Last week CMS announced the meaningful use attestation process will be available on April 18. With this announcement, CMS has provided an early glimpse into the attestation process. This announcement is accompanied by the usual disclaimers, for example, “Please note that these screenshots are only examples—the final appearance and language may incorporate additional changes.” Nevertheless, this preview provides some insight into what we might expect to see in two weeks.
First Medicare Payments Pushed Back
The first and most obvious insight is that, outside of the Medicaid program, no one may attest prior to the 18th of April. Those of you who began collecting data in early January will need to wait a few more weeks before submitting your attestation. This delay will likely push back the first Medicare payments to the end of May or early June based on what was previously described as a 4-6 week turnaround time from attestation to receipt of the incentive.
Actual Numbers Required
The second insight this preview provides is that for the clinical quality measures (CQM), and perhaps for some of the objectives with a threshold, the user will be required to enter actual numbers for a measures numerator and denominator. This will not be problematic as most certified EHRs will capture and display the appropriate numerator and denominator for the meaningful use objectives. The challenge will be in those circumstances where the provider is expected to “count” events that occur outside the EHR (handwritten prescriptions for example).
Reporting Where Data Is From
Third, and perhaps most confusing, providers will have the opportunity to let CMS know if the data the provider is reporting for certain objectives is extracted from one of two sources:
• ALL patient records, not just those maintained using certified EHR technology, or
• Only patient records maintained using certified EHR technology.
This is likely to cause confusion so I will put on my translator hat and take a crack at it. The final rule contains a section entitled “Discussion of the Burden Created by the Measures associated with the Stage 1 Meaningful Use Objectives.” This section describes the approach ONC has taken to reduce the administrative burden in reporting the meaningful use objectives. One of the strategies is to limit reporting data for certain objectives to patients whose records are maintained in the provider’s certified EHR. They specifically highlight the following provider-based meaningful use objectives as being restricted to only those patients whose records are maintained in the certified EHR:
• Use CPOE
• Generate and transmit permissible prescriptions electronically (eRx)
• Record and chart changes in vital signs
• Record smoking status for patients 13 years old or older
• Incorporate clinical lab-test results into certified EHR technology as structured data
• Provide patients with an electronic copy of their health information upon request
• Provide clinical summaries for patients for each office visit
• Send reminders to patients per patient preference for preventive/follow-up care
• Perform medication reconciliation at relevant encounters and each transition of care
• Provide summary care record for each transition of care and referral
Other objectives require the provider to report on ALL eligible patients, whether their records are in the EHR or not. For example, problem list, med list and allergy list (the high threshold objectives) are to be reported on all patients seen in venues of care where certified technology is deployed. By setting the target at 80% for these measures, ONC has in effect insured that at least 80% of your patient’s records are maintained in the EHR. If it is exactly 80% then every one of the eligible patients must have a problem on their problem list, med on their med list and an appropriate response to the allergy question or you will not clear the 80% hurdle established for these measures.
Suppose, for example, I saw 1,000 unique patients during the reporting period. I would need to maintain a minimum of 800 patients in the EHR, and if only 800 were in the EHR, each of those patients must have a problem on their problem list (or notation they have no problems) in order to meet the 80% threshold for the problem list objective (800/1,000).
What does this mean for the typical nephrologist? I think for most, these two sources of data will be identical. That is to say, unless your practice makes a habit of entering some patients in the EHR but not others, the data you report for meaningful use is extracted from ALL patients, which will in fact be equivalent to every patient whose records are maintained in the certified EHR. Clear as mud right?
When Is the Reporting Period?
Finally, a couple of other items are not apparent in this preview. The first is related to the reporting period. Originally I assumed the provider would be asked to enter at least a start date for their reporting period. Perhaps this is not the case and instead the provider will simply attest to the fact that the data submitted was collected during a continuous 90-day period during the calendar year. Or it is possible CMS will assume your reporting period begins on the day you registered for the meaningful use program. I would anticipate additional clarity regarding this point before April 18.
What About the 50% Rule?
Furthermore, I see no reference to the “50% rule”. Again, attestation may imply the provider had access to deployed certified technology within the venue(s) of care where at least 50% of his or her encounters occurred during the reporting period.
The release of this preview provides us with a window into the attestation process for the CMS EHR incentive program. It contains a few surprises but these are not insurmountable. Keep your eyes on the CMS website as additional detail is expected over the next couple of weeks as April 18 draws near.
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