Promoting Interoperability Program : Meaningful Use of Certified EHR Technology

Definition of Meaningful Use

The Medicare and Medicaid PI Programs provide a financial incentive for the Meaningful Use of certified technology to achieve health and efficiency goals. By implementing and using EHR systems, Eligible Professionals can also expect benefits beyond financial incentives, such as reduction of clerical errors, immediate availability of records and data, clinical decision support, and e-prescribing and refill automation.

The American Recovery and Reinvestment Act of 2009 specifies three main components of Meaningful Use:

• The use of a certified EHR in a meaningful manner, such as e-prescribing
• The use of CEHRT for electronic exchange of health information to improve quality of health care
• The use of CEHRT to submit clinical quality and other measures

In short, Meaningful Use means Eligible Professionals need to demonstrate that they are using EHR technology in ways that can be measured in quality and quantity.

Eligible Professionals are required to attest to cooperation with the following policies:

• Demonstration of supporting information exchange and prevention of information blocking
• Demonstration of good faith with a request relating to the Office of the National Coordinator for Health Information Technology direct review of CEHRT

Electronic Health Record Reporting Period for Meaningful Use

The EHR reporting period is defined as the timeframe when Eligible Professionals report Meaningful Use to the Wisconsin Medicaid PI Program.

In Program Year 2020, the EHR reporting period for all Eligible Professionals is any continuous 90 days between January 1, 2020, and December 31, 2020.

In Program Year 2021, the EHR reporting period for all Eligible Professionals is any continuous 90 days between January 1, 2021, and July 31, 2021.

Meaningful Use Criteria Overview

CMS has split the Meaningful Use criteria into separate stages that have been introduced over the course of the PI Program through the federal rulemaking process.

• Stage 1 sets the baseline for electronic data capture and information sharing.
• Stage 2 and Modified Stage 2 advance clinical practices and further promote information sharing.
• CMS established a modified set of criteria for attestation in Program Years 2015 through 2018, known as Modified Stage 2. Modified Stage 2 replaces the core and menu structure of Stages 1 and 2 with a single set of objectives and measures, and establishes several other changes to the PI Program.
• Eligible Professionals will no longer attest to Stage 1 and Stage 2 criteria. Archived versions of the Online Handbook containing previous attestation criteria are available for audit purposes.
• Stage 3 uses advanced clinical practices to improve outcomes.

Requirements for Stage 3 Meaningful Use

The requirements for Stage 3 contain eight objectives with one or more measures to which Eligible Professionals are required to attest. Eligible Professionals will attest to all eight objectives by either meeting the measure or satisfying an exclusion, if applicable. Eligible Professionals may choose to satisfy an exclusion, rather than meet the measure, when the measure is not applicable to them and they meet the exclusion criteria.

Information for Eligible Professionals regarding objectives and measure specifications is available in the CMS Stage 3 Meaningful Use Specification Sheets.

Stage 3 includes flexibility within certain objectives to allow Eligible Professionals to choose the measures most relevant to their patient population or practice. The Stage 3 objectives with flexible measure options include:

• Coordination of Care through Patient Engagement—Eligible Professionals must attest to all three measures and must meet the thresholds for two measures for this objective. If the Eligible Professional meets the criteria for exclusion from one measure, the remaining two measure thresholds must be met. If the Eligible Professional meets the exclusion criteria for two measures, the threshold for the one remaining measure must be met. If the Eligible Professional meets the exclusion criteria for all three measures, they may claim all three exclusions and satisfy the objective.
• Health Information Exchange—Eligible Professionals must attest to all three measures and must meet the thresholds for two measures for this objective. If the Eligible Professional meets the criteria for exclusion from one measure, the remaining two measure thresholds must be met. If the Eligible Professional meets the exclusion criteria for two measures, the threshold for the one remaining measure must be met. If the Eligible Professional meets the exclusion criteria for all three measures, they may claim all three exclusions and satisfy the objective.
• Public Health Reporting—Eligible Professionals must meet two measures for this objective. If the Eligible Professional cannot satisfy at least two measures, they may claim exclusions from all remaining measures they cannot meet to satisfy this objective.

Stage 3 Objective 1, Protect Electronic Health Information

For Program Year 2020, the SRA must be completed prior to the date of attestation and no later than December 31, 2020. For groups, practices may provide one SRA for all of their Eligible Professionals.

For Program Year 2021, Eligible Professionals do not need to complete the SRA prior to the date of attestation, but it must be completed by the end of day on December 31, 2021. Eligible Professionals who do not have the SRA completed by the date of attestation must attest to their intent to complete it by December 31, 2021.

Stage 3 Public Health Reporting Objective

For Stage 3, Eligible Professionals are required to attest to a consolidated public health objective, which has five measure options.

Public Health and Clinical Data Registry Reporting Objective and Measures

The public health and clinical data registry reporting objective requires Eligible Professionals to demonstrate active engagement with a public health agency or clinical data registry to submit electronic health data from CEHRT. The public health and clinical data registry reporting objective contains five measure options. In Program Years 2020 and 2021, all Eligible Professionals must do one of the following:

• Meet two or more of the five measure options
• Meet fewer than two measures and satisfy the exclusion criteria for all other measure options
• Satisfy the exclusion criteria for all measure options

Note: If an Eligible Professional is in active engagement with two public health or clinical data registries, they may choose to report on these measures twice to meet the required number of measures for the public health reporting objective.

The following is an overview of the public health and clinical data registry reporting objective for Eligible Professionals with details on how to successfully demonstrate active engagement and obtain supporting documentation for public health reporting.

The following table shows the five measure options that make up the public health and clinical data registry reporting objective.

Note: In determining whether an Eligible Professional meets the first exclusion for each measure, the registries in question are those sponsored by the public health agencies with jurisdiction over the area where the Eligible Professional practices and by national medical societies covering the Eligible Professional's scope of practice. Therefore, an Eligible Professional is required to complete a minimum of two actions in order to determine available registries or claim an exclusion: 1) determine if the jurisdiction (state, territory, etc.) endorses or sponsors a registry, and 2) determine if a National Specialty Society or other specialty society with which the provider is affiliated endorses or sponsors a registry. Registries sponsored by Wisconsin can be found on the Public Health Meaningful Use website.

Demonstrating Active Engagement for Public Health Reporting

For the Stage 3 public health reporting objective, Eligible Professionals are required to be in active engagement with a public health agency to submit electronic public health data from CEHRT. Active engagement means the Eligible Professional is progressing toward sending production data or is sending production data to a public health agency or clinical data registry. Submitting production data shows that an Eligible Professional regularly reports data generated through clinical processes involving patient care from CEHRT to a public health program using appropriate standards and specifications.

An Eligible Professional can meet a public health reporting measure by registering to submit data and demonstrating any of the following Stage 3 active engagement options:

• Option 1—Completed Registration to Submit Data: The Eligible Professional registered to submit data with the public health agency or, where applicable, with the clinical data registry to which the information is being submitted; registration was completed no later than 60 days after the start of their EHR reporting period; and the Eligible Professional is awaiting invitation to begin testing and validation. With this option:
• Eligible Professionals are able to meet the measure even when the public health agency or clinical data registry has limited resources to initiate the testing and validation process.
• Eligible Professionals are able to meet the measure by registering their intent to report with a registry if a registry declares readiness at any point in the calendar year after the initial 60 days. (However, if an Eligible Professional had already planned to exclude based on the registry not being ready to allow for registrations of intent within the first 60 days of the reporting period, they may still exclude for that calendar year.)
• Eligible Professionals who have completed registration in previous years do not need to submit a new registration to meet this requirement for each EHR reporting period as long as the registration accurately reflects their intent to submit data. Eligible Professionals whose completed registrations do not accurately reflect their intent to submit data for a public health measure are required to update their registration no later than 60 days after the start of their EHR reporting period.

For example, if an Eligible Professional previously only registered intent to submit immunization data and has now decided to also attest to the specialized registry measure for cancer reporting, the Eligible Professional will have to update the existing registration.

• Option 2—Testing and Validation: The Eligible Professional is in the process of testing and validation of the electronic submission of data.
• Option 3—Production: The Eligible Professional has completed testing and validation of the electronic submission and is electronically submitting production data to the public health agency or clinical data registry.

Public Health Reporting Exclusions

There are multiple exclusions for each of the public health reporting measures. Claiming an exclusion for a measure does not count toward the total number of public health reporting measures an Eligible Professional is required to meet. Instead, to meet the public health objective, an Eligible Professional is required to do one of the following:

• Demonstrate active engagement with a public health agency for at least two measures.
• Demonstrate active engagement with a public health agency for less than two measures and claim an applicable exclusion for all remaining measures.

Eligible Professionals who do not collect appropriate or relevant data to submit to a public health agency may be able to claim an exclusion or pick another public health reporting measure. If an Eligible Professional meets the exclusion criteria, they can claim the exclusion to the measure. If an Eligible Professional is part of a group that submits data to a registry, but the Eligible Professional does not contribute to that data (for example, does not administer immunizations), the Eligible Professional should not attest to meeting the measure and should claim the exclusion.

Although exclusions are available for the public health reporting measures, the Wisconsin Medicaid Promoting Interoperability Program does not formally grant exclusions to Eligible Professionals or offer documentation for Eligible Professionals to use when claiming an exclusion. Eligible Professionals are required to self-attest to exclusions in the attestation system based on CMS exclusion criteria. It is the Eligible Professional's responsibility to claim an exclusion and maintain the proper documentation to substantiate the attestation.

Meaningful Use Audit Documentation

All information is subject to audit at any time and must be retained by Eligible Professionals for six years post-attestation. If selected for an audit, the applicant must be able to supply supporting documentation.

Registration for Public Health Program

All Eligible Professionals participating in Meaningful Use (regardless of scheduled stage) should register with DPH for the public health program and/or registry (e.g., immunizations) to which they intend to electronically submit data. In January 2014, DPH launched PHREDS, a Microsoft^® SharePoint^® site where Eligible Professionals register their intent to submit data from CEHRT to a public health program/registry. Eligible Professionals who would like to electronically submit data from CEHRT to a public health program are required to register through PHREDS.

After a registration form is successfully submitted in PHREDS, Eligible Professionals receive a registration confirmation email and are put into a queue with the public health registries for which they have registered. Eligible Professionals in the queue will await an invitation from registry personnel to begin the onboarding process. Onboarding is the testing and validation process Eligible Professionals and public health programs engage in prior to the achievement of ongoing submission of production data. Each registry has a separate process for onboarding Eligible Professionals, but all use PHREDS to manage registrations and the onboarding queue.

In order to meet active engagement option one, all Eligible Professionals who collect the appropriate data should register their intent to submit data to the relevant public health registry no later than 60 days after the start of their EHR reporting period. Based on the registry's onboarding policies, Eligible Professionals may not be invited to further participate in the onboarding process before their EHR reporting period ends; however, they will have successfully demonstrated the public health reporting objective criteria for Active Engagement Option 1 — Completed Registration to Submit Data (and would not have to claim an exclusion).

Meaningful Use Acknowledgements for Public Health Programs

Meaningful Use Acknowledgements are the mechanism DPH uses to acknowledge that Eligible Professionals have registered, completed a test, or reached ongoing submission of production data from CEHRT. The Wisconsin Medicaid EHR Incentive Program strongly encourages Eligible Professionals to retain these documents (i.e., registration confirmation email and Acknowledgements file) because they are the only forms of documentation produced by DPH for this purpose.

The Wisconsin Medicaid EHR Incentive Program also recommends that all Eligible Professionals save a copy of the Acknowledgements file (in Excel format) dated after the end of their EHR reporting period, even if they are still in the onboarding queue or have achieved ongoing submission of production data. In the event of an audit, Eligible Professionals will use the Acknowledgments file to substantiate their Meaningful Use attestation. The auditor will want to see an Acknowledgments file dated after the end of the EHR reporting period being audited, to confirm the organization's or site's active engagement status with the public health registry at that time. To facilitate the audit process, all Eligible Professionals are encouraged to save a printed or PDF copy of the PHREDS page explaining the contents of the Acknowledgements file.

Specialized Registries

Modified Stage 2 allows for a wide range of reporting options now and in the future, explicitly stating that Eligible Professionals may choose to report to clinical data registries to satisfy the measure. This means the category of specialized registries used to satisfy the specialized registry measure is not limited to those sponsored by state or local public health agencies, and Eligible Professionals may work with specialized registries outside of DPH to satisfy the Specialized Registry Reporting measure. The registries outside of DPH might include applicable registries sponsored by the Centers for Disease Control and Prevention, national medical specialty organizations, patient safety organizations, and/or quality improvement organizations. This flexibility in use of specialized registries allows Eligible Professionals to continue in the direction they may have already planned for reporting to specialized registries.

The DPH does not provide registration, administrative onboarding, compliance, or audit support to Eligible Professionals trying to meet the Specialized Registry Reporting measure if the an Eligible Professional has chosen to use a registry outside of those offered by DPH. Eligible Professionals are strongly encouraged to consider the availability of supporting documentation before attesting to the use of a specialized registry outside of those offered by DPH. In order to be considered a specialized registry by the Wisconsin Medicaid EHR Incentive Program, the agency/registry must:

• Publicly declare readiness to receive electronic data submissions.
• Publicly declare the ability to support the registration/onboarding and production processes.
• Provide proper documentation to providers to support active engagement.

Documentation maintained by an Eligible Professional to support electronic data submission to the specialized registry may also be used, in addition to any documentation provided by the agency/registry.

Eligible Professionals will be prompted to attest to the name of the specialized registry during the application process. The Wisconsin Medicaid EHR Incentive Program also encourages Eligible Professionals to upload documentation supporting their attestation. If an Eligible Professional is intending to attest to a specialized registry sponsored by DPH, appropriate documentation would be the Acknowledgements file provided on the PHREDS SharePoint site.

Stage 3 Meaningful Use Supporting Documentation

Documentation Required at Attestation

Eligible Professionals are required to submit the following documentation to support attestation:

• CEHRT documentation.
• Patient volume documentation.
• SRA documentation.
• For Program Year 2020: The SRA must be submitted with the application. For groups, practices may provide one SRA for all of their Eligible Professionals.
• For Program Year 2021: If the SRA has been completed by the date of attestation, the Eligible Professional is required to submit the SRA documentation with the application. If the SRA has not been completed by the date of attestation, the Eligible Professional is required to complete it by the end of day December 31, 2021. Upon completion of the SRA, the Eligible Professional must submit the supporting documentation to the DHS via secure email to dhspromotinginteroperabilityprogram@dhs.wisconsin.gov by the end of day, January 31, 2022. The Eligible Professional must identify the organization to which the SRA applies, so it may be properly applied to all applicable Eligible Professionals. Eligible Professionals who do not complete their SRAs by December 31, 2021, and submit their SRA documentation by the January 31, 2022, deadline are subject to audit and may have their incentive recouped.
• Meaningful Use report(s) supporting all Meaningful Use percentage-based measures (with numerators and denominators) and/or any other source material used by the Eligible Professional to enter the Meaningful Use measure numerators and denominators.

Applicable percentage-based measures include:

Eligible Professionals should use SRA documentation and Meaningful Use reports to demonstrate that requirements were met for Meaningful Use measures during the EHR reporting period. For percentage-based measures, Eligible Professionals' EHR will electronically record the numerator and denominator and generate a report that includes the numerator, denominator, and percentage. If their Meaningful Use reports do not support the exact data entered in the Attestation section of the application, Eligible Professionals may also submit any other source material used to enter the Meaningful Use measure numerators and denominators.

Eligible Professionals are not required to submit documentation supporting their Electronic Clinical Quality Measures.

The following table further describes the acceptable types of documentation:

Stage 3 Meaningful Use Audit Documentation

The following table contains examples of supporting documentation an Eligible Professional would be expected to provide if selected for an audit of an application submitted for the Wisconsin Medicaid Promoting Interoperability Incentive Program under Stage 3 Meaningful Use.