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Countdown to MU Attestation: Top 10 Tips to Remember

By eHealth Specialist Christine Sweeny

  1. Run Meaningful Use (MU) reports now to make sure that you are on track to meet thresholds for your MU reporting period.
  2. Complete/update your Security Risk Assessment (SRA) prior to your attestation date (new rule!). Be sure to include in the document all of the EP names and NPI numbers the SRA covers. See CMS FAQ 10754 for more information.
  3. If an EP sees patients at more than one location, at least 50 percent of the patient encounters during the reporting period must be at a location equipped with certified electronic health record technology (CEHRT). In order to prove this, information about patient encounters at other locations should be maintained.
  4. Maintain dated screen shots or other documentation to support Y/N measures and exclusions:
    • Drug Formulary, Drug-Drug, and Drug-Allergy Checks: Screenshots from the CEHRT showing that the functionality was active for the entire reporting period, or obtain a letter from your vendor stating this.
    • Clinical Decision Support (CDS): Screenshots of the rule(s) being implemented and/or triggered during the EHR reporting period and statement of methodology of how the rule was utilized for patient care. For Stage 2, statement of how rules relate to Clinical Quality Measures (CQMs). If no CQMs relate to your scope of practice, a statement of how your CDS rules relate to high-priority health conditions.
    • Vital Signs: Exclusion #1: A de-identified report showing ages of patients seen during reporting period. Exclusion #2: Statement describing irrelevance of vital signs. Exclusion #’s 3 & 4: Statement describing irrelevance of vital signs specific to BP or height and weight.
    • Other exclusions: As appropriate, a report or other documentation showing a zero denominator for exclusion.
  5. Clinical Quality Measure (CQM) attestation numerators and denominators must be generated by your 2014 CEHRT software, but remember, CQMs do not have any minimum required thresholds.
  6. If Core and Menu measures are reported using sources external to your CEHRT, maintain those records. See CMS FAQ 10589 for more information.
  7. Maintain immunization measure documentation:
    • Stage 1 Test Submission or Ongoing Submission: For test submission, keep email message, copy of MyVITL ticket, screenshot or letter from registry acknowledging the tests, including EP’s NPIs and date. For ongoing submission, if you need additional documentation, email AHS.VDHPHMeaningfulUse@state.vt.us.
    • Stage 2 Ongoing Submission: Keep email message, copy of MyVITL ticket, screenshot, or letter from registry, including EP’s NPI and date, acknowledging registration intent within 60 days of start of reporting period; comply with all other requirements per VDH website. If you need additional documentation, email AHS.VDHPHMeaningfulUse@state.vt.us.
    • Exclusion: Report showing no immunizations were done during the reporting period, or, for Stage 1, letter indicating why EP could not onboard due to HL7 incompatibility.
  8. Keep copies of all MU reports used for your attestation.
  9. If you plan to take advantage of the 2014 CEHRT Flexibility Rule, be aware that when attesting to the Vermont Medicaid EHR Incentive program they will require a statement explaining why the rule is being applied, along with any supporting documentation.
  10. Upon successful completion of your attestation, print and save a copy of your successful submission.

If you need additional details about these tips: