It’s been three months since my last blog post and a lot has changed! While I was off enjoying my newborn daughter, CMS released the much anticipated final rule for stage 2 modifications in 2015-2017.
If you read Dr. Ketchersid’s blog post a few weeks back, you already know the highlights. If not, here is a quick run-down:
- Shortened reporting period to 90 days for everyone in 2015 (regardless of stage)
- Condensed number of objectives to 10
- Eliminated redundant, duplicative, and topped-out measures
- Reduced performance thresholds on a few measures
- Removed the core and menu framework
Seeing as the final rule came out a week into the last possible 90-day reporting period, it doesn’t leave a lot of time for practices to create a game plan. Here are the 8 things you should do before the year’s end.
- Choose your reporting period
This may seem like a no-brainer. Everyone planning to attest to meaningful use must select a continuous 90-day reporting period. However, some providers may need to carefully select their reporting period based on points #2 and #3 below. Also, in some cases, providers may need more than 90 days to meet some of the objectives. CMS will allow providers to report on a continuous period greater than 90 days up to a reporting period of 365 days (the entire calendar year).
- Make sure all functionality was enabled on day 1 of your reporting period
Pay close attention to the wording of each measure. Some of the measures require that certain functionality be enabled for the entire reporting period. You may want to ask yourself the following questions:
- Was my secure messaging feature enabled for the entire reporting period?
- Did I have at least 4 CQM alerts turned on for the entire reporting period?
- Were drug-drug/drug-allergy alerts enabled for the entire reporting period?
It would be terrible to realize you forgot to turn on secure messaging halfway through your reporting period! If so, you may want to choose another 90 days (or jump right down to point #8 below).
- Contact your public health agency
Registration with intent to send data to a public health agency must be completed within 60 days after the start of the EHR reporting period. If you are excluded from all of the Public Health measures, you can move right along to #4 below.
- Don’t overlook objective #1 (Protect PHI)
THIS APPLIES TO YOU. IT HAS TO BE DONE EVERY YEAR. IT MUST BE DONE PRIOR TO ATTESTATION. I hope that was clear enough! I’ve heard of too many practices failing an audit due to not completing this objective correctly. If you need help, the ONC, in collaboration with the HHS Office for Civil Rights (OCR) and the HHS Office of the General Counsel (OGC), developed a downloadable Security Risk Assessment Tool (SRA Tool) to help guide you through the process.
- Read the exclusions
If you are scheduled for stage 1 this year, there are quite a few exclusions that apply to you. Basically you can be excluded from the majority of the objectives (due to there being no equivalent objective or because the objective wasn’t mandatory in the original stage 1 lineup).
If you are in stage 2, there are no changes to the exclusions for you. However, the 90-day reporting period may work in your favor. For example, the HIE (summary of care) measure states that a provider is excluded if he/she doesn’t transition patients out of his/her care over 100 times during the “reporting period” (aka 90 days). The same goes for CPOE. Providers can be excluded from one (or more) of the CPOE measures if he/she doesn’t order at least 100 meds, labs,or rads during the reporting period.
- Select your CQMs
You may have noticed Clinical Quality Measures (CQMs) missing from the 10 objectives, but selecting CQMs is still an integral part of being a “meaningful user.” There were no changes to the CQM definition or CQM selections in the latest final ruling. Providers are still required to report on 9 CQMs across 3 National Quality Strategy (NQS) domains for any 90-day period in 2015.
- Create your audit folder
Don’t throw caution to the wind on this one. Practices should maintain documentation to support provider attestation data for up to 6 years after attestation. Take a look at each objective carefully and put yourself in the auditor’s shoes. If you still need help on what to do, take a look at the CMS supporting documentation guide. If you need to be convinced that an audit is a real thing, read what happened to another nephrology practice here.
- Explore the hardship exception options
CMS has not added any new hardship exception categories; however, they did release a new FAQ (#12845) that will allow any provider to apply for a hardship exception for 2015 under the “extreme and uncontrollable” circumstances category due to the lateness of the modifications rule. Each application will be reviewed on a case-by-case basis.
Can I attest now?
Due to all the changes late in the year, CMS doesn’t expect the MU attestation portal to be available until January 4, 2016. The attestation window will open on January 4 and close on February 29. Any provider who does not attest during that time frame (or submit a hardship exception) will be subject to the 2017 payment adjustment.
There are only 45 days left before this year ends. Will you be ready to attest or will you take the hardship?
Diana Strubler, Senior Product Analyst, Health IT Standards, joined Acumen in 2010 as an EHR trainer then quickly moved into the role of certification and health IT standards subject matter expert. She has successfully led Acumen through three certifications while also guiding our company and customers through the world of Meaningful Use, ICD-10 and PQRS.