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2015 Meaningful Use Attestation Guide

Contents Introduction ............................................................................................................................................................................... 2

Note for 2015 ........................................................................................................................................ 2

Preparing for Attestation ..................................................................................................................................................... 3

Attesting to 2015 Meaningful Use .................................................................................................................................... 4

Attestation Information ........................................................................................................................................................ 5

Meaningful Use Objectives ................................................................................................................................................... 7

Objective 1 ............................................................................................................................................ 7

Objective 2 ............................................................................................................................................ 8

Objective 3 ............................................................................................................................................ 9

Objective 4 .......................................................................................................................................... 10

Objective 5 .......................................................................................................................................... 11

Objective 6 .......................................................................................................................................... 12

Objective 7 .......................................................................................................................................... 13

Objective 8 .......................................................................................................................................... 14

Objective 9 .......................................................................................................................................... 15

Objective 10 ........................................................................................................................................ 16

Clinical Quality Measures ................................................................................................................................................... 17

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Introduction This document is intended to assist providers using the Valant EHR to attest to Meaningful Use

for 2015. It provides an overview of how to generate reports in Valant for Meaningful Use and

walks through each step of the online attestation process for Medicare providers. Note that the

attestation process for Medicaid providers may vary by state.

As this document is intended for use by providers who are at the attestation step, it does not

explain how Meaningful Use Measures are completed and tracked in the EHR. For additional

Valant documentation on Meaningful Use, refer to the Knowledge Base.

Note for 2015:

In early October 2015, CMS published a final rule that revised the criteria that providers must

meet in order to participate in the Medicare and Medicaid Electronic Health Record (EHR)

Incentive Programs.

Under these provisions:

1. All providers will be required to attest to a single set of 10 objectives (Modified

Stage 2) for 2015 instead of the previous list of core and menu measures which

varied by stage.

2. To assist providers who had been scheduled to attest to Stage 1 of Meaningful Use

in 2015, there are alternate exclusions and specifications within several

objectives. These are noted later in this document.

3. The EHR reporting period for all providers in 2015 may be any continuous 90 day

period from January 1 through December 31, 2015 (example: October 1 –

December 31).

4. Providers may attest for 2015 between January 4 through February 29, 2016.

The attestation instructions in this document account for these provisions.

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Preparing for Attestation Prepare for attestation in Valant by generating reports of your Meaningful Use Measures and

Clinical Quality Measures (2014).

The attestation period for 2015 may be any consecutive range of 90 days or more. Enter the

attestation date range you have chosen to attest to into the “From” and “To” date fields of the

Meaningful Use Measures report and click to generate the report and

to save a copy for your records (recommended).

NOTE: items in gray were tracked in previous years of Meaningful Use, but are not required for

2015

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Attesting to 2015 Meaningful Use Begin the online attestation process by accessing the CMS EHR Incentives site.

After logging in using your User ID and Password, click

The online attestation will consist of three sections. Begin by clicking the first: Attestation

Information

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Attestation Information Confirm that the following information is correct:

1. The attesting provider’s Name and Tax ID

2. EHR Certification Number (1314E01P3Sj2EAF)

3. EHR Reporting Period – This should be the same date range entered in the Meaningful

Use Measures report in Valant (referenced above).

After confirming, click

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The next screen will list the first nine Meaningful Use Objectives, and below that, the Public

Health Reporting Objective (Objective 10).

Most private practices in the Behavioral Healthcare specialty will EXCLUDE from all three

Reporting Objective measures. In order to do this later in the attestation:

Select all three and click

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Meaningful Use Objectives Objective 1: Protect electronic protected health information (ePHI) created or maintained by the

certified EHR technology through the implementation of appropriate technical capabilities

This objective is attested to with a “Yes” or “No” response and is not reflected on the Valant

Meaningful Use Measures report.

To state that your practice conducted or reviewed the required Security Risk Analysis:

Select “Yes” and click

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Objective 2: Use clinical decision support to improve performance on high-priority health

conditions

Both measures in this objective are attested to with a “Yes” or “No” response and are not

reflected on the Valant Meaningful Use Measures report. The requirements for Measures 2A

and 2B are successfully met by the Clinical Decision Support rules in Valant and DrFirst

respectively. If these are enabled in your EHR:

Select “Yes” for each measure and click

NOTE: Providers who were scheduled to participate in Stage 1 for 2015 are only required to

implement ONE clinical decision support rule.

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Objective 3 (Measures 3A, 3B, and 3C): Use CPOE for medication, laboratory, and radiology

orders

Providers may EXCLUDE from any of these measures for which they performed the action* less

than 100 times during the attestation period (*ie: ordered less than 100 medications, labs, or

radiology images). It is also possible to exclude from 3B and 3C and satisfy a 30% threshold for

3A for providers who were scheduled to be on Stage 1 for 2015

Under “Does this exclusion apply to you?”:

To exclude: Select Yes. If you are not excluding from the measure, Select No.

In response to the “PATIENT RECORDS” section, select the second option: “This data was

extracted from patient records maintained using certified EHR technology.” This option should

be selected for all measures which you will report on from the Valant Meaningful Use Measures

Report.

For 3A - C, enter the Numerators and Denominators from the following items in your MU

Measures report:

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Objective 4: Generate and transmit permissible prescriptions electronically (eRx)

Note that the threshold for this objective is 40% for providers scheduled to attest to Stage 1.

This objective provides two options for reporting: excluding or including controlled substances.

Depending on whether you do or do not electronically prescribe controlled substances, enter

the numerator and denominator from the appropriate of the two items below in your MU

Measures report:

Click

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Objective 5: Provide a summary of care record (for transitions of care/referrals)

A provider may EXCLUDE from this measure if he or she transfers a patient to another setting

or refers a patient to another provider less than 100 times during the attestation period.

Providers scheduled to attest to Stage 1 may also EXCLUDE from this objective.

Providers who are attesting to the measure:

Enter the Numerator and Denominator from the following item on your MU Measures

report:

Click

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Objective 6: Patient-Specific Education Resources

Note that Providers scheduled to attest to Stage 1 may exclude from this objective if they did not

intend to select the Stage 1 Patient Specific Education menu objective.

Enter the Numerator and Denominator from the following item on your MU Measures

report:

Click

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Objective 7: Medication reconciliation

Note that Providers scheduled to attest to Stage 1 may exclude from this objective if they did not

intend to select the Stage 1 Medication Reconciliation menu objective.

Enter the Numerator and Denominator from the following item on your MU Measures

report:

Click

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Objective 8 (Measures 8A and 8B): Patient electronic access – Timely Access & View,

Download, Transmit

Note that Providers scheduled to attest to Stage 1 may exclude from measure two (8B) of this

objective.

For Measures 8A and 8B, enter the Numerators and Denominators from the following

items on your MU Measures report:

Note that the current requirement for 8B (View, Download, Transmit) is that at least ONE patient

has viewed, downloaded, or transmitted a health summary sent to their Patient Portal account

(not the previous 5% target).

Click

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Objective 9: Secure Electronic Messaging

Note that Providers scheduled to attest to Stage 1 may exclude from this objective.

This objective is attested to with a “Yes” or “No” response and is not reflected on the Valant

Meaningful Use Measures report. As your Valant account DOES have the required capability for

patients to send and receive a secure electronic message fully enabled:

Select “Yes” and click

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Objective 10 (Measures 10A, 10B, and 10C): Public health agency reporting

Private practice behavioral healthcare providers will likely EXCLUDE from objectives 10A, 10B,

and 10C. To do so, under “Does this exclusion apply to you?”, select “Yes” and click

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Clinical Quality Measures After completing the Meaningful Use Objectives, you will be prompted to select how you will

submit your clinical quality measure (CQM) data. Note that CQM measures have no target

threshold, but providers attesting to Meaningful Use ARE required to submit CQM data.

Select Option 2 and click

In the following screen, you will be prompted to select a minimum of nine Clinical Quality

Measures from a list and include measures from at least six of the available domains.

Many available CQM measures typically do not apply in behavioral healthcare practice, so not

all measures on the list are reported on in Valant. Refer to the Clinical Quality Measures

(2014) report in Valant as you select the nine measures you will attest to. It is

recommended that you select measures with numbers on said report, even if some of these

numbers are ‘0’ – use the “CMS-ID” to easily identify the measures referred to.

After calculating your Quality Measures, click to save a copy of the report for your

records.

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For each measure selected you will be prompted to enter some or all of the following fields:

Denominator, Numerator, Performance Rate (%), Denominator Exclusions, and Denominator

Exceptions. Required fields vary by measure, but all of these values can be pulled from the

corresponding column of the CQM Report in Valant.

Upon the successful completion of your Attestation Information, Meaningful Use Measures, and

Clinical Quality Measures, you will be prompted to confirm that all information entered is correct.

After confirming accuracy, click to complete the Meaningful Use attestation

for 2015.