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Meaningful Use and Clinical Quality Measures Supporting Documentation

Meaningful Use (MU) and Clinical Quality Measures (CQMs) Supporting Documentation: Eligible Professionals (EPs) must upload EHR screenshots and other supporting documentation that fully support their MU and CQM data at the time of attestation in order for the payment request to be processed. To prevent risk of modification of audit documents, print to a version that is not modifiable such as PDF and/or paper. Per CMS, EPs must retain supporting documentation showing their demonstration of meaningful use for 6 years.

IMPORTANT

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. Screenshots must meet the requirements outlined in the New Hampshire Guidelines – Modified Stage 2 Meaningful Use Supporting Documentation Adobe Acrobat Reader Symbol.

The following are general guidelines for MU and CQM screenshots. For measure-specific guidelines, please refer to the New Hampshire Guidelines – Modified Stage 2 Meaningful Use Supporting Documentation Adobe Acrobat Reader Symbol.

Screenshots must:

  • Be generated from Certified EHR Technology (CEHRT).
  • Display dates that are within the MU reporting period. Reports/Screenshots dated outside of the reporting period will not be accepted as supporting documentation. Vendor verification of functionality will be required.
  • Display an Eligible Professional’s (or, where appropriate, an Administrator’s) first and last name and the facility/organization name and address (or other identifying information) that would tie the documentation to the attesting EP.
  • Display the name of the objective and measure.
  • Display the appropriate Document Type on ePIP (with corresponding File Name and Memo that clearly describe the content of the document).
  • Not include HIPPA data. If patient data has been redacted, it must not be legible.
  • Be uploaded in sequential order
    • Best practice: upload one document containing screenshots for each report category, i.e., one report with all MU measures and one report with all CQMs.
    • Acceptable (but not preferable): upload individual screenshots; if this option is used, the measure identification number must be included in the ePIP Memo.
  • Be submitted even for EPs that are excluded from a measure because they have no patients in the numerator and denominator.
    • If an EP is not listed on a report because he/she is claiming exclusion, handwrite the EP's name on the report with an explanation (example: "Dr. John Smith was excluded from this measure"), and sign and date.

Adobe Acrobat Reader Symbol Adobe Acrobat Reader format. You can download a free reader from Adobe.

 
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