Meaningful Use Audit Webinar Series March 25, 2015: An Overview of the Meaningful Use Audit Process 1 in 10 providers will receive a MU audit letter April 1, 2015: Preparing for EHR Incentive Program Audit Tips and Suggestions The time to prepare for an audit is before you receive the letter April 8, 2015: EHR Incentive Program Appeals Process Steps to Complete a Meaningful Use Audit Appeal

Preparing for EHR Incentive Program Audit Tips and Suggestions Brenda Simms RN, BSN, CHTS-CP Meaningful Use Specialist IL-HITREC Northern Illinois University © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Disclaimer This webinar is based on official guidance provided by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC), experiences from IL-HITREC, and other Regional Extension Centers. It is by no means all-inclusive of the types of documentation you must keep to support your attestation, but this webinar provides a starting point. IL-HITREC is not giving legal advice. If you are audited, you should consult your Certified EHR Technology (CEHRT) vendor and/or legal advisor.

The time to prepare for an audit is before you receive the letter. “You cannot escape the responsibility of tomorrow by evading it today." Abraham Lincoln The time to prepare for an audit is before you receive the letter.

Preparing for Audit Treat a Meaningful Use Audit as a Team Sport: Secure Administrative Buy-In and Involvement: The Auditor may ask to interview administration/management Include Stake Holders from other departments Develop a formal MU Audit Team with an oversight committee Designate a person or committee to oversee and coordinate meaningful use criteria and share the work load Designate a facility “Primary Contact” Team Approach provides coverage if the Primary Contact is unavailable

Preparing for Audit Establish a process for building an “EHR Attestation Binder”: Comprehensive book of evidence in both electronic and paper form Define Terms Organize book by objectives Develop an Audit Plan: Written compliance plan and data repository Gather supporting data for each MU objective/validate data Develop and maintain detailed policy and procedures for use of your certified EHR technology Conduct internal audits on compliance Maintain all supporting data for six years post-attestation Document payment calculations and cost report data

11/12/2017 6:48 AM Source Documentation Primary Documentation is referred to as “Source Documentation” The numerators and denominators for the measures The time period the report covers Evidence to support that it was generated for that EP, eligible hospital, or CAH [e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.] Evidence to support that the report was generated by the certified EHR system (e.g., screenshot of the report before it was printed from the system) © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

11/12/2017 6:48 AM Source Documentation Documentation should be saved for 6 years post-attestation to support Meaningful Use Objectives and Clinical Quality Measures: Maintain paper copies Maintain electronic copies Maintain cost reports to calculate payment Organize and categorize your information and keep it up to date! Anticipate what an auditor might ask for before the audit © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Points to Remember Make sure your numbers are accurate 11/12/2017 6:48 AM Points to Remember Make sure your numbers are accurate Your numerators and denominators are from your certified EHR Identify reporting period specific to provider (NPI) System audit log provides documentation that functions are enabled, along with screenshots for “Yes or No” functions Drug Allergy interaction and clinical decision support must be enabled during the entire reporting period Security Risk Analysis must be specific to your practice: Not generalized and performed yearly prior to attestation Mitigation Plan for identified deficiencies © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Stage 1 Non-Percentage-Based Objectives Meaningful Use Objective Audit Validation Suggested Documentation Drug-Drug/Drug-Allergy Interaction Checks and Clinical Decision Support Functionality is available, enabled, and active in the system for the duration of the EHR reporting period. One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation. Report ambulatory or hospital clinical quality measures Clinical quality measure data is reported directly from certified EHR systems. Report from the certified EHR system to validate all clinical quality measure data entered during attestation. Exclusions Documentation to support each exclusion to a measure claimed by the provider. Report from the certified HER system that shows a zero denominator for the measure or otherwise documents that the provider qualifies for the exclusion. Source: cms.gov

Stage 1 Non-Percentage-Based Objectives Meaningful Use Objective Audit Validation Suggested Documentation Electronic Exchange of Clinical Information One test of certified EHR technology’s capacity to electronically exchange key clinical information to another provider of care with a distinct certified EHR or other system capable of receiving the information was performed during the EHR reporting period. Dated screenshots from the EHR system that document a test exchange of key clinical information (successful or unsuccessful) with another provider of care during the reporting period. A dated record of successful or unsuccessful electronic transmission (e.g., email, screenshot from another system, etc.). A letter or email from the receiving provider confirming a successful exchange, including specific information such as the date of the exchange, name of providers, and whether the test was successful.

Stage 1 Non-Percentage-Based Objectives Meaningful Use Objective Audit Validation Suggested Documentation Protect Electronic Health Information Security risk analysis of the certified EHR technology was performed prior to the end of the reporting period Report the documents the procedures performed during the analysis and the results. Report should be dated prior to the end of the reporting period and should include evidence to support that it was generated for that provider’s system [e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.] Drug Formulary Checks Functionality is available, enabled, and active in the system for the duration of the EHR reporting period. One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation. Generate Lists of Patients by Specific Conditions One report listing patients of the provider with a specific condition. Report from the certified EHR system that is dated during the EHR reporting period selected for attestation. Patient-identifiable information may be masked/blurred before submission.

Stage 2 Non-Percentage-Based Objectives Meaningful Use Objective Audit Validation Suggested Documentation Clinical Decision Support Rule Functionality is available, enabled, and active in the system for the duration of the EHR reporting period. One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation. Generate Lists of Patients by Specific Conditions One report listing patients of the provider with a specific condition. Report with a specific condition that is from the certified EHR system and is dated during the EHR reporting period selected for attestation. Patient‐ identifiable information may be masked/blurred before submission.

Organize Your Documentation Create an EHR Incentive Binder To: Tell the Story About Your Journey to Meaningful Use Prepare Your Facility Information Before You Receive an Audit Notification Keep the Binder Up To Date Keep the Binder Organized Provider Meaningful Use Data Should be Separated by Provider If You Have to “Dig” for Information It Opens the Door for the Auditor to “Dig” Deeper EHR Incentive Program Binder For: Facility Name Attestation Year

EHR Certified Software Contract Invoice Purchase Order Lease Documents License Documents ONC Certification ID Number Vendor Contacts, Help Desk Number, Site ID Number Software Version List of Software Updates EHR Incentive Program Binder For: Facility Name Attestation Year

System Administrators and Designated “Acting on Behalf Of” List Responsible Staff: Provider Registration Attestation Acting on Behalf Of Keep Administrators UP TO DATE Obtain and Secure Passwords in case of staff departure or unexpected absence Registration Data of Responsible Staff Current Copy of CMS EHR Incentive Program Registration and Attestation Guide EHR Incentive Program Binder For: Facility Name Attestation Year

Provider Registration/Attestation Information Spreadsheet with list of providers CMS Registration ID, License Number, Facility NPI and Tax ID Number (TIN) Multiple Location Info Lists if applicable Attestation Documentation of PECOS/CMS Information – Review and Update Quarterly or More Often Attestation: Date of Attestation Reporting Period for Meaningful Use

Eligibility Requirements: Volume Document how you calculated your patient volume: Calculations Reports Used Pre- Approval (State specific) Hospital Payment Calculations – Cost reports and Hospital Calculation worksheets Copies of Cost Report Used

Meaningful Use Source Documentation Meaningful Use Dashboard by Provider Reasons for Claiming Exclusions (MU Worksheet) Screen Shots of Non-Percentage Measures: Screen Shots of Enabling Functionality Drug to Drug; Drug to Allergy, CDS for Entire Reporting Period Policy and Procedure for Clinical Summaries Public Health Registry Tests and Ongoing Electronic Transmission

HIPAA Security Risk Analysis Documentation: Physical Inspection Report List of Deficiencies and Mitigation Plan Stage 2 Encryption/Security of Data Copy of Business Associate Agreements readily available

Additional Documentation Copy of Core Measures used in Attestation Copy of Menu Measures used in Attestation Copy of Clinical Quality Measures Grid used in Attestation (Including Recommended) Copy of Stage Appropriate Attestation Guides Copy of “CMS Tip Sheets” Used to aid in Interpretation of Measures List of Clinical Labs and LOINC Codes Copy of Public Health Email with Test File Copy of Public Health Email Verifying Test

About IL-HITREC The Illinois Health Information Technology Regional Extension Center (IL-HITREC), under contract with the Illinois Department of Health and Family Services (HFS), is providing education, outreach and support to Medicaid providers for the Electronic Health Record (EHR) Provider Incentive Payment (PIP) Program. Northern Illinois University (NIU) serves as the Illinois Health Information Technology Regional Extension Center providing EHR and meaningful use services to providers in Illinois, outside the City of Chicago 606 zip code area.

announcing References 11/12/2017 6:48 AM © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Contacts Telligen ILHITREC Linda Brewer Brenda Simms Sr. Quality Improvement Facilitator Meaningful Use Specialist Linda.brewer@area-d.hcqis.org bsimms@niu.edu CHITREC Telligen HITREC Sam Ross Antonio Vega Clinical Implementation Manager HIT Advisor s-ross@chitrec.org avega@telligen.com Telligen Telligen Terrey Currie Sarah Cottington Quality Improvement Facilitator Sr. Quality Improvement Facilitator Terrey.currie@area-d.hcqis.org Sarah.Cottington@area-D.hcqis.org This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-IL-D1-03/15-079