Meaningful Use Toolkit for EP

Overview of New Requirements for Program Year 2018

Meaningful Use (MU) refers to the use of Certified Electronic Health Record Technology (CEHRT) in a meaningful way to increase efficiency, reduce costs, and improve patient care. By demonstrating MU, an Eligible Professional (EP) can earn financial incentives.
 

• EPs are recommended to use the new PVT Calculator to determine their PVT. To learn more click here.
   

• For program year 2018, an EP needs to attest to either Modified Stage 2 or Stage 3.
   

• Modified Stage 2 has 10 objectives replacing the original core and menu sets of Stages 1 and 2.
   

• Stage 3 has only 8 objectives that further consolidate the objectives and measures of Modified Stage 2.
   

• An EP also needs to meet the requirements for the Clinical Quality Measures (CQMs).
   

• EPs can no longer initiate first-time participation in the program and AIU attestation is no longer available.
   

• However, any EP who previously attested and was approved for payment can continue in the program.
   

• This includes EPs who have switched employer and have not yet received 6 incentive payments. 
   

• The MU attestation deadline is Wednesday, Apr 3, 2019. MAPIR is open for PY2018 attestations.
   

• The MU reporting period will be any continuous 90-day period from Jan 1, 2018 through Dec 31, 2018.
   

• Note: Read the 365 day CQM Reporting Period warning in the CQM section of the MU tab of this toolkit.
   

• Modified Stage 2 requires a 2014 or 2015 CEHRT Edition.
   

• Stage 3 requires a 2015 CEHRT Edition, or a combination of 2015 and 2014 Editions that meets the Stage 3 requirements.
   

• Use the information presented in the Program, Registration, Attestation, and other tabs to apply for incentives. 

Promoting Interoperability (PI) Programs

In 2018, CMS renamed the EHR Incentive Programs to the Promoting Interoperability (PI) Programs, which covers both the HITECH and MACRA programs. As such, the Medicaid EHR Incentive Program is now part of the PI Programs. The name of the Medicaid EHR Incentive Program has not changed.

What an EP needs to know for Program Year 2019

On Jul 12, 2018, CMS released a Notice of Proposed Rulemaking (NPRM) with proposed policies for 2019. The NPRM proposes to keep the thresholds for View Download Transmit and Secure Messaging at 5% for the remainder of the MU program, and to update to the Syndromic Surveillance requirements (see page 468). We will post the corresponding final rule upon its release by CMS.

Medicaid EHR Incentive Program Registration

To participate in the EHR Incentive Program, EPs must be recognized in MMIS, MassHealth's Medicaid Management Information System. EPs are required to register through the CMS Registration and Attestation System (R&A). The data entered (name, address, NPI,...) will be matched against MMIS. To successfully register with CMS, EPs must have:

• National Provider Identifier (NPI)
• Identify and Access (I&A) Id and Password
• Payee Tax Identification Number (TIN)
• EHR Certification Number

As of Program Year 2017, EPs can no longer use the CMS R&A system to initiate first-time participation in the Medicaid EHR Incentive Program. However, existing Meaningful Use participants can access the R&A system to make changes to an EP's registration to update the information, e.g. after a switch to a different organization.

Note: EPs can register and attest themselves and/or can authorize a designee to act on their behalf. A successful registration results in a “Welcome to MAPIR” email notification with instructions on how to access MAPIR to begin the attestation process.

Adopt, Implement, or Upgrade (AIU) to CEHRT

As of Program Year 2017, EPs can only earn incentives for Meaningful Use (MU). EPs can no longer earn incentives for Adopting, Implementing or Upgrading (AIU) to Certified EHR Technology (CEHRT). The information below is provided for participants who have an outstanding AIU application, for a prior Program Year, that has not yet been approved for payment. 

Up to Program Year 2016, first year participants needed to attest that they met the program's eligibility criteria, and demonstrate they had Adopted, Implemented, or Upgraded (AIU) to CEHRT. As of 2014, participants also had the option to immediately attest to Meaningful Use in the first year, skipping AIU attestation. To qualify for AIU, EPs had to either:
•   Adopt:          Acquire, purchase or secure access to CEHRT
•   Implement:   Install or initiate the use of CEHRT
•   Upgrade:      Expand existing EHR functionality to CEHRT

Public Health Measures Reporting

MU Modified Stage 2 and Stage 3 require EPs to attest to the Public Health Reporting objective, which requires using Certified EHR Technology (CEHRT) to submit data to public health and/or specialized registries.

Immunization Registry (Measure 1)

MIIS, the Massachusetts Immunization Information System, is a web-based registry that collects patient immunization data. MIIS accepts electronic immunization messages (VXU) from CEHRT systems in the HL7 2.5.1 format. This satisfies Meaningful Use purposes. Technical specifications can be found on the MIIS Providers webpage. 

Note that pursuant to M.G.L. Chapter 111, Section 24M, all licensed health care providers who administer immunizations are required to report immunization data to MIIS. EPs can claim an exclusion for the MU measure if they do not administer immunizations to any of the populations for which data is collected during the EHR reporting period.

For more information, and to register intent to submit immunization data, contact the MIIS Help Desk at 617-983-4335 or miishelpdesk@state.ma.us.
The MDPH also holds weekly MIIS Technical Support calls:
When: Every Thursday from 10:BAM to 11:00 AM EST
Phone: (605) 562-3000. Enter Access Code: 580574#

Syndromic Surveillance (Measure 2)

MDPH accepts syndromic surveillance data from EPs who practice in a freestanding urgent care facility. All other EPs can claim an exclusion for this measure. Save or print a screenshot of the MDPH Meaningful Use and Public Health Reporting webpage to document the reason for claiming the exclusion. 

Specialized Registry / Public Health Registry (Modified Stage 2 Measure 3 / Stage 3 Measure 4)

Specialized Registry Reporting is a Modified Stage 2 measure. In Stage 3, this measure is renamed to Public Health Reporting, but the requirements stay the same.

EPs who do not collect data relevant to a Specialized / Public Health Registry within their "jurisdiction" may claim an exclusion for this measure, since there is no registry available relevant to their scope of practice. However, the definition of “jurisdiction” is dependent on the type of registry, and the scope of "jurisdiction" may be local, state, regional or national.

EPs may be able to meet the Specialized / Public Health Registry measure by reporting to a national clinical data registry:

• Some national professional associations, such as the American College of Cardiology, American Academy of Ophthalmology, and American College of Rheumatology have made clinical data registries available to their members.

The Commonwealth of Massachusetts offers two options for Specialized / Public Health Registry Reporting:

1. The Massachusetts Cancer Registry (MCR) supports electronic reporting from CEHRT systems. If you are an EP who treats cancer patients and are interested in reporting to the MCR, contact Susan T. Gershman at susan.gershman@state.ma.us. 
    
2. The Bureau of Infectious Disease Prevention at the MDPH has implemented electronic infectious disease case reporting into a specialized registry, the Massachusetts Virtual Epidemiologic Network (MAVEN). The registry accepts electronic medical case reports for acute hepatitis, active tuberculosis, and sexually-transmitted diseases. As onboarding participants is resource intensive, MDPH limits participation via a threshold based on incidence of reportable conditions seen by providers over a 12-month period. For EPs, the combined number of cases of syphilis, gonorrhea, chlamydia, acute hepatitis, and active tuberculosis seen at your facility must be greater than 1,000 in the most recent 12-month period. If your facility meets the threshold and you are interested in reporting data to this registry, contact Sita C. Smith at sita.c.smith@state.ma.us.

At this time, the MDPH has not declared the Prescription Drug Monitoring Program (PDMP) a Specialized Registry.

Electronic Case Reporting (Stage 3 Measure 3 - future program years)

Electronic Case Reporting is a new Stage 3 requirement, but is not yet available in Program Year 2018.

Clinical Data Registry (Stage 3 Measure 5 - future program years)

Clinical Data Registry is a new Stage 3 requirement, but is not yet available in Massachusetts in Program Year 2018.

Reporting Requirements

Medicaid EHR Incentive Program - Validation and Audits

All Medicaid EHR Incentive Program applications will go through a pre-payment validation process. After the incentives have been paid, the provider may also be selected for a post-payment audit. The audits are performed by EOHHS, or their contractors. For audit purposes, all supporting documentation must be retained for at least six years after attestation.