providers to simply register their intent to onboard with the MS Immunization Registry. Some providers would be excluded from this Measure because they do not administer any immunizations (within the normal scope of practice). This is a quick and easy process. Once a clinic registers, the MS Immunization Registry will send a Letter Of Acknowledgement. This will be used as the Evidence that supports the Level of Active Engagement Registration and will be a required document attachment for this Measure. 2) Choose Syndromic Surveillance Reporting and take any (all) of the allowable exclusions. 3) All providers that actually have a Specialized Registry they are reporting or submitting data with to report accordingly in the MS SLR. However, we will permit providers to select the Specialized Registry Measure and take any (all) of the allowable exclusions. The MS SLR requires that a document be uploaded into the application, regardless of reporting or excluding this measure. Please use the Notice of Exclusion as your supporting documentation and attach it with this measure.

Steps: 1) Indicate the highest Level of Active Engagement status that your clinic has achieved Choose Options 1, 2 or 3 i. Registration (completed Registration of Intent to Onboard with the MS Immunization Registry prior to 12/31/2015) ii. Testing and Validation (include latest test date submission) iii. Production currently submitting data to the MS Immunization Registry 2) If you registered in a previous year - answer Yes. If you registered in 2015 answer No The MS SLR asks for a date that is prior to the 60 th day of your EHR Reporting Period. *Mississippi will accept any date entered in this field as long as it occurs prior to December 31, 2015. We will verify the date on the Acknowledgement Letter that you attach. 3) Please upload the Letter of Acknowledgement that you received from the MS Immunization Registry. You are not required to register multiple times (once is good for all).

If you select Option 3 Production, please upload an evidence of your data submission to the Immunization Registry (confirmation of receipt, etc )

You may select any/all of the exclusions for this Public Health Reporting Measure. Mississippi does not collect Syndromic Surveillance Reporting from EPs. However. If your clinic is already connected to a hospital system through a Wide Area Network, and this hospital is already on boarded and is presently submitting Syndromic Surveillance data then you may submit this type of data as well. Please include an evidence or sample transmission to this type of registry.

For Program Year 2015, Mississippi will accept any/all of the available Exclusions from EPs and clinics for Specialized Registry Reporting. Because Modified Stage 2 providers (MU3/MU4) are expected to report on two Public Health Measures, there is a required supporting document that must be loaded into the MS SLR. Please download the Notice of Public Health Reporting Exclusion from our website and upload this document on this screen. For additional information, please follow this link: Public Health Reporting Options

Clinical Quality Measures CQM Reporting There are no changes to the CQM reporting requirements for program year 2015. We are using the same criteria for CQM selection and manual reporting of data that we used for 2014. The CQM selection screen is below. Providers will choose one of three CQM reporting options: 1) Adult Recommended Population CQMs (9 that come from the full list of CQMs) 2) Pediatric Recommended Population CQMs (9 that come from the full list of CQMs) 3) Self-Selected CQMs (9 that come from the full list of CQMs taken from at least three of the six National Quality Strategy Domains) Note: CQMs must be an output from your EHR and should appear on the Providers Meaningful Use Summary Report. They may be taken from the same date range as the other MU objectives, or they may be reported using a different 90-day period within 2015. Steps: 1) Select the Reporting Option (Adult, Pediatric, Self-Selected) 2) Click the Save Button 3) A List of CQMs will be displayed in the Left-hand Navigation Panel in the SLR. Enter data from your EHR Meaningful Use Summary Report that contains CQM objectives/measures. 4) Move through each CQM screen and respond appropriately for numerators, denominators, exclusions, etc. There are not minimum threshold requirements for CQM reporting. For additional information, please follow this link: Clinical Quality Measures Basics