FAQ on Meaningful Use
Frequently Asked Questions about Meaningful Use
In October 2015, the Centers for Medicare and Medicaid Services (CMS) issued a final rule covering meaningful use (MU) changes for 2015 through 2017. The rule eliminated Stage 1, incorporating it into the new Modified Stage 2. In November 2016, CMS released a final rule(www.federalregister.gov) that specifies reporting requirements for eligible professionals (EPs) in 2016 who are participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.
Note: As of January 1, 2017, under MACRA, the Quality Payment Program is being implemented by CMS and the EHR Incentive Payment Program previously known as Meaningful Use will become known as Advancing Care Information (ACI). The ACI performance category is one of four performance categories under the new Merit-Based Incentive Payment System (MIPS), and details about ACI requirements for 2017 and beyond will soon be available among all other MACRA resources.
The following are frequently asked questions (FAQs) about the EHR Incentive Programs in 2016.
Q: How did the final rule change the electronic health record (EHR) reporting period?
A: The November 2016 final rule changed the reporting period for all eligible professionals (EPs) to any 90 continuous days in the 2016 calendar year. (Prior to this final rule, new attesters were able to report any 90 continuous days in 2016, whereas returning attesters were required to report for the full calendar year from January 1 to December 31, 2016).
The final year for providers to demonstrate meaningful use for the first time under the Medicaid EHR Incentive Payment Program is 2016.
Q: Is reporting for a three-month period the same as reporting for 90 days?
A: No. A three-month period may include fewer or more than 90 days. The Centers for Medicare & Medicaid Services (CMS) specifically states that the reporting period must be a full 90 continuous days. In addition, CMS allows providers to begin and end their 90-day reporting period at any point during a month. Reporting for a three-month period would reduce flexibility by tying the reporting period to the beginning and end of the month.
Q: What is a “topped-out” measure?
A: The Centers for Medicare & Medicaid Services (CMS) defines a topped-out measure as a measure that has “achieved widespread adoption at a high rate of performance and no longer represent[s] a basis upon which provider performance may be differentiated.” Measures that are topped out or redundant are removed from CMS reporting requirements.
Q: If a measure has been removed because it is topped out or redundant, do I still have to capture data on it?
A: While CMS no longer requires you to report on topped out or redundant measures, you are still encouraged to continue capturing data on these measures.
Q: Will I still be able to capture data in my electronic health record (EHR) on topped-out or redundant measures?
A: Yes. The data standards and functions for topped-out and redundant measures will remain part of the certification criteria for EHRs.
Q: Can I substitute a topped-out measure if I am unable to meet one of the required measures?
A: No. CMS will not accept reporting on any topped out or redundant measure.
Q: What do I have to report for the Electronic Health Record (EHR) Incentive Programs in 2016?
A: For 2016, you will report on ten objectives(www.cms.gov), including one public health objective. All eligible providers (EP’s) are required to attest to a single set of objectives and measures. This replaces the core and menu objectives structure of previous stages. If you wish, Medicare Attestation Worksheets are available for 2016(www.cms.gov) that allow you to log your Meaningful Use measures on a document that can be used as a reference while attesting for the Medicare EHR Incentive Program via the Registration and Attestation System.
Q: Will alternate measures and exclusions be available to providers in 2016?
A: Yes, the EHR Registration and Attestation System will automatically identify those who are eligible for alternate exclusions in 2016(www.cms.gov). EP’s eligible for alternate exclusions may choose to use alternate exclusions during attestation, but are not required to use them. Many of the alternate exclusions available in 2015 are not applicable in 2016. Two objectives offer alternate exclusions in 2016:
- #3 – Computerized Provider Order Entry: Lab and Radiology orders (measures 2 and 3). For details, see Alternate Exclusions and Specifications(www.cms.gov).
- #10 – Public Health Reporting – measure 2 (syndromic surveillance reporting) and measure 3 (specialized registry reporting). For details, see Alternate Exclusions and Specifications(www.cms.gov).
Q: If I choose to use an alternate exclusion for one of the objectives, what proof is required to verify that I did not intend to attest to the objective? Will the Centers for Medicare & Medicaid Services (CMS) audit me?
A: No. If you claim an exclusion for an objective, CMS does not require documentation that you did not intend to attest to that objective.
Q: What level of documentation does CMS expect to be be kept to substantiate what eligible professionals report through attestation?
A: See CMS Audit Information and Guidance on Supporting Documentation for Audits(www.cms.gov).
Q: Some measures are based on actions for unique patients. Can I count actions that occurred before or after the reporting period?
A: If the patient action occurred outside of the reporting period and in a different calendar year, it will not satisfy the numerator requirements. However, if the action occurred outside of the reporting period but within the same calendar year, it can count toward the numerator. For example, if your reporting period is 90 continuous days, a patient action that occurs before or after the 90-day period and within the same calendar year can count toward the numerator. However, it is important to note that if you are attesting prior to the end of the calendar year, the patient action must occur before attestation is completed.
Q: Is reporting on clinical quality measures (CQMs) still required?
A: Yes. Providers must report on nine CQMs, and the measures selected must cover at least three National Quality Strategy (NQS) domains. For 2016, the reporting period for CQMs is 90 continuous days. However, providers who are electronically reporting CQMs for multiple programs (e.g., EHR Incentive Program and Physician Quality Reporting System [PQRS]) must report for a full calendar year.
Modified Stage 2, Objective 1: Protect Patient Health Information(www.cms.gov)
Q: Are alternate exclusions available for small practices?
A: No. The Centers for Medicare & Medicaid Services (CMS) does not offer exclusions for this measure. It is required for all eligible professionals (EPs) attesting to meaningful use.
Q: What is a security risk assessment (SRA), and how often must I conduct a security risk assessment(www.cms.gov)?
A: A risk assessment is essentially a series of questions designed to help you determine the areas where your protected health information (PHI) may be at risk, then helps to assess potential impacts of the risk(s), and prompts you to determine how best to mitigate risks. Risk assessments help ensure compliance with HIPAA’s administrative(www.hhs.gov), physical(www.hhs.gov), and technical safeguards(www.hhs.gov). HIPAA requires covered entities not only to identify their practice’s vulnerabilities and threats, but also to mitigate those risks with policies, procedures, and training(www.hhs.gov).
As required by HIPAA, a security risk assessment must be conducted or reviewed each year and should cover the entire year for which the assessment is conducted/reviewed. If the reporting period is less than a full calendar year, the assessment can occur before or after the reporting period. However, the assessment must occur within the same calendar year as the reporting period. If you are attesting before the end of the year, the security risk assessment must be completed prior to your attestation date.
Q: Where can I find resources and information about the HIPAA Security Rule, Security Risk Analysis requirements under the Security Rule, and risk assessment tools to assist Covered Entities (providers) with compliance?
A: The Office of the National Coordinator for Health IT (ONC) has put together a downloadable HIPAA Security Risk Assessment (SRA) Tool(www.healthit.gov) to assist with the task of completing and documenting an annual security risk analysis. Both an electronic version and a paper version(www.healthit.gov) of the tool are available. ONC also created a Health IT Playbook(www.healthit.gov) with information about requirements to protect the confidentiality, integrity, and availability of PHI, while ensuring understanding of patients’ rights to access information so as to avoid information blocking. HHS has also compiled numerous relevant HIPAA Resources for Professionals(www.hhs.gov) with supportive information.
Modfied Stage 2, Objective 2: Clinical Decision Support(www.cms.gov)
Q: There is an exclusion for the Measure 2 for any eligible professional (EP) who writes fewer than 100 prescriptions. Does this cover the full calendar year or just the reporting period?
A: The exclusion does not specify the length of the electronic health record (EHR) reporting period. It just states that a provider can be excluded if he or she writes fewer than 100 prescriptions during the reporting period.
Modified Stage 2, Objective 3: Computerized Provider Order Entry(www.cms.gov)
Q: Who is considered a credentialed user?
A: The following qualify as credentialed users:
- Licensed health care professionals
- Credentialed medical assistants
- Medical staff members credentialed to perform duties equivalent to a credentialed medical assistant
- Interns who have completed their medical training and are working toward appropriate licensure.
The user must be credentialed by an entity that is separate from the employer. The Centers for Medicare & Medicaid Services (CMS) defers to providers to determine, on the basis of CMS guidelines, whether a staff member is appropriately credentialed to have the clinical training, knowledge, and experience required to enter orders. A specific job title is not required; however, CMS states that a scribe does not meet the requirements for a medical staff member who may enter orders for the purposes of the computerized provider order entry (CPOE) objective.
Q: Am I required to include standing orders in the CPOE numerator and denominator?
A: No. CMS allows providers to exclude orders that are predetermined for a given set of patient characteristics or for a given procedure.
Modified Stage 2, Objective 4: Electronic Prescribing(www.cms.gov)
Q: Does the measure for this objective include electronic prescribing of controlled substances?
A: Controlled substances are no longer excluded from the definition of “permissible prescriptions.” However, according to CMS(questions.cms.gov), for the purpose of the eRx Meaningful Use objective, inclusion of controlled substances is an option for providers, but not required. Providers may include prescriptions for controlled substances in the denominator if electronic prescription of a specific medication or schedule of medications is permissible under state or federal law.
Q: What if no formulary is available for a prescription?
A: If no formulary is available, you may still count the patient in the numerator for the electronic prescribing measure.
Modified Stage 2, Objective 5: Health Information Exchange(www.cms.gov) (Summary of Care)
Q: What is included in a summary of care?
A: A summary of care should include the following information, if the provider knows it:
- Patient name
- Referring or transitioning provider’s name and office contract information
- Encounter diagnosis
- Laboratory test results
- Vital signs (height, weight, blood pressure, body mass index [BMI])
- Smoking status
- Functional status, including activities of daily living, and cognitive and disability status
- Demographic information (preferred language, sex, race, ethnicity, date of birth)
- Care plan field, including goals and instructions
- Care team, including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider
- Reason for referral
In some cases, there may be no information available to populate one or more of the fields, either because the provider can be excluded from recording such information or because there is no information to record. In such cases, the provider may leave the field(s) blank. However, at minimum, a provider must record:
- Current problem list (providers may also include historical problems at their discretion)
- Current medication list
- Current medication allergy list
Eligible professionals (EPs) must verify that these three fields are not blank and include the most recent information known by the EP when the summary of care document is generated.
Q: Are all labs included in laboratory test results?
A: A provider must have the ability to send all laboratory test results in the summary of care document. However, the provider can use his or her discretion to send the most appropriate results for a given referral or transition. A provider must send all laboratory test results at the request of the receiving provider or the patient.
Q: What constitutes a transition of care for this objective?
A: For this objective, a transition of care is defined as a transition or referral in which the referring provider is recognized as a different billing identity for the Electronic Health Record (EHR) Incentive Programs than the receiving provider.
Q: What if I push the summary of care document out to my health information exchange (HIE)?
A: As the referring provider, you must have reasonable certainty that a summary of care document was received. You may count the use of the HIE in the numerator if you can confirm that a query was made by the receiving provider, but simply publishing the document to your HIE is insufficient to meet the measure for this objective.
Modified Stage 2, Objective 6: Patient-specific Education(www.cms.gov)
Q: What is the timeframe for providing patient-specific education? For example, if a patient received a diagnosis for a chronic condition in the previous reporting period, do I need to provide education on the condition to him or her each year?
A: This action must take place no earlier than the start of your reporting period and no later than your attestation date. Regardless of how many visits the patient has within the reporting period, you can meet the minimum requirements by providing patient-specific educational materials to him or her one time during the reporting period. Provision of patient-specific education is not limited to an office visit; it may occur at any point during the reporting period.
Patient education provided at the initial diagnosis of a chronic condition will not count for the numerator in perpetuity. If a patient who has a chronic condition has an office visit during the reporting period, he or she must receive some form of patient-specific education. However, it does not have to be related to the patient’s chronic condition.
Q: Does education have to be provided to the patient electronically?
A: Patient-specific resources must be identified by the certified electronic health record technology (CEHRT), but the Modified Stage 2 measure for this objective does not state that the education must be provided to the patient electronically.
Modified Stage 2, Objective 7: Medication Reconciliation(www.cms.gov)
Q: What is the definition of medication reconciliation?
A: The Centers for Medicare & Medicaid Services (CMS) defines medication reconciliation as “the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider.”
Q: What constitutes a transition of care for the medication reconciliation objective?
A: For this objective, a transition of care is defined as the movement of a patient from one setting of care (for example, a hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health care, rehabilitation facility) to another. Movement of a patient between providers who are recognized as different billing identities (as defined under the Electronic Health Record [EHR] Incentive Programs) also constitutes a transition of care. In addition, referrals are defined as cases in which a patient is referred to another provider, but the referring provider continues to provide care for the patient.
Q: Are new patients included? If so, what is the definition of a new patient?
A: Yes, new patients are included in the denominator for this objective’s measure. The provider must complete medication reconciliation at the first encounter with a new patient. New patients include all patients who have never before been seen by the provider.
Q: Does the measure include referrals that are not received electronically?
A: Yes. In addition, medication reconciliation should occur with the transition or referral of the patient and is not dependent upon receipt of an electronic referral or summary of care document.
Modified Stage 2, Objective 8: Patient Electronic Access(www.cms.gov)
Q: What information must be made available to the patient?
A: The following information must be made available to the patient electronically within four business days of the information becoming available to the eligible professional (EP):
- Patient name
- Provider’s name and office contact information
- Current and past problem list
- Laboratory test results
- Current medication list and medication history
- Current medication allergy list and medication allergy history
- Vital signs (height, weight, blood pressure, body mass index [BMI], growth charts)
- Smoking status
- Demographic information (preferred language, sex, race, ethnicity, date of birth)
- Care plan field(s), including goals and instructions
- Any known care team members, including the primary care provider of record
Q: If my patient population is highly unlikely to access personal health information online, do I still have to make it available?
A: Yes. Information must be made available to all patients, regardless of whether or not they are able or likely to access online information. The Centers for Medicare & Medicaid Services (CMS) also states that a patient who opts out or does not have an email address is not excluded from the denominator for Measure 1 of this objective. You can still satisfy Measure 1 by informing the patient how to access his or her health information online and how to opt in.
Q. Who qualifies for an exclusion to Measure 2 of this objective?
A. A provider qualifies for an exclusion if he or she conducts 50 percent or more of his or her patient encounters in a county in which 50 percent or more of the housing units do not have 4Mbps broadband availability according to the latest information available from the Federal Communications Commission (FCC) on the first day of the reporting period.
Q: Does information need to be made available to the patient for all encounters during the reporting period?
A: Yes. The patient must have timely access to updated information related to his or her care for each encounter that takes place during the electronic health record (EHR) reporting period. Patients seen during the reporting period who are not enrolled at the initial visit or are not given timely access to information from the initial visit cannot be counted in the numerator.
Q: What if a patient accesses his or her information outside of the reporting period?
A: Patient access can be counted for Measure 2 if the action occurred within the same calendar year as the reporting period and prior to attestation.
Q: What is the phased approach for Measure 2?
A: For 2015 and 2016, CMS set the threshold for Measure 2 at one patient viewing or downloading his or her health information, or transmitting it to a third party. This was intended to allow providers additional time to adopt the proper technology. The threshold was originally planning to be increased in 2017 to 5% of all unique patients seen by the EP during the reporting period, though 2017 has since become the transition year into the Quality Payment Program and MIPS where the threshold for this measure for 2017 will remain at one patient viewing or downloading his or her health information or transmitting it to a third party.
Modified Stage 2, Objective 9: Secure Messaging(www.cms.gov)
Q: If my patient population is highly unlikely to send electronic messages (e.g., elderly, ill, low-income, rural), do I qualify for an exclusion from this objective?
A: You may qualify for an exclusion from this objective if you conduct 50 percent or more of your patient encounters in a county in which 50 percent or more of the housing units do not have 4Mbps broadband availability according to the latest information available from the Federal Communications Commission (FCC) on the first day of the reporting period.
Q: What is the phased approach for the secure messaging objective?
A: To allow providers time to work toward a goal of greater patient involvement, the Centers for Medicare & Medicaid Services (CMS) is using a phased approach to increase the threshold for this objective’s measure. In 2015, the capability for patients to send and receive secure electronic messages was required to be fully enabled for the entire reporting period. In 2016, at least one patient (or an authorized representative) must receive a response to a patient-initiated message or be sent a message electronically. The threshold was originally slated to increase to more than 5% of patients (or their patient-authorized representatives) receiving or sending a secure electronic message in 2017. However, 2017 has since become the transition year into the Quality and Payment Program (QPP) and MIPS, where the threshhold for this measure will remain at one patient receiving or sending a secure electronic message.
Modified Stage 2, Objective 10: Public Health(www.cms.gov)
Q: What is the difference between ongoing submission and active engagement?
A: The Centers for Medicare & Medicaid Services (CMS) modified the public health reporting objective to offer flexibility to providers. For the Electronic Health Record (EHR) Incentive Programs in 2015 through 2017, “active engagement” replaces the ongoing submission requirement. Any action acceptable under the Stage 1 or Stage 2 public health reporting objectives counts toward meeting this active engagement requirement.
Providers have three options for active engagement:
Option 1: Completed registration to submit data
- The eligible professional (EP) registered to submit data with the public health agency (PHA) or, where applicable, the clinical data registry (CDR) to which the information is being submitted. (Note: Providers who have registered in previous years do not need to submit additional registrations in subsequent EHR reporting periods to meet this requirement.)
- Registration was completed within 60 days of the start of the EHR reporting period.
- The EP is awaiting an invitation from the PHA or CDR to begin testing and validation.
Option 2: Testing and validation
- The EP is in the process of testing and validation of electronic submission of data.
- Providers must respond to requests from the PHA or, where applicable, the CDR within 30 days.
- A provider who fails to respond twice within the EHR reporting period does not meet the measure.
Option 3: Production
- The EP has completed testing and validation of electronic submission and is electronically submitting production data to the PHA or CDR.
Q: Do I have to register for each measure?
A: Yes. You must register with the appropriate PHA or CDR for each measure you intend to use to meet meaningful use requirements. Registration for purposes of Option 1 for active engagement will only count if the provider has not attested to the measure in a previous EHR reporting period.
Q: Can I attest to a measure if I am part of a group that has registered with a PHA or CDR?
A: A provider can attest to a measure if he or she has registered as an individual or is part of a group that has registered with a PHA or CDR. If a provider who is part of a group uses the same certified electronic health record technology (CEHRT) as the group, he or she may attest using documentation provided to the practice or organization.
Q: What are the alternate exclusions available in 2016?
A: EPs may claim an alternate exclusion for measure 2 (syndromic surveillance reporting) and measure 3 (specialized registry reporting). An alternate exclusion may only be claimed for up to 2 measures, then the EP must either attest to or meet the exclusion requirements for the remaining measure.
Q: What counts as a specialized registry?
A: CMS(questions.cms.gov) addresses whether or not a specialized registry meets the requirements to enable an EP to attest to this MU measure. To qualify as a specialized registry, an entity must have declared readiness to accept data as a specialized registry and be using the data to improve population health outcomes. The entity must also be able to receive data electronically from CEHRT via a secure mechanism including, but not limited to, a secure upload function on a web portal, sFTP, or Direct. However, manual data entry into a web portal would not qualify as submission to a specialized registry. Reporting to a QCDR may count for the public health specialized registry measure as long as the submission to the registry is not only for the purpose of meeting CQM requirements through PQRS, or for MU (e.g., so long as the entity/registry is receiving data from CEHRT, transmitted electronically, for a public health purpose.
Q: In 2016, is use of a Prescription Drug Monitoring Program (PDMP) an option under the specialized registry measure?
A: Yes, according to the CMS technical specifications sheet for Objective 10(www.cms.gov). CMS “continue[s] to allow registries such as the Prescription Drug Monitoring Program reporting and electronic case reporting registries to be considered specialized registries for purposes of reporting for the EHR reporting period in 2016.” However, AAFP also encourages providers to begin, or continue, making earnest progress toward being able to successfully report to a specialty specific specialized registry which is recognized by CMS as a Qualified Registry(www.cms.gov) or qualified clinical data registry (QCDR(www.cms.gov)).
Q: What if I report to more than one specialized registry?
A: You may count specialized registry reporting for up to two measures.
Q: Is reporting to a cancer registry still an option under this objective?
A: Yes. CMS has incorporated cancer registry reporting into specialized registry reporting. If you report to more than one specialized registry, you may count specialized registry reporting for up to two measures.
Last updated: January 2017