1. 2017 Supporting Documentation Requirements Massachusetts Medicaid EHR Incentive Program September 19 & 20, 2017
Good Morning Everyone My name is Elisa Lopez. I am an Analyst here at MeHi. For those of you who don’t know we are the ones who validate your applications and answer the phones when you call.
Today’s presenters:
Elisa Lopez
Ariana Matias

2. MU Supporting Documentation
Agenda
Program Year 2017
Requirements
Timeline
Attestation Protocol
MU Supporting Documentation
Modified Stage 2
Stage 3
This is our Agenda. *Read the Bullets* As we flip through we are going to expand upon what is written on the slides.

3. Program Year 2017 Requirements
For Program Year 2017:
EPs who have never submitted an application can no longer participate in the Medicaid EHR Incentive Program
Program Year 2017 and beyond focuses on Meaningful Use participants only
EPs must have acquired a 2014 or 2015 Edition CEHRT or combination CEHRT
EPs who have attested at least once still have time to collect the total incentive payout of $63,750 (EPs) or $49,585 (board-certified pediatricians) by 2021
All actions or exchanges for MU must be completed and recorded prior to or within the calendar year of the attesting Program Year (Jan 1, 2017 – Dec 31, 2017)
Can no longer include actions taken after end of CY but before date of attestation
I want to start by congratulating everyone here, if you are planning to attest for 2017 that means your providers have completed at least 1 year of the program. Many of you have already done AIU, and wile eligibility needs to be proved for every program year, it should be easier to prove for you going forward. *Read the slides*
One key difference that I want to point out is that the date requirements for the documentation has changed. Previously folks were able to submit documentation that was collected prior to the Date of Attestation. All documentation must be collected prior to or within the calendar year for the attesting program year. In this case it will need to be dated Between January and December of 2017

4. Program Year 2017 Timeline For Program Year 2017:
EHR reporting period is any continuous 90 days from Jan 1, 2017 – Dec 31, 2017
MAPIR scheduled launch is date is Oct 2017
PY2017 deadline is slated for March 31, 2018
Providers who receive an incentive payment for their 6th and final participation year
Will receive a congratulatory
Can no longer attest in MAPIR
*Read Bullets* MAPIR is scheduled to be open to accept applications from Oct of 2017 until March 31st of 2018

5. Attestation Protocol For Program Year 2017 and beyond:
All attesting Providers must prove eligibility each Program Year:
Non-Hospital-Based or Practice Predominantly at an FQHC
Acquired a 2014 Edition CEHRT or higher
Satisfies the Medicaid Patient Volume Threshold (PVT) requirement
All MU supporting documentation must be uploaded to the EP’s MAPIR application
All PHI must be removed from supporting documentation detail or it will not be accepted
All EPs attesting to MU must upload an MU Aggregation Form to confirm data was combined across all locations where the EP rendered services
This presentation will focus on MU, but a quick reminder what is required for eligibility. One thing I want to highlight here that have noted on the 2017 supporting documentation guide that we will not accept PHI. There is a need for some patient information in order to validate accuracy of information. When it comes to the Meaningful use documentation, identifying information should be redacted. An example of the PHI we are talking about here is displaying a patient’s full name, and medical conditions. If the information is part of a screenshot, it needs to be redacted in order to be accepted.
The MU aggregation form is your first piece of Meaningful use documentation that will need to be uploaded to MAPIR.
This form is simply stating were the provider worked during the 90 days and checking off whether or not the locations are utilizing certified HER. This is used to confirm providers data is being aggrigated

6. Objective: Protect ePHI
Modified Stage 2 & Stage 3
Security Risk Analysis (SRA)/Security Risk Review (SRR) must be submitted for each location where the EP practiced and utilized CEHRT during the EHR reporting period.
Be sure to include:
Name of practice
Location
Date completed
Signature of authorized official
Name and title of person who conducted SRA/SRR
Mitigation plan detailing action steps to correct/diminish identified security gaps
Completed SRA/SRR cover sheet attesting to the truthfulness and accuracy of the analysis must also be submitted.
So this is an example where the date requirement has changed. The SRA Must have been completed during Calendar year This may require some planning as we are approaching the last quarter of Analyst have our own checklists we use when validating documents. These bullets points are what we are looking for when reviewing an SRA. We need to sign off that all information is present before moving the application forward. Please do not forget to include a cover sheet which can be found on our website.

7. Objective: Clinical Decision Support (CDS)
Modified Stage 2 & Stage 3
Upload Supporting Documentation for Measure 1
EHR-generated screenshots of 5 CDS interventions dated within EHR reporting period and identifying both EP and organization
Documentation showing interventions relate to 4 or more CQMs related to the scope of practice, OR a letter from EP’s Supervisor or Medical Director explaining CDS’s relationship to patient population and high priority conditions
For global CDS implementations:
Screenshot with practice name and enabled date
If screenshots don’t display enabled dates, submit either CEHRT audit logs with enabled dates,
OR a vendor letter confirming enabled dates and that EPs are unable to deactivate interventions
Letter on letterhead and signed by Medical Director confirming relevance to EP and including
a list of all EPs using the CDS
Clinical Decision support
This year 5 clinical decision support intervention screenshots are needed. Of these 5, at least 4 need to align with the CQM's that are being reported.
If for some reason, these 2 things cannot align, documentation showing that the interventions relate to the EP's scope of practice, or the high priority patient population, is needed. This should be written and signed by the Medical Director. For the Global option, the screenshots still need to show practice name, and enable date and should be accompanied by a letter from Medical director. The letter should have a list of providers, and should be confirming the relevance of the alerts to the attesting EP's.
If the screenshots cannot display the enable dates, either audit log, or letter from your vendor confirming enable dates, and a statement that EP’s are not able to deactivate interventions, can be submitted.

8. Objective: Clinical Decision Support, continued
Modified Stage 2 & Stage 3
Upload Supporting Documentation for Measure 2
Documentation from CEHRT identifying both EP & organization showing drug-drug & drug-allergy interaction checks were enabled for the entire reporting period
And again for drug to drug and drug to allergy, we are going to be looking to the dashboard. If this information does not display on the dashboard, the requirement is much like the CDS in that we will need screenshots dated within the EHR reporting period, an audit log, or a vendor letter.

9. Objective: Computerized Provider Order Entry (CPOE)
Modified Stage 2 & Stage 3
In MAPIR, enter the numerators/denominators lifted directly from the MU report to show the EP meets the required threshold
Upload Supporting Documentation
EHR generated report that displays:
Selected MU reporting period
EP’s name
Recorded volumes for; medication, lab and radiology orders
Computerized Provider Order Entry.
We will be looking to the dashboard for numerator and denominators to tie out the 3 measures. We rely heavily on the dashboards for the validation process. We will be looking for an EHR generated dashboard that should display the EP’s name and correct 90 day reporting period, and correct/matching numerators and denominators. If the exclusion was taken we will be looking to see fewer than 100 in the denominator. In the case that you qualify for the exclusion, but also can report on the measure, we recommend reporting on it. Its ultimately up to you, but we do use resources to validate that you qualify for the exclusion, these resources can cause a delay in the validation.

10. Objective: eRx Modified Stage 2 & Stage 3
In MAPIR, enter the numerators/denominators lifted directly from the MU report to show the EP met the required threshold
Upload Supporting Documentation
EHR generated report that displays:
Selected MU reporting period
EP’s name
Recorded volumes for eRx
E-Prescribing
Again here we are going to look to the dashboard for the numerator and denominator to tie out to what was entered into MAPIR.
At this point I am going to hand the presentation over to Ariana who will be going over Objective 5-10 with you.

11. Objective: Health Information Exchange (HIE)
Modified Stage 2 & Stage 3
In MAPIR, enter the numerators/denominators lifted directly from the MU report to show the EP met the required threshold
Upload Supporting Documentation
Measure 1:
EHR generated report that displays:
Selected MU reporting period
EP’s name
Recorded volumes for HIE
One unique Summary of Care Record per EP that:
Occurred within the same calendar year of the EHR reporting period
Includes, at a minimum, current problem list, current medication list, current medication allergy list
Is in human readable format
Confirmation of receipt, or proof that the receiving provider made a query,
of this one Summary of Care record
*Now we will be reviewing Measure 1 of the Health Information Exchange objective which is in both Modified Stage 2 and Stage 3. Ep’s who transfer a patient to another setting of care or another provider less than 100 transfers during the MU reporting period may claim the exclusion in MAPIR and no additional documentation is required beyond the dashboard. We will be checking the dashboard for a denominator less than 100 for this measure.
*Providers who do not qualify for the exclusion must meet the 10% threshold requirement. As in 2016, the MU Dashboard along with a Summary of Care document is still required. The Summary of care document should pertain to a unique patient, and it must be a real patient not a sample or test patient, with all PHI redacted. As Elisa said it is very important not to provide us identifying details. The exchange must date-compliant, taking place within the calendar year of the EHR reporting period and must include at a minimum the current problem list, medication list and medication allergy list.
*In prior years Ep’s only need to have reasonable certainty that their transmission reached the intended party. In 2017 confirmation or proof of receipt by the second party is required. This means another piece of documentation is required.
*The documentation submitted to show proof of receipt will look and be different depending on how this data is captured across EHRs. In general, however, will be required including an identification of the organization/provider, the transmission date, and confirmation of a successful submission.

12. Objective: Health Information Exchange (HIE)
Stage 3
In MAPIR, enter the numerators/denominators lifted directly from the MU report to show the EP met the required threshold
Measure 2: a SOC document is created for transitions or referrals received and patient encounters where the Provider never before encountered the patient
Measure 3: for transitions or referrals received and patient encounters where the Provider never before encountered the patient, the Provider performs a clinical information reconciliation. The EP must implement reconciliation for 3 clinical information sets:
1. Medication
2. Medication Allergy
3. Current Problem List
Upload Supporting Documentation
*All providers are required to meet Measure 1 as we just went over but in Stage 3 there are additional measures as shown here. The good news is that additional supporting documents is not required. This data is captured in the dashboard.
*Both measures depend on the receipt of patients from other setting or providers of care. If the Meaningful Use dashboard demonstrates a denominator less than 100 for these measures additional documentation is not required.
EHR generated report that displays:
Selected MU reporting period
EP’s name
Recorded volumes for HIE

13. Objective: Medication Reconciliation
Modified Stage 2
In MAPIR, enter the numerator/denominator lifted directly from the MU Dashboard to show the EP met the required threshold
Upload Supporting Documentation
EHR generated report that displays:
Selected MU period
EP’s name
Recorded volumes for Medication Reconciliation
*This measure is also validated using the Meaningful Use dashboard. Eps who did not receive any patient transitions of care may claim the exclusion and we check to see that the denominator is zero for this measure. All other Eps are required to meet the 50% threshold.
*I think now is a good time to say that you will hear us say this a lot, what we are looking for on the dashboard, since many of the next few objectives deal with measures that are dashboard driven. This is why it is so important that the EHR is set up correctly to ensure the data is being captured to reflect all of the hard work that you do every day.

14. Objective: Patient Specific Education
Modified Stage 2
In MAPIR, enter the numerators/denominators lifted directly from the MU report to show the EP met the required threshold
Upload Supporting Documentation T
EHR generated report that displays:
Selected MU period
EP’s name
Recorded volumes for Patient Specific Education
*This objective only pertains to providers in Modified Stage 2. In Stage 3 this objective is combined with the patient electronic access objective.
*Again this objective is verified using the Meaningful Use Dashboard. Providers who do not have office visits during the EHR reporting period are able to claim the exclusion. Providers with office visits during the reporting period are required to meet the 10% threshold. Whether you are reporting on the measure or taking the exclusion only the dashboard is needed.

15. Objective: Patient Electronic Access
Modified Stage 2
In MAPIR, enter the numerators/denominators lifted directly from the MU Dashboard to show the EP met the required thresholds
Measure 1: Patients were given timely access to View, Download and Transmit (VDT)
Measure 2: Number of Patients who actually Viewed, Downloaded or Transmitted
Upload Supporting Documentation
EHR generated report that displays:
Selected MU period
EP’s name
Recorded volumes for Patient eAccess
*This objective in Stage 2 is also validated with the meaningful use dashboard. If you are reporting on the measure only the dashboard is required. Providers who are electing to take the exclusion for either measure must submit signed confirmation in writing that they do not order or create information for inclusion as part of the measure. Personally I have not seen anyone take this exclusion but if you qualify, the documentation submitted needs to confirm that you meet the exclusion eligibility requirement.

16. Objective: Patient e-Access to Health Information
Stage 3
In MAPIR, enter the numerators/denominators lifted directly from the MU Report to show the EP met the required thresholds
Upload Supporting Documentation
Measure 1: Access to View, Download and Transmit and API Access
EHR generated report displaying the selected reporting period, the EP’s name, and recorded volumes
Documentation that shows an API was enabled prior to or during the EHR reporting period
Copy of instructions provided to patients on how to access API
Measure 2: e-Access to Patient Specific Education
*The MU dashboard is required for Measure 1 and we will be confirming the patient ability to view, download and transmit their health information as well as accessing the API (Application Programming Interface). We will need signed documentation from the vendor confirming enabled functionality of an API during the reporting period and a copy of instructions provided to patients on how to access the API. The patient instructions should include instructions on how to authenticate their access and the information on other available applications that leverage the API.
*Measure 2 is simple, we validate this measure off of the MU Dashboard.

17. Objective: Coordination of Care through Patient Engagement
Stage 3
In MAPIR, enter the numerators/denominators lifted directly from the MU Dashboard to show the EP met the required thresholds
Measure 1: Patients Viewed, Downloaded or Transmitted, or Accessed API
Measure 2: Secure Messaging
Measure 3: Incorporation of Patient Generated Health Data or Data from a Non-Clinical setting
Upload Supporting Documentation
*This is a brand new measure. In stage 3 this objective combines the Patient Electronic Access and Secure Messaging objectives from stage 2 and includes a new measure that requires patient generated health data or data from a nonclinical setting to be incorporated into the CEHRT.
*Yet again this is an objective that is verified using the Meaningful Use Dashboard. Providers who have no office visits during the EHR reporting period may claim the exclusion as well as any Ep who conducts 50% or more of their services in a count that does not have 50% or more of its housing units with 4Mbps broadband availability. Otherwise providers must meet the 5% threshold for at least two of the three measures. All measures must be reported on.
EHR generated report that displays:
Selected MU period
EP’s name
Recorded volumes for all 3 components of Coordination of Care

18. Objective: Medication Reconciliation
Modified Stage 2
In MAPIR, enter the numerator/denominator lifted directly from the MU Dashboard to show the EP met the required threshold
Upload Supporting Documentation
EHR generated report that displays:
Selected MU period
EP’s name
Recorded volumes for Medication Reconciliation
*For this measure in Stage 2, we use the Meaningful use dashboard, additional documentation is not required.

19. Objective: Secure Electronic Messaging
Modified Stage 2
In MAPIR, enter the numerator/denominator lifted directly from the MU Report to show the EP met the required threshold
Upload Supporting Documentation
EHR generated report that displays:
Selected MU period
EP’s name
Recorded volumes for Secure eMessaging
*This is another measure validated using the Meaningful Use dashboard. Eps who do not have any office visits during the reporting period may claim the exclusion and do not need to submit documentation to support the exclusion. As Elisa previously touched on, we have resources to validate that providers did not have any office visits during the reporting period and we recommend reporting on the measure when possible. Eps who do have office visits during the reporting period must meet the 5% threshold.
*In Stage 3 this measure is combined with the Coordination of Care Objective.

20. Objective: Public Health Reporting - Modified Stage 2
Measure 1 – Immunization Registry
MIIS Immunization Acknowledgement (ACK), MIIS Registration of Intent, or MIIS MU Scorecard to demonstrate active engagement
Exclusion: PCPs claiming an immunization exclusion must upload a letter attesting to the accuracy of the exclusion
Measure 2 – Syndromic surveillance
Applies to EPs in freestanding Urgent Care Facility. Documentation to demonstrate active
engagement.
*There are some changes in 2017 regarding the public health objectives for Modified Stage 2. Active engagement is a key word in this objective and that just means the provider is in the process of moving towards sending “production data” to a registry.
*For Measure 1, the immunization registry, one of the available exclusion reasons is that the EP did not perform immunizations during the reporting period. PCPs or primary care physicians who are claiming this exclusion need to submit a letter signed by the provider on letterhead explaining why they do not administer immunizations. Specialty providers are not required to submit documentation when claiming this exclusion, it makes sense due to their specialty that they do not administer immunizations. *Providers who are attesting to the measure are required to submit documentation from MIIS, either an Acknowledgement (ACK), Registration of Intent or MU Scorecard. If submitting a registration of intent, we look to see that it is date compliant within 60 days of the beginning of the reporting period. It is important that the supporting documentation for this measure comes in one of those three forms. An conversation between MIIS and the organization making sure the group is “good” is not sufficient, a more official document like the MU Scorecard is needed.
*In previous years all Massachusetts providers were able to claim the exclusion for measure 2, syndromic surveillance. In 2017 Eps practicing in a Freestanding Urgent Care facility are required to submit documentation from the Syndromic surveillance registry confirming active engagement.
*The required documentation for the public health registry, measure 3, is the same as in Depending on your specialty this measure may not apply to. Providers who do not directly treat or diagnose any disease or condition associated with a clinical registry may submitting a letter signed by the provider advising their circumstance. Providers reporting Yes to the measure must submit a letter from the selected registry confirming active engagement.
*The cancer registry and infectious diseases registry have been popular options in the past but any registry collecting medical data is sufficient as long as the registry has declared themselves a specialized registry. The infectious disease registry actually requires that your organization diagnose a specific number of infectious disease cases before you are able to submit data to them. They have a formalized letter for groups that do not qualify to submit data to them, we accept that document to support the exclusion as well.
Measure 3 – Specialized Registry
Documentation from a Specialized Registry to demonstrate active engagement with the Cancer Registry and/or Infectious Disease Registry

21. Objective: Public Health Reporting – Stage 3
Measure 3 – Electronic Case Reporting
Not required for PY2017
Measure 4 – Public Health Registry
Documentation from a Public Health Registry to demonstrate active engagement with
the Cancer and/or Infectious Disease Registry
*In Stage 3 additional measures have been added to this objective. Since measure 3, Electronic Case Reporting, is not required and measure 5, Clinical data registry reporting, is unavailable, supporting documentation is not required. You can simply choose the exclusion in MAPIR. Measure 4 is very similar to Measure 3 in Stage 2. Providers must attest to at least two measures so the choice is yours.
Measure 5 – Clinical Data Registry Reporting
Unavailable in MA

22. Disclaimer
This presentation was current at the time it was presented, published or uploaded onto the web. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage attendees to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.