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Attestation under the Medicare Electronic Health Records Incentive program
HEALTH INFORMATION TECHNOLOGY Attestation under the Medicare Electronic Health Records Incentive program
T
he U.S. Centers for Medicare & Medicaid Services (CMS) is now accepting applications for payment under the Medicare Electronic Health Records (EHR) Incentive program. Practitioners who apply for payment early stand the best chance of maximizing their payments under the program, according to the American Optometric Association (AOA) Health Information Technology (HIT) Subcommittee. Like other aspects of the incentive program, the application process may be easier than many optome-
Optometrists can now earn payments under the Medicare EHR Incentive program by attesting compliance with utilization standards through an online process. trists believe, according to Philip Gross, O.D., the AOA HIT Subcommittee chair. As previously noted in this series, the Medicare EHR Incentive program rewards eligible professionals (EPs) for implementing EHR systems certified for use under the program and then documenting that they have complied with EHR utilization standards (known as the ‘‘meaningful use’’ objectives) over a specified reporting period. Physicians, including optometrists, are designated EPs under the Medicare incentive program. For optometrists who are entering the program for the first time, the reporting period is 90 days. Health care practitioners who meet those requirements during 2011 will qualify for a payment of up to $18,000 this year and could earn up to a total of $44,000 ($48,000 in federally designated Health Professional Shortage Areas) over the next 5 years. CMS officials are attempting to issue payments within 30 days of receiving a qualifying application. In order to take part in the program, optometrists must first register for the program using the new Medicare & Medicaid EHR Incentive Program Registration and Attestation System (https://ehrincentives.cms.gov). Practitioners will then use the same system to apply for payment. The system can also be used to check on the status of applications and payments. This article is based on the CMS online guidance document, Preview of the Medicare EHR Incentive Program Attestation Process. Opinions expressed are not necessarily those of the American Optometric Association.
Before applying for payments and as part of their registration file, practitioners must enter the certification number for the EHR system they are using. They must also have a National Plan and Provider Enumeration System (NPPES) user identification number and password. The NPPES ID and password will be used to log on to the Medicare attestation system. In coming years, practitioners will be required to document compliance with the meaningful use standards by downloading data directly from their EHR systems to the CMS. However, the agency acknowledges the required technology is not yet in place. As a result, practitioners this year will simply be required to report compliance with the meaningful use objectives, a process the CMS calls ‘‘attestation.’’ Like the EHR incentive program registration process, attestation involves providing required information by completing a series of screens on the CMS Registration and Attestation Web site. According to the CMS’ Preview of the Medicare EHR Incentive Program Attestation Process, practitioners will use the site to report compliance with the Medicare EHR Incentive program: 1) Meaningful use core measures – Compliance with all 15 is required (see Box 1); 2) Meaningful use menu measures – Practitioners must comply with 5 of the 10 measures, deferring compliance with the others (see Box 2); 3) Core clinical quality measures (CQM) – Compliance with 3 of 6 measures is required (see Box 3); 4) Alternative core clinical quality measures – Compliance is required only if the EP reports the CQMs are not applicable to any patients seen during the reporting period; 5) Additional clinical quality measures – Compliance with 3 measures out of a list of 38 is required (see Box 3). The reporting of clinical quality measures is actually required as part of compliance with meaningful use Core Measure 10. Under that measure, EPs must specify the exact quality measures used and the percentage of patients for whom they were implemented. The AOA HIT Subcommittee has identified core clinical quality measures that fall well within the scope of optometric practice and believe few optometrists will have reason to report ‘‘alternative’’ quality measures. For most of the core and menu objectives, practitioners will be able to report compliance with a simple ‘‘Yes’’ or ‘‘No’’ response. For example, when reporting on Core Measure 2 (Implement drug-drug and drug-allergy interaction check), EPs will be asked ‘‘Have you enabled the functionality for drug-drug and drug-allergy interaction
1529-1839/$ - see front matter Ó 2011 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2011.05.004
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Box 1
Core objectives 1. Computerized provider order entry (CPOE) for medication orders Measure: More than 30% of all unique patients with at least 1 medication in their medication list seen by the eligible professional (EP) have at least 1 medication order entered using CPOE. 2. Drug interaction checks Measure: The EP has enabled this functionality for the entire electronic health reporting period. 3. Maintain problem list Measure: More than 80% of all unique patients seen by the EP have at least 1 entry (or an indication that no problems are known) for the patient recorded as structured data. 4. Generate and transmit permissible prescriptions electronically (e-Rx) Measure: More than 40% are transmitted electronically using certified electronic health record (EHR) technology. 5. Active medication list Measure: More than 80% of all unique patients seen by the EP have at least 1 entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data. 6. Medication allergy list Measure: More than 80% of all unique patients seen by the EP have at least 1 entry (or an indication that the patient has no known medication allergies) recorded as structured data. 7. Record demographics Measure: More than 50% of all unique patients seen by the EP have demographics recorded as structured data. 8. Record vital signs Measure: For more than 50% of all unique patients age 2 or older by the EP, height, weight, and blood pressure are recorded as structured data. 9. Record smoking status Measure: More than 50% of all unique patients age 13 years or older seen by the EP have smoking status recorded as structured data. 10. Clinical quality measures (CQMs) Measure: Successfully report to the Centers for Medicare and Medicaid Services (CMS) ambulatory clinical quality measures selected by the CMS in the manner specified by the CMS. 11. Clinical decision support rule Measure: Implement 1 clinical decision support rule. 12. Electronic copy of health information Measure: More than 50% of all patients who request an electronic copy of their health information are provided it within 3 business days. 13. Clinical summaries Measure: Clinical summaries provided to patients for more than 50% of all office visits within 3 business days. 14. Electronic exchange of clinical information Measure: Performed at least 1 test of certified EHR technology’s capacity to electronically exchange key clinical information. 15. Protect electronic health information Measure: Conduct or review a security risk analysis in accordance with the requirements set down under federal regulation and implement security updates as necessary and correct identified security deficiencies as part of its risk management process.
checks (in your EHR system)?’’ To attest compliance, a practitioner will simply click the ‘‘Yes’’ button. However, for a number of objectives practitioners will also have to report the number of patients for whom the
function was used, as well as the total number of patients seen, during the reporting period. EHR systems, certified for use in the incentive program, must provide readouts indicating the number of patients for whom various
446
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Box 2
Menu elements 1. Implement drug formulary checks Measure: Drug formulary check system is implemented and access maintained to at least 1 internal or external drug formulary for the entire reporting period. 2. Incorporate clinical laboratory test results into EHRs as structured data Measure: More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data. 3. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach Measure: Generate at least 1 listing of patients with specific conditions. 4. Use EHR technology to identify patient-specific education resources and provide to the patient as appropriate Measure: More than 10% of patients are provided patient-specific education resources. 5. Perform medical reconciliation between care settings Measure: Medication reconciliation is performed for more than 50% of transitions of care. 6. Provide summary of care record for patients referred or transitioned to another provider or setting Measure: Summary of care record is provided for more than 50% of patient transitions or referrals. 7. Submit electronic immunization data to immunization registries or immunization information systems Measure: Perform at least 1 test of data submission and follow-up submission (where registries can accept electronic submission). 8. Submit electronic syndromic surveillance data to public health agencies Measure: Perform at least 1 test of data submission and follow-up submission (where public health agencies can accept electronic submission). 9. Send reminders to patients (per patient preference) for preventive and follow-up care Measure: More than 20% of patients age 65 years or older or age 5 years or younger are sent appropriate reminders. 10. Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, and medication allergies) Measure: More than 10% of patients are provided electronic access to information within 4 days of it being updated in the EHR.
functions are used, as well as total patient count. Those readouts should make attestation relatively easy, the AOA HIT Subcommittee notes. (For some core and menu measures, the practitioner will have the choice of reporting the total patient count based on either total patient records or only patient records maintained using certified EHR technology. Practitioners will be asked specifically which method was used.) For some core and menu measures, practitioners may claim exclusions if the objective is not applicable to their scope of practice. However, the AOA HIT Subcommittee believes optometrists might appropriately claim an exclusion from only 3. (For additional information, see the AOA Web site EHR page at www.aoa.org/EHR). The inappropriate use of exclusions could jeopardize the practitioner’s ability to receive payment under the incentive program, the subcommittee warns. Moreover, because EHR incentive program data will be among the factors health care
policymakers will consider in establishing rules for America’s rapidly changing health care system, extensive use of exclusions could also have an adverse impact on optometry’s status as an important provider of primary health care (see Box 4). A summary of the steps involved in the attestation process follows.
Step 1 – Enter system Log on to the Medicare and Medicaid EHR Incentive Program Registration and Attestation System (https:// ehrincentives.cms.gov). The system will display an introductory ‘‘About this Site’’ page on which payment applicants will be asked to specify whether they are representatives of health care institutions or individual health care practitioners. There, optometrists should select the ‘‘Eligible Professionals (EPs)’’ link. The link will take the practitioner to a login page.
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Box 3
Clinical quality measures (CQMs) To comply with meaningful use standards under the Medicare EHR Incentive program, health care practitioners are required to report specified CQMs. They are required to report on a set of 3 core measures (with the option to report on a set of 3 alternative measures should none of the core set measures prove applicable to patients in a practice), as well as 3 additional measures selected by practitioners from a list of 38. The AOA Health Information Technology Subcommittee believes most optometrists will report the core measures and will not need to report alternative measures. A half-dozen of the 38 additional measures are appropriate to optometric practice (see below). The measures can be reported to Medicare or to the state CHIPRA program. The EHR quality measures are aligned with PQRS measures and the CHIPRA initial core set, officials of the CMS note. The CMS plans to merge the PQRS and EHR quality measure programs over the coming years. Additional information on CQM reporting objectives is available on the CMS Web site (www.cms.gov/EHRIncentivePrograms) and on the AOA Web site (www.aoa.org/EHR). EHR incentive program – CQMs Core Set (Complete all 3.) NQF 0013 Title: Hypertension: Blood Pressure Measurement NQF 0028 Title: Preventive Care and Screening Measure Pair: a.) Tobacco Use Assessment b.) Tobacco Cessation Intervention PQRS 128 (NQF 0421) Title: Adult Weight Screening and Follow-up Alternative Set (Complete as needed if numerator of any of core set measures is ‘‘O’’dpractitioner must report a total of 3 measures from the core and alternative sets.) NQF 0024 Title: Weight Assessment and Counseling for Children and Adolescents NQF0041 (PQRS 110) Title: Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older NQF 003 Title: Childhood Immunization Status Additional set (applicable to optometry) (Complete 3 of 6.) PQRS 12 (NQF 0086) Title: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation Description: Percentage of patients age 18 years and older with a diagnosis of POAG who have an optic nerve head evaluation during 1 or more office visits within 12 months PQRS 18 (NQF 0088) Title: Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Description: Percentage of patients age 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed that included documentation of the level of severity of retinopathy and the presence or absence of macular edema during 1 or more office visits within 12 months PQRS 19 (NQF 0089) Title: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Description: Percentage of patients age 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months PQRS 115 (NQF 0027) Title: Preventive Care and Screening: Advising Smokers to Quit Description: Percentage of patients age 18 years and older who are smokers who received advice to quit smoking PQRS 117 (NQF 0055) Title: Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient Description: Percentage of patients age 18-75 years with a diagnosis of diabetes mellitus who had a dilated eye exam PQRS 128 (NQF 0421) Title: Adult Weight Screening and Follow-Up Description: Percentage of patients age 18 years and up with a calculated body mass index in the past 6 months or during the current visit documented in the medical record and, if it is outside parameters, a follow-up plan is documented CHIPRA 5 Children’s Health Insurance Program Reauthorization Act; PQRS 5 Physician Quality Reporting System.
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Box 4
Exclusions from meaningful use objectives for optometrists The CMS allows exclusions from specific EHR meaningful use objectives, under certain circumstances, to prevent cases in which practitioners are unable to qualify for incentives because they are unable to meet objectives that are not applicable to their scope of practice. An exclusion will effectively allow a practitioner to defer compliance with an objective, according to the AOA Advocacy Group. However, even though optometrists may be able to claim exclusions in some cases, it may not always be advantageous to do so – for either the practice or the profession of optometry, according to the AOA Health Information Technology (HIT) Subcommittee. The CMS will allow exclusions for 5 of the 15 core meaningful use objectives: computerized provider order entry (CPOE), record vital signs, smoking status, electronic copies of health information, and clinical summaries. The agency also offers exclusions for several of the menu objectives. However, the AOA HIT Subcommittee believes optometrists can appropriately seek exclusions from only 3 core objectives: CPOE: Eligible providers (EPs) can opt out of the CPOE objective if they write fewer than 100 prescriptions in the 90-day reporting period e-Prescribing: EPs can opt out of the e-prescribing objective if they write fewer than 100 prescriptions in the 90-day reporting period Electronic copy of health records: If no patients ask for an electronic copy of their health records during the 90-day reporting period Appropriately claiming 1 or more exclusions could facilitate efforts by optometrists and other health care practitioners to achieve Stage 1 meaningful use – the entry-level EHR utilization that an EP must achieve during the EP’s first year in the incentive program – and thereby qualify for incentive payments, the AOA HIT Subcommittee acknowledges. However, practitioners should be aware that even if they successfully claim an exception for an objective to achieve Stage 1 meaningful use, they may ultimate have to meet that objective anyway, at some point over the course of the program, in order to keep receiving incentives. That is because CMS officials could tighten rules for exclusions when they issue the criteria for more advanced Stages 2 and 3 meaningful use. Ultimately, the agency plans on virtually all health care practitioners meeting virtually all of the objectives. Moreover, meeting the objectives helps to solidify optometry’s place in America’s primary health care system. For example, recording patient vital signs and smoking status can help to establish such functions as within the scope of optometry and reinforce the value of the optometric practice as an entry point to the health care system, the AOA HIT Subcommittee notes. Eventually, reporting data collected through EHRs could become an important determinant in health care policy and funding decisions that could impact both individual practices and the profession of optometry.
Step 2 – Enter user ID and password On the login page, the practitioners will enter a NPPES user identification and password to gain access to the attestation system. The practitioner will then be taken to the ‘‘Welcome’’ page.
Step 3 – Enter attestation system On the welcome page, the EP will select the ‘‘Attestation’’ tab. (After completing the attestation process, EPs will be able to check on the status of an attestation or payment by selecting a ‘‘Status’’ tab.)
Step 4 – Review categories of utilization objectives A ‘‘Topics for this Attestation’’ page will then list the 5 categories of EHR utilization measures the EP must
‘‘complete’’ in order to successfully demonstrate meaningful use of an EHR:
Meaningful use core measures Meaningful use menu measures Core clinical quality measures Alternative core clinical quality measures Additional clinical quality measures
Clicking on the ‘‘Start Attestation’’ button will allow the practitioner to begin providing required documentation. On successfully attesting compliance for all measures in a category, the practitioner will be returned to this page, where check marks will indicate the categories for which the practitioner has provided all of the required documentation.
Practice Strategies
Step 5 – Core measure data source, exclusion questionnaire The system will then display a series of ‘‘questionnaire’’ screens for each of the 15 EHR core measures. Up to 3 screens will be displayed for each measure. For measures requiring data entry, practitioners will be asked if the data is obtained from an EHR or paper patient records. Practitioners may also be asked if they wish to claim an exclusion from the measure; however, the AOA HIT Subcommittee generally recommends optometrists not claim exclusions.
Step 6 – Core measure compliance questionnaire A second questionnaire page will then ask practitioners to indicate whether they have met the meaningful use measure by answering yes or no.
Step 7 – Core measure data questionnaire For measures that require practitioners to provide EHR functions for specified percentages of patients, EPs will then be asked to indicate the total number of patients for which the function was used during the reporting period, as well as the total number of patients seen. As in the Medicare Physician Quality Reporting System, responses must be provided in a numerator and denominator format.
Step 8 – Select meaningful use menu measures Practitioners must then select 5 meaningful use menu measures for which they will report compliance over the reporting period. When selecting the 5 measures, practitioners must choose at least 1 of 2 public health objectives on the menu (Objectives 9 and 10). When selecting menu measures, they should choose objectives relevant to their scope of practice. Measures will be selected using check boxes on the right side of the screen.
Step 9 – Menu measure data source, compliance questionnaire Questionnaires will then be displayed for each of the selected menu measures. Just as with the core measures,
449 practitioners will indicate whether or not they have complied with each of the selected menu measures. They will also indicate, when appropriate, whether the data used in document compliance has been solely extracted from an EHR or from all patient records used during the reporting period, including paper records.
Step 10 – Report quality measures Practitioners will then be asked to indicate which clinical quality measures they implemented under core meaningful use Objective 10 (‘‘Report ambulatory clinical quality measures to CMS’’), as well as the number of patients for whom those quality measures were met and the total number of patients seen during the reporting period.
Step 11 – Summary of measures After providing the required information for all the core, menu, and quality measures, the practitioner will be returned to the ‘‘Topics for Attestation’’ screen. If check marks appear on the screen indicating all of the topics have been completed, the practitioner can click on the ‘‘Submit & Attest’’ button to file the application for payment. A ‘‘Summary of Measures’’ screen will immediately appear. The summary will allow the practitioner to know whether the attestation was successful. For each objective, the screen will indicate whether documentation of compliance was accepted or rejected, the reason the documentation was accepted or rejected, and the percentages of patients for whom each objective was met.
Additional information For additional information about the Medicare and Medicaid EHR Incentive Program, including an Attestation User Guide for EPs with step-by-step instructions on completing attestation and educational Webinars that describe the attestation process in detail, visit the CMS Web site’s EHR Incentive Programs page (www.cms.gov/ ehrincentiveprograms). Direct links to those and other resources can also be found on the AOA EHR page (www. aoa.org/EHR).
T
he U.S. Centers for Medicare & Medicaid Services (CMS) is now accepting applications for payment under the Medicare Electronic Health Records (EHR) Incentive program. Practitioners who apply for payment early stand the best chance of maximizing their payments under the program, according to the American Optometric Association (AOA) Health Information Technology (HIT) Subcommittee. Like other aspects of the incentive program, the application process may be easier than many optome-
Optometrists can now earn payments under the Medicare EHR Incentive program by attesting compliance with utilization standards through an online process. trists believe, according to Philip Gross, O.D., the AOA HIT Subcommittee chair. As previously noted in this series, the Medicare EHR Incentive program rewards eligible professionals (EPs) for implementing EHR systems certified for use under the program and then documenting that they have complied with EHR utilization standards (known as the ‘‘meaningful use’’ objectives) over a specified reporting period. Physicians, including optometrists, are designated EPs under the Medicare incentive program. For optometrists who are entering the program for the first time, the reporting period is 90 days. Health care practitioners who meet those requirements during 2011 will qualify for a payment of up to $18,000 this year and could earn up to a total of $44,000 ($48,000 in federally designated Health Professional Shortage Areas) over the next 5 years. CMS officials are attempting to issue payments within 30 days of receiving a qualifying application. In order to take part in the program, optometrists must first register for the program using the new Medicare & Medicaid EHR Incentive Program Registration and Attestation System (https://ehrincentives.cms.gov). Practitioners will then use the same system to apply for payment. The system can also be used to check on the status of applications and payments. This article is based on the CMS online guidance document, Preview of the Medicare EHR Incentive Program Attestation Process. Opinions expressed are not necessarily those of the American Optometric Association.
Before applying for payments and as part of their registration file, practitioners must enter the certification number for the EHR system they are using. They must also have a National Plan and Provider Enumeration System (NPPES) user identification number and password. The NPPES ID and password will be used to log on to the Medicare attestation system. In coming years, practitioners will be required to document compliance with the meaningful use standards by downloading data directly from their EHR systems to the CMS. However, the agency acknowledges the required technology is not yet in place. As a result, practitioners this year will simply be required to report compliance with the meaningful use objectives, a process the CMS calls ‘‘attestation.’’ Like the EHR incentive program registration process, attestation involves providing required information by completing a series of screens on the CMS Registration and Attestation Web site. According to the CMS’ Preview of the Medicare EHR Incentive Program Attestation Process, practitioners will use the site to report compliance with the Medicare EHR Incentive program: 1) Meaningful use core measures – Compliance with all 15 is required (see Box 1); 2) Meaningful use menu measures – Practitioners must comply with 5 of the 10 measures, deferring compliance with the others (see Box 2); 3) Core clinical quality measures (CQM) – Compliance with 3 of 6 measures is required (see Box 3); 4) Alternative core clinical quality measures – Compliance is required only if the EP reports the CQMs are not applicable to any patients seen during the reporting period; 5) Additional clinical quality measures – Compliance with 3 measures out of a list of 38 is required (see Box 3). The reporting of clinical quality measures is actually required as part of compliance with meaningful use Core Measure 10. Under that measure, EPs must specify the exact quality measures used and the percentage of patients for whom they were implemented. The AOA HIT Subcommittee has identified core clinical quality measures that fall well within the scope of optometric practice and believe few optometrists will have reason to report ‘‘alternative’’ quality measures. For most of the core and menu objectives, practitioners will be able to report compliance with a simple ‘‘Yes’’ or ‘‘No’’ response. For example, when reporting on Core Measure 2 (Implement drug-drug and drug-allergy interaction check), EPs will be asked ‘‘Have you enabled the functionality for drug-drug and drug-allergy interaction
1529-1839/$ - see front matter Ó 2011 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2011.05.004
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Box 1
Core objectives 1. Computerized provider order entry (CPOE) for medication orders Measure: More than 30% of all unique patients with at least 1 medication in their medication list seen by the eligible professional (EP) have at least 1 medication order entered using CPOE. 2. Drug interaction checks Measure: The EP has enabled this functionality for the entire electronic health reporting period. 3. Maintain problem list Measure: More than 80% of all unique patients seen by the EP have at least 1 entry (or an indication that no problems are known) for the patient recorded as structured data. 4. Generate and transmit permissible prescriptions electronically (e-Rx) Measure: More than 40% are transmitted electronically using certified electronic health record (EHR) technology. 5. Active medication list Measure: More than 80% of all unique patients seen by the EP have at least 1 entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data. 6. Medication allergy list Measure: More than 80% of all unique patients seen by the EP have at least 1 entry (or an indication that the patient has no known medication allergies) recorded as structured data. 7. Record demographics Measure: More than 50% of all unique patients seen by the EP have demographics recorded as structured data. 8. Record vital signs Measure: For more than 50% of all unique patients age 2 or older by the EP, height, weight, and blood pressure are recorded as structured data. 9. Record smoking status Measure: More than 50% of all unique patients age 13 years or older seen by the EP have smoking status recorded as structured data. 10. Clinical quality measures (CQMs) Measure: Successfully report to the Centers for Medicare and Medicaid Services (CMS) ambulatory clinical quality measures selected by the CMS in the manner specified by the CMS. 11. Clinical decision support rule Measure: Implement 1 clinical decision support rule. 12. Electronic copy of health information Measure: More than 50% of all patients who request an electronic copy of their health information are provided it within 3 business days. 13. Clinical summaries Measure: Clinical summaries provided to patients for more than 50% of all office visits within 3 business days. 14. Electronic exchange of clinical information Measure: Performed at least 1 test of certified EHR technology’s capacity to electronically exchange key clinical information. 15. Protect electronic health information Measure: Conduct or review a security risk analysis in accordance with the requirements set down under federal regulation and implement security updates as necessary and correct identified security deficiencies as part of its risk management process.
checks (in your EHR system)?’’ To attest compliance, a practitioner will simply click the ‘‘Yes’’ button. However, for a number of objectives practitioners will also have to report the number of patients for whom the
function was used, as well as the total number of patients seen, during the reporting period. EHR systems, certified for use in the incentive program, must provide readouts indicating the number of patients for whom various
446
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Box 2
Menu elements 1. Implement drug formulary checks Measure: Drug formulary check system is implemented and access maintained to at least 1 internal or external drug formulary for the entire reporting period. 2. Incorporate clinical laboratory test results into EHRs as structured data Measure: More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data. 3. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach Measure: Generate at least 1 listing of patients with specific conditions. 4. Use EHR technology to identify patient-specific education resources and provide to the patient as appropriate Measure: More than 10% of patients are provided patient-specific education resources. 5. Perform medical reconciliation between care settings Measure: Medication reconciliation is performed for more than 50% of transitions of care. 6. Provide summary of care record for patients referred or transitioned to another provider or setting Measure: Summary of care record is provided for more than 50% of patient transitions or referrals. 7. Submit electronic immunization data to immunization registries or immunization information systems Measure: Perform at least 1 test of data submission and follow-up submission (where registries can accept electronic submission). 8. Submit electronic syndromic surveillance data to public health agencies Measure: Perform at least 1 test of data submission and follow-up submission (where public health agencies can accept electronic submission). 9. Send reminders to patients (per patient preference) for preventive and follow-up care Measure: More than 20% of patients age 65 years or older or age 5 years or younger are sent appropriate reminders. 10. Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, and medication allergies) Measure: More than 10% of patients are provided electronic access to information within 4 days of it being updated in the EHR.
functions are used, as well as total patient count. Those readouts should make attestation relatively easy, the AOA HIT Subcommittee notes. (For some core and menu measures, the practitioner will have the choice of reporting the total patient count based on either total patient records or only patient records maintained using certified EHR technology. Practitioners will be asked specifically which method was used.) For some core and menu measures, practitioners may claim exclusions if the objective is not applicable to their scope of practice. However, the AOA HIT Subcommittee believes optometrists might appropriately claim an exclusion from only 3. (For additional information, see the AOA Web site EHR page at www.aoa.org/EHR). The inappropriate use of exclusions could jeopardize the practitioner’s ability to receive payment under the incentive program, the subcommittee warns. Moreover, because EHR incentive program data will be among the factors health care
policymakers will consider in establishing rules for America’s rapidly changing health care system, extensive use of exclusions could also have an adverse impact on optometry’s status as an important provider of primary health care (see Box 4). A summary of the steps involved in the attestation process follows.
Step 1 – Enter system Log on to the Medicare and Medicaid EHR Incentive Program Registration and Attestation System (https:// ehrincentives.cms.gov). The system will display an introductory ‘‘About this Site’’ page on which payment applicants will be asked to specify whether they are representatives of health care institutions or individual health care practitioners. There, optometrists should select the ‘‘Eligible Professionals (EPs)’’ link. The link will take the practitioner to a login page.
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Box 3
Clinical quality measures (CQMs) To comply with meaningful use standards under the Medicare EHR Incentive program, health care practitioners are required to report specified CQMs. They are required to report on a set of 3 core measures (with the option to report on a set of 3 alternative measures should none of the core set measures prove applicable to patients in a practice), as well as 3 additional measures selected by practitioners from a list of 38. The AOA Health Information Technology Subcommittee believes most optometrists will report the core measures and will not need to report alternative measures. A half-dozen of the 38 additional measures are appropriate to optometric practice (see below). The measures can be reported to Medicare or to the state CHIPRA program. The EHR quality measures are aligned with PQRS measures and the CHIPRA initial core set, officials of the CMS note. The CMS plans to merge the PQRS and EHR quality measure programs over the coming years. Additional information on CQM reporting objectives is available on the CMS Web site (www.cms.gov/EHRIncentivePrograms) and on the AOA Web site (www.aoa.org/EHR). EHR incentive program – CQMs Core Set (Complete all 3.) NQF 0013 Title: Hypertension: Blood Pressure Measurement NQF 0028 Title: Preventive Care and Screening Measure Pair: a.) Tobacco Use Assessment b.) Tobacco Cessation Intervention PQRS 128 (NQF 0421) Title: Adult Weight Screening and Follow-up Alternative Set (Complete as needed if numerator of any of core set measures is ‘‘O’’dpractitioner must report a total of 3 measures from the core and alternative sets.) NQF 0024 Title: Weight Assessment and Counseling for Children and Adolescents NQF0041 (PQRS 110) Title: Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older NQF 003 Title: Childhood Immunization Status Additional set (applicable to optometry) (Complete 3 of 6.) PQRS 12 (NQF 0086) Title: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation Description: Percentage of patients age 18 years and older with a diagnosis of POAG who have an optic nerve head evaluation during 1 or more office visits within 12 months PQRS 18 (NQF 0088) Title: Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Description: Percentage of patients age 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed that included documentation of the level of severity of retinopathy and the presence or absence of macular edema during 1 or more office visits within 12 months PQRS 19 (NQF 0089) Title: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Description: Percentage of patients age 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months PQRS 115 (NQF 0027) Title: Preventive Care and Screening: Advising Smokers to Quit Description: Percentage of patients age 18 years and older who are smokers who received advice to quit smoking PQRS 117 (NQF 0055) Title: Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient Description: Percentage of patients age 18-75 years with a diagnosis of diabetes mellitus who had a dilated eye exam PQRS 128 (NQF 0421) Title: Adult Weight Screening and Follow-Up Description: Percentage of patients age 18 years and up with a calculated body mass index in the past 6 months or during the current visit documented in the medical record and, if it is outside parameters, a follow-up plan is documented CHIPRA 5 Children’s Health Insurance Program Reauthorization Act; PQRS 5 Physician Quality Reporting System.
448
Practice Strategies
Box 4
Exclusions from meaningful use objectives for optometrists The CMS allows exclusions from specific EHR meaningful use objectives, under certain circumstances, to prevent cases in which practitioners are unable to qualify for incentives because they are unable to meet objectives that are not applicable to their scope of practice. An exclusion will effectively allow a practitioner to defer compliance with an objective, according to the AOA Advocacy Group. However, even though optometrists may be able to claim exclusions in some cases, it may not always be advantageous to do so – for either the practice or the profession of optometry, according to the AOA Health Information Technology (HIT) Subcommittee. The CMS will allow exclusions for 5 of the 15 core meaningful use objectives: computerized provider order entry (CPOE), record vital signs, smoking status, electronic copies of health information, and clinical summaries. The agency also offers exclusions for several of the menu objectives. However, the AOA HIT Subcommittee believes optometrists can appropriately seek exclusions from only 3 core objectives: CPOE: Eligible providers (EPs) can opt out of the CPOE objective if they write fewer than 100 prescriptions in the 90-day reporting period e-Prescribing: EPs can opt out of the e-prescribing objective if they write fewer than 100 prescriptions in the 90-day reporting period Electronic copy of health records: If no patients ask for an electronic copy of their health records during the 90-day reporting period Appropriately claiming 1 or more exclusions could facilitate efforts by optometrists and other health care practitioners to achieve Stage 1 meaningful use – the entry-level EHR utilization that an EP must achieve during the EP’s first year in the incentive program – and thereby qualify for incentive payments, the AOA HIT Subcommittee acknowledges. However, practitioners should be aware that even if they successfully claim an exception for an objective to achieve Stage 1 meaningful use, they may ultimate have to meet that objective anyway, at some point over the course of the program, in order to keep receiving incentives. That is because CMS officials could tighten rules for exclusions when they issue the criteria for more advanced Stages 2 and 3 meaningful use. Ultimately, the agency plans on virtually all health care practitioners meeting virtually all of the objectives. Moreover, meeting the objectives helps to solidify optometry’s place in America’s primary health care system. For example, recording patient vital signs and smoking status can help to establish such functions as within the scope of optometry and reinforce the value of the optometric practice as an entry point to the health care system, the AOA HIT Subcommittee notes. Eventually, reporting data collected through EHRs could become an important determinant in health care policy and funding decisions that could impact both individual practices and the profession of optometry.
Step 2 – Enter user ID and password On the login page, the practitioners will enter a NPPES user identification and password to gain access to the attestation system. The practitioner will then be taken to the ‘‘Welcome’’ page.
Step 3 – Enter attestation system On the welcome page, the EP will select the ‘‘Attestation’’ tab. (After completing the attestation process, EPs will be able to check on the status of an attestation or payment by selecting a ‘‘Status’’ tab.)
Step 4 – Review categories of utilization objectives A ‘‘Topics for this Attestation’’ page will then list the 5 categories of EHR utilization measures the EP must
‘‘complete’’ in order to successfully demonstrate meaningful use of an EHR:
Meaningful use core measures Meaningful use menu measures Core clinical quality measures Alternative core clinical quality measures Additional clinical quality measures
Clicking on the ‘‘Start Attestation’’ button will allow the practitioner to begin providing required documentation. On successfully attesting compliance for all measures in a category, the practitioner will be returned to this page, where check marks will indicate the categories for which the practitioner has provided all of the required documentation.
Practice Strategies
Step 5 – Core measure data source, exclusion questionnaire The system will then display a series of ‘‘questionnaire’’ screens for each of the 15 EHR core measures. Up to 3 screens will be displayed for each measure. For measures requiring data entry, practitioners will be asked if the data is obtained from an EHR or paper patient records. Practitioners may also be asked if they wish to claim an exclusion from the measure; however, the AOA HIT Subcommittee generally recommends optometrists not claim exclusions.
Step 6 – Core measure compliance questionnaire A second questionnaire page will then ask practitioners to indicate whether they have met the meaningful use measure by answering yes or no.
Step 7 – Core measure data questionnaire For measures that require practitioners to provide EHR functions for specified percentages of patients, EPs will then be asked to indicate the total number of patients for which the function was used during the reporting period, as well as the total number of patients seen. As in the Medicare Physician Quality Reporting System, responses must be provided in a numerator and denominator format.
Step 8 – Select meaningful use menu measures Practitioners must then select 5 meaningful use menu measures for which they will report compliance over the reporting period. When selecting the 5 measures, practitioners must choose at least 1 of 2 public health objectives on the menu (Objectives 9 and 10). When selecting menu measures, they should choose objectives relevant to their scope of practice. Measures will be selected using check boxes on the right side of the screen.
Step 9 – Menu measure data source, compliance questionnaire Questionnaires will then be displayed for each of the selected menu measures. Just as with the core measures,
449 practitioners will indicate whether or not they have complied with each of the selected menu measures. They will also indicate, when appropriate, whether the data used in document compliance has been solely extracted from an EHR or from all patient records used during the reporting period, including paper records.
Step 10 – Report quality measures Practitioners will then be asked to indicate which clinical quality measures they implemented under core meaningful use Objective 10 (‘‘Report ambulatory clinical quality measures to CMS’’), as well as the number of patients for whom those quality measures were met and the total number of patients seen during the reporting period.
Step 11 – Summary of measures After providing the required information for all the core, menu, and quality measures, the practitioner will be returned to the ‘‘Topics for Attestation’’ screen. If check marks appear on the screen indicating all of the topics have been completed, the practitioner can click on the ‘‘Submit & Attest’’ button to file the application for payment. A ‘‘Summary of Measures’’ screen will immediately appear. The summary will allow the practitioner to know whether the attestation was successful. For each objective, the screen will indicate whether documentation of compliance was accepted or rejected, the reason the documentation was accepted or rejected, and the percentages of patients for whom each objective was met.
Additional information For additional information about the Medicare and Medicaid EHR Incentive Program, including an Attestation User Guide for EPs with step-by-step instructions on completing attestation and educational Webinars that describe the attestation process in detail, visit the CMS Web site’s EHR Incentive Programs page (www.cms.gov/ ehrincentiveprograms). Direct links to those and other resources can also be found on the AOA EHR page (www. aoa.org/EHR).