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Welcome  » May 15, 2024 5:33 AM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Physician
05/15/2024  

Promoting Interoperability Program : Meaningful Use of Certified EHR Technology

Topic #21677

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:

Stage 3
  • Objective 2: Electronic Prescribing, Measure 1
  • Objective 4: Computerized Provider Order Entry, Measures 1-3
  • Objective 5: Patient Electronic Access to Health Information, Measures 1 and 2
  • Objective 6: Coordination of Care through Patient Engagement, Measures 1-3
  • Objective 7: Health Information Exchange, Measures 1-3

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:

Documentation Type Documentation Description Submission Method Required
Security Risk Analysis For Objective 1, Protect Patient Health Information, supply detail on security risk analysis including:
  • Approach for assessment
  • Results of the assessment
  • Indication of who performed the assessment
Detail on security update performed as a result of the security risk analysis including, but not limited to:
  • Update made
  • Date made
Note: No exclusion is available for this objective.		 Upload or email* Yes
Meaningful Use Reports This type of documentation can be used for:
  • Percentage-based measures
  • Any claimed exclusions where the report displays a "0" for the or the report displays a denominator that is less than a threshold specified in the measure exclusion criteria. (For example, if the requirement states that an exclusion may be used by an Eligible Professional with "less than 100 orders" and the report supports that the Eligible Professional had less than 100 orders.)

  • If Eligible Professionals' Meaningful Use reports do not support the exact data entered in the Attestation section of the application, they may also submit any other source materials used to enter the Meaningful Use measure numerators and denominators.
 Upload or email* Yes
*Send a secure email to dhspromotinginteroperabilityprogram@dhs.wisconsin.gov.

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.

  Measure Required Documentation Required Exclusion Documentation
General Requirement 01: Percent of CEHRT Use Must have 50 percent or more of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with CEHRT
  • List of total encounters with detail including date, patient identifier, payer, and rendering provider
  • List of encounter with CEHRT with detail on location and CEHRT used
N/A
General Requirement 02: Unique Patients in CEHRT Must have 80 percent or more of their unique patient data in the CEHRT during the EHR reporting period List of all unique patients with indication of whether they are in CEHRT (If practicing at multiple locations, indicate which patients were seen in what location) N/A
Objective 01 Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1) and implement security updates as necessary and correct identified security deficiencies
  • Documentation of procedures performed during the analysis, results and person(s) who performed the assessment
  • Evidence that the deficiencies noted during the assessment were recorded
  • A remediation plan developed based on the risks identified by the assessment
  • Verification that encryption and security of data stored in the EHR technology has been addressed
  • Verification that the assessment was completed prior to the date of attestation
Required Elements: IT Asset Inventory & Final Report 		N/A
Objective 02 More than 60 percent of all permissible prescriptions written by the Eligible Professional are queried for a drug formulary and transmitted electronically using CERHT
  • CEHRT generated report showing numerator and denominator and
  • Verification each Rx was queried for a drug formulary (CEHRT Screenshots showing Formulary)
 Evidence Eligible Professional wrote fewer than 100 permissible prescriptions, or no pharmacy within your organization and no pharmacies that accept electronic prescriptions within 10 miles of the Eligible Professional's practice location
Objective 03 Measure 01 Implement five clinical decision support interventions related to four or more clinical quality measures Screen shot(s) demonstrating implementation of the rules and alignment with four clinical quality measures as well as a list of the five clinical support rules implemented N/A
Objective 03 Measure 02 Implement drug-drug and drug-allergy checks Screenshot(s) and/or an audit log from the CEHRT showing the system setting for drug-drug and drug-allergy interaction check are enabled Evidence that the Eligible Professional wrote fewer than 100 medication orders
Objective 04 Measure 01 More than 60 percent of medication orders are recorded using CPOE
  • CEHRT generated report showing numerator and denominator for medication orders and
  • List of individuals who entered CPOE with their credentials or verification CPOE entered by only credentialed individuals
Evidence that the Eligible Professional wrote fewer than 100 medication orders
Objective 04 Measure 02 More than 60 percent of laboratory orders are recorded using CPOE CEHRT generated report showing numerator and denominator for laboratory orders Evidence that the Eligible Professional wrote fewer than 100 laboratory orders
Objective 04 Measure 03 More than 60 percent of diagnostic imaging orders are recorded using CPOE CEHRT generated report showing numerator and denominator for diagnostic imaging orders Evidence that the Eligible Professional wrote fewer than 100 diagnostic imaging orders
Objective 05 Measure 01 More than 80 percent of all unique patients are provided timely online access to view, download, and transmit their health information and provider ensures patient's health information is available for the patient to access using any application of their choice that meets Application Programming Interface in the CEHRT
  • CEHRT generated report showing numerator and denominator and
  • Evidence the Eligible Professional has installed and is using a Patient Portal or an ePHR solution (screenshots showing patient portal and documentation explaining how patients are directed to the portal) and
  • Evidence provider has made patient's health information available using any application that meets CEHRT Application Programming Interface requirements (date Application Programming Interface was enabled, screenshots verifying Application Programming Interface functionality and documentation explaining how patients are informed of availability of the Application Programming Interface functionality)
 Evidence the Eligible Professional had no office visits during the EHR reporting period
Objective 05 Measure 02 More than 35 percent of all unique patients specific educational resources along with electronic access to the educational materials identified by CEHRT
  • CEHRT generated report showing numerator and denominator and
  • Documentation confirming use of patient education materials is based on information stored in the CEHRT system (screen shots showing patient educational materials are available electronically in the CEHRT or EHR-generated reports)
 Evidence the Eligible Professional had no office visits
Objective 06 Measure 01 More than five percent of all unique patients actively engage with the EHR and view, download or transmit their health information or access their information through the use of an Application Programming Interface CEHRT generated report showing numerator and denominator Evidence that the Eligible Professional did not have any office visits
Objective 06 Measure 02 More than five percent of all unique patients sent or received a secure electronic message using the electronic messaging function of the CEHRT CEHRT generated report showing numerator and denominator Evidence that the Eligible Professional did not have any office visits
Objective 06 Measure 03 More than five percent of all unique patients have patient generated health data or data from a non-clinical setting incorporated into the CEHRT CEHRT generated report showing numerator and denominator Evidence that the Eligible Professional did not have any office visits
Objective 07 Measure 01 More than 50 percent of transitions of care and referrals (outgoing) had a summary of care record created by the CEHRT and electronically exchanged the summary of care record with the receiving party
  • CEHRT generated report showing numerator and denominator and
  • Summary of care record sample and
  • Explanation of how the summary of care records were transmitted or log of exchange that took place during the EHR reporting period
 Evidence that the Eligible Professional transferred or referred patients to another setting or provider less than 100 times
Objective 07 Measure 02 More than 40 percent of transitions of care and referrals received (incoming) by the provider had a summary of care record incorporated into the CEHRT by the provider
  • CEHRT generated report showing numerator and denominator and
  • Documentation confirming a summary of care document from another provider was incorporated into the provider's CEHRT
Evidence that the total transitions or referrals received and patient encounters in which the provider has never encountered the patient is fewer than 100
Objective 07 Measure 03 More than 80 percent of transitions of care and referrals received (incoming) by the provider had a clinical information reconciliation performed, including: medications, medication allergies and problem lists (a review of patients current and active diagnoses) CEHRT generated report showing numerator and denominator Evidence that the total transitions or referrals received and patient encounters in which the provider has never encountered the patient is fewer than 100
Objective 08 Measure 01

Note: Eligible Professional must attest to two of the five measures

Eligible Professional is in active engagement with a public health agency to submit immunization data and receive immunization forecast

 Confirmation the provider has registered with the DHS PHREDS program and documentation verifying ongoing submission (or intent of ongoing submission) and documentation verifying the provider is receiving immunization forecasts Evidence that the Eligible Professional did not perform immunizations
Objective 08 Measure 02 Eligible Professional is in active engagement with a public health agency to submit syndromic surveillance data Confirmation the provider has registered with the DHS PHREDS program and documentation verifying ongoing submission (or intent of ongoing submission) Documentation verifying the provider is not in a category of providers from which ambulatory syndromic surveillance data is collected
Objective 08 Measure 03 Eligible Professional is in active engagement with a public health agency to submit case reporting of reportable conditions Confirmation the provider has registered with the DHS PHREDS program and documentation verifying ongoing submission (or intent of ongoing submission) Documentation verifying the provider does not treat or diagnose any reportable diseases for which data is collected by their jurisdictions reportable disease system
Objective 08 Measure 04 Eligible Professional is in active engagement with a public health agency to submit data to public health agencies Confirmation the provider has registered with the DHS PHREDS program and documentation verifying ongoing submission (or intent of ongoing submission) Documentation verifying the provider does not diagnose or directly treat any disease or condition associated with a public health registry in their jurisdiction (Verification statement that the provider conducted a due diligence search and was unable to locate a specialized registry in their jurisdiction that they potentially could submit data to)
Objective 08 Measure 05 Eligible Professional is in active engagement with a public health agency to submit data to a clinical data registry Documentation verifying the provider is in active engagement with a clinical data registry Documentation verifying the provider does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction (Verification statement that the provider conducted a due diligence search and was unable to locate a specialized registry in their jurisdiction that they potentially could submit data to)
 
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