Meaningful Use Toolkit for EP

Overview of New Requirements for Program Year 2017

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 2017, 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).
   

• The alternate exclusions that were available for program year 2015 and 2016 are no longer available.
   

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

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

• The MU attestation deadline is Thursday Jun 21, 2018.  MAPIR opened for PY2017 on Nov 20, 2017.
   

• The MU reporting period will be any continuous 90-day period from Jan 1, 2017 through Dec 31, 2017.
   

• 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. 

What an EP needs to know for Program Year 2018

In the Final Rule published on 8/14/17, CMS announced the option to continue with Modified Stage 2 in program year 2018. Participants will again be able to attest to either Modified Stage 2 or Stage 3, based on either a 2014 or 2015 Edition CEHRT, or a combination of the two CEHRT editions. The MU requirements for 2018 will be the same as for 2017. Stage 3 will become mandatory in program year 2019.

Documentation Requirements and Key Program Updates for 2017
Documentation Guide CMS Spec Sheets CMS Spec Sheets ​ MeHI Presentations Attestation Document Attestation Document Info Sheet Table Group Proxy Guide		2017 Supporting Documentation Guide for EPs - Version 2/21/2018 2017 Modified Stage 2 Specification Sheets for EPs 2017 Stage 3 Specification Sheets for EPs Modified Stage 2 Meaningful Use Presentations for Each Objective MU Aggregation Form - Version 2/21/2018 Security Risk Analysis/Review Cover Sheet The cover sheet can be signed by an authorized individual, e.g. Chief Medical Officer, Chief Information Officer, Director of Compliance, Consultant, Eligible Provider, Designee 2015-2017 Medicaid 1115 Waiver Population Grid 2017 Chip Factor Calculating Patient Volume Threshold Using Group Proxy Methodology "Last update 2015"
Resources to Learn More About the Final Rule
CMS Final Rule CMS Fact Sheet MeHI Slides CMS Slides CMS Recording		Stage 3 and Modifications to Meaningful Use 2015 through 2017 2015-2017 Modified Stage 2 Overview Final Rule on MU Modifications for 2015-2017 and Stage 3 MU Final Rule and What You Need to Know for 2015-2017 Final Rule and What You Need to Know for 2015-2017 Enter name (use prefilled password & key). Click View Recording. Enter email & company. Click View Recording.

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.

Step 1: Assign a Designee (Optional for EPs)
I&A Instructions I&A FAQ Sheet Go to I&A System  Go to PECOS System		Identity & Access Quick Reference Guide to assign designee to attest on behalf of EP Identity & Access FAQs Identity & Access Management System (Login with your PECOS Username and Password) Provider Enrollment, Chain, and Ownership System (Includes the I&A system)
Step 2: Register in the CMS R&A System
Registration Instructions Go to CMS R&A System CMS Checklist		CMS Registration & Attestation (CMS R&A) User Guide for EPs Centers for Medicare & Medicaid Services Registration & Attestation System Registration, Attestation, PECOS Checklist
Step 3: Special Enrollment (Upon Request only, for EPs not recognized or inactive in MMIS )
Checklist and Forms		Special Enrollment Checklist for EPs  Updated on 7/18/16 to include Psychiatric Clinical Nurse Specialists

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

AIU Resources
MeHI EHR Toolkit MeHI Website Tips EHR Workbook ONC Website ONC Guide ONC Info Sheet Go to CEHRT Website		EHR Planning and Procurement Toolkit EHR Implementation Tips EHR System Selection Workbook This workbook was developed by NJ-HITEC, with funding from the Regional Extension Center award issued by ONC.​ Health IT Playbook ONC EHR Contract Guide ONC Guide to Understanding EHR Vendor Contract Terms ONC Certified Health IT Product List (CHPL) website

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.

The Public Health Reporting objective requires active engagement with two or more of the following: Immunization Registry Syndromic Surveillance Registry Specialized / Public Health Registry        Stage 3 future program years: Electronic Case Reporting Clinical Data Registry Watch this video, read the details below, or visit this website to learn how the Massachusetts Department of Public Health (MDPH) assists EPs in meeting the objectives.

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 2017.

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 2017.

Reporting Requirements

Measure	MU Measure Description	Action to Meet MU Measure
Eligible Professionals
1	Immunization Registry	Demonstrate active engagement* with the Massachusetts Immunization Information System (MIIS); or   Claim an exclusion if no immunizations are administered.
2	Syndromic Surveillance Registry	Demonstrate active engagement* with the MDPH Syndromic Surveillance Registry if the EP practices at a freestanding urgent care facility; or   Claim an applicable exclusion.
3   4	Modified Stage 2 - Specialized Registry    Stage 3 - Public Health Registry Note: This is Option 3 in MAPIR!	Demonstrate active engagement* with the MDPH Cancer Registry if applicable;   Demonstrate active engagement* with the Massachusetts Virtual Epidemiologic Network (MAVEN) if applicable;   Demonstrate active engagement* with another specialized / Public Health registry (such as a clinical data registry offered through a national professional association) if applicable; or   Claim an exclusion if none of the above apply.
*CMS defines “active engagement” as any one of the following: Completed Registration to Submit Data – must be completed within 60 days of start of EHR reporting period; Testing and Validation – must respond to requests within 30 days; failure to respond twice within an EHR reporting period would result in failure to meet the measure; Production EPs who select YES to any of the three options should not claim any exclusions associated with that measure. Medicaid Program participants who claim an exclusion for a public health reporting measure are responsible for ensuring they meet the qualifications and retain all required documentation to fully support their attestation selection.

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.