Promoting Interoperability Program : Meaningful Use of Certified EHR Technology

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.