To meet Stage 1 Meaningful Use (MU) requirements, Eligible Professionals (EPs) must attest to meeting MU criteria that consist of Core measures; Menu measures; and Clinical Quality Measures (CQMs). In 2014, EPs attest to 2014 MU measures and Clinical Quality Measures (CQMs) if they have successfully implemented 2014 Edition Certified EHR Technology (CEHRT). If they have not transitioned to 2014 CEHRT due to delays in 2014 CEHRT availability, they may attest (using 2011 Edition CEHRT or Combination 2011/2014 Edition CEHRT) to 2013 Core and Menu measures and CQMs. Check the CMS Meaningful Use webpage to learn more about the Stage 1 MU requirements for EPs and download specification sheets for each MU measure.
If the EP practices in more than one site/location that has CEHRT, the Meaningful Use numerators and denominators need to include the patient records from all CEHRTs and any records maintained in paper or noncertified EHR. For further guidance on calculating numerators and denominators from multiple locations, refer to the Guide for Practicing in Multiple Locations .
The following guidelines apply to Stage 1 MU attestations in 2014.
Reporting period: in 2014 the reporting period for Stage 1 MU for all providers is 90-days in the 2014 calendar year. In 2015, first time providers will attest for Stage 1 MU based on a 90-day reporting period in the current calendar year. (Note the distinction between the patient volume reporting period which is based on 90-days of data from the prior calendar year.) Each year thereafter, a 365-day reporting period must be used.
Stage 1 Meaningful Use Supporting Documentation: EPs must upload EHR screenshots and other supporting documentation with Protected Health Information redacted (i.e., HIPAA protected information) at the time of attestation in order for the payment request to be processed. In addition, screenshots must be dated from within the 90-day Meaningful Use reporting period or the EP will be deemed ineligible to receive an incentive payment during that payment year. For further guidance, refer to the New Hampshire Guidelines for Meaningful Use and Supporting Documentation .
2014 Edition CEHRT:
Core Measures: EPs must meet 13 (of 13) Core measures based on thresholds established by CMS. If exclusion is claimed on a measure (that offers exclusion), the measure is considered met.
Menu Measures: EPs must meet 5 (of 9) Menu measures based on thresholds established by CMS. At least one must be a Public Health measure. The State of New Hampshire is currently unable to accept data for either of the Public Health measures, EPs must attest to an exclusion for one of these measures. The public health measure will not count towards the 5 required Menu measures.
Clinical Quality Measures: EPs using 2014 certified EHR technology must attest to 9 (of 64) CQMs which must cover a minimum of 3 of the 6 National Quality Strategy domains. These include:
- Patient and Family Engagement
- Patient Safety
- Care Coordination
- Population/Public Health
- Efficient Use of Healthcare Resources
- Clinical Process/Effectiveness
2011 Edition CEHRT or Combination 2011/2014 Edition CEHRT
Core Measures: EPs must meet 13 (of 13) Core measures. If exclusion is claimed on a measure (that offers exclusion), the measure is considered met.
Menu Measures: EPs must meet 5 (of 10) Menu measures. At least one must be a Public Health measure. The State of New Hampshire is currently unable to accept data for either of the Public Health measures, EPs must attest to an exclusion for one of these measures. The public health measure will count towards the 5 required Menu measures.
EPs who do not have the same Menu objectives implemented across each of their practice locations equipped with CEHRT may attest to the five Menu objectives that represent the greatest number of their patient encounters. For measures that require a percentage threshold, they can limit the denominator to the location or locations that pursued that menu objective. (Medicare and Medicaid EHR Incentive Program – Stage 2 – Final Rule p. 53981)
Clinical Quality Measures (CQMs): in 2013, EPs may choose from two options based on their edition of CEHRT.
2011 Edition CEHRT:
- 3 (of 3) Core CQMs;
- 0-3 Alternate Core CQMs. (An Alternate Core CQM must be reported as a substitute for each Core CQM that had a denominator of 0.);
- 3 (of 38) Additional CQMs that relate to the EP’s practice. It is acceptable to use the value of zero (0) as a denominator if this value was produced by CEHRT.
Combination of 2011 and 2014 Edition or 2014 Edition CEHRT:
- 2 Core CQMs;
- 1 mandatory Alternate Core CQM plus 0-2 Alternate Core CQMs. (An Alternate Core CQM must be reported as a substitute for each Core CQM that was reported with a denominator of 0.);
- 3 (of 27) Additional CQMs that relate to the EP’s practice. It is acceptable to use the value of zero (0) as a denominator if this value was produced by certified EHR technology.
EPs having greater than 50% of their clinical activity at one site can include only CQM data from the site where they see greater than 50% of their patients. For further guidance, refer to the CMS Clinical Quality Measures webpage.
- EPs that work at multiple practice locations: at least 50 percent of their total patient encounters must take place at a location(s) where certified EHR technology is available. (These EPs would base all MU measures only on those encounters that occurred at locations with CEHRT.) For the purpose of calculating the 50 percent threshold, all encounters (and not just Medicaid and/or Needy Individual encounters) should be considered in this calculation.
- MU measures may not be applicable to every clinical practice. For example, dentists do not typically perform immunizations. In these cases, providers would not have any eligible patients or actions for the measure denominator and could attest to an exclusion (i.e., be excluded from having to meet that measure). Claiming an exclusion (i.e., providing a ‘yes’ response to an exclusion) for a specific measure qualifies as submission of that measure.
- Measure results do not round up. For example, a numerator of 199 and a denominator of 1,000 is 19%.
- Measures that require a result greater than a given percentage must be more than that given percentage to pass. For example, in a measure requiring a result of greater than 80%, a result of 80.1% will pass, but a result of 80.0% will not pass.
- There are two types of percentage-based denominators reported for MU measures. The first is when the denominator equals all patients seen or admitted during the EHR reporting period. In this instance, the denominator is all patients regardless of whether their records are maintained using certified EHR technology. The second is based on actions or subsets of patients seen or admitted during the EHR reporting period. In this instance, the denominator only includes patients, or actions taken on behalf of those patients, whose records are maintained using certified EHR technology.
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