Dealing with Meaningful Use Attestation Aggravation

Physicians at Family Practice Associates of Lexington, Ky., had been using an EHR for two years when "meaningful use" came along.

So last year, when it came time to put CMS' EHR incentive program into effect, they hit a wall, recalls practice administrator Susan Miller.

"Even though our practice was relatively mature from the standpoint of technology, there were quite a number of processes we had to rework," says Miller. "We didn't actually attest until the 90-day period ending June 30, for a lot of our providers."

Among the more difficult adjustments was the patient-education process. Physicians used to hand out materials to patients - such as instructions on caring for a sprained ankle - in the exam room. But in order to meet the goal to "identify patient-specific education resources and provide those resources to the patient if appropriate" (one of the optional menu set objectives in Stage 1 of CMS' meaningful use program), that responsibility shifted to the checkout person. "When you begin to involve checkout in patient education, clinical summaries, and prescriptions, that's a whole different set of skills," says Miller. "That's not stuff available to you in the practice management system. That information is only available in the EHR. It's an entire retraining process."

Like Miller, a number of practices and their physicians have found the meaningful use attestation process stressful. But changing a longstanding routine isn't the only source of attestation aggravation. Here's what you need to know to make sure that attesting is as smooth as possible.

Process-related aggravators

Attesting for meaningful use seems easy enough.

To receive incentive money, CMS says participants in the Medicare EHR Incentive Program simply need to "attest" that during a 90-day reporting period, they used a certified EHR and met Stage 1 criteria for meaningful use objectives and clinical quality measures. For the Medicaid EHR Incentive Program, providers will follow a similar process using their state's attestation system. In their first year, practices are required to adopt, implement, or upgrade their EHR to demonstrate meaningful use, and adhere to a few of their state's reporting requirements (for details, visit http://go.cms.gov/MedicaidStateInfo.

But many physicians have found that changing their day-to-day processes to achieve the expectations set by the meaningful use incentive program is easier said than done.

Like Miller, family-practice physician Christopher Tashjian of Western Wisconsin Medical Associates in River Falls and Ellsworth, Wis., said he had to change his routine in order to satisfy CMS' Stage 1 requirement of "clinical summaries for patients for each office visit" for more than 50 percent of patients. Though Tashjian purchased his EHR from Cerner in 2010, making the change required adding a few minutes to each visit in addition to getting used to a new onscreen feature.

"It wasn't part of our normal work routine and normal work flow and it was something that Cerner just implemented," recalls Tashjian.

Reporting-related aggravators

Let's say you've survived the cumbersome process change. Before you pop the champagne, beware of some of these other common aggravators that have delayed payment, triggered error messages, or otherwise slowed the process of attestation altogether:

• Misconstruing language. One CMS measure requires demographics to be taken down for "more than 50 percent of all unique patients seen by the EP (eligible professional)." But Karen Berg, a healthcare executive in Cerner's ambulatory ASP division, recalls at least one of Cerner's provider clients getting an error message during attestation because he thought CMS meant "50 percent or more" when the agency called for "more than 50 percent." The provider had only reached 50 percent.

• Picking quality indicators your EHR doesn't support. As part of Stage 1, CMS requires that 15 core measures and five out of 10 menu-set measures are attested to in order to achieve Medicare EHR incentives. A provider must be careful to purchase a federally certified EHR that is able to report on all of these measures. "An EHR that is federally certified may meet only the bare minimum measurement-reporting requirements to achieve Stage 1 of meaningful use," says Matt Esker, director of the Central Ohio Health Information Exchange (COHIE), central Ohio's regional extension center, adding that the EHR might be federally certified, but may have the designation of "Modular EHR" rather than "Complete EHR." And if the EHR is modular, the provider will be required to purchase additional "add-ons" to achieve meaningful use, Esker says. If you haven't purchased an EHR yet, Esker suggests using the Certified HIT Product List (http://onc-chpl.force.com/ehrcert) to see all federally certified EHRs, the EHR's status as a "complete" or "modular" EHR, and the specific meaningful use criteria that the EHR satisfies.

• Not doing all things in a measure. If a Stage 1 measure calls for a physician to do three things, such as record blood pressure, height, and weight, physicians that only do one or two things may be held up in attestation. If they haven't collected this information, they won't be able to record it. "What we're hearing about now is how some of these specialties, say ophthalmology, will tell us 'only blood pressure is relevant, not height and weight,'" says Sarah Corley, chief medical officer for NextGen Healthcare.

• Your state isn't ready. One of the biggest areas of confusion related to meaningful use attestation that Corley has seen arises with reporting the population health measures: the electronic syndromic surveillance data (so public health departments can track, for example, flu epidemics) and the immunization registry data. Providers have to report one of the two, but to date many states aren't ready to do the testing. "Both of those measures are dependent upon their states or their public health organizations being ready to receive the information in the correct format, and not all states and public health agencies are ready yet," says Corley, who recommends providers contact their regional extension centers to find out whether both public health measures are available to them. If no options are available, they can exclude themselves from those measures when they attest.

• Not hitting financial thresholds. Tashjian says that while he was able to attest, his first payment was delayed several weeks because he didn't have the minimum $24,000 of billable Medicare charges. "The one thing that did surprise me was that just meeting [meaningful use] isn't enough," Tashjian said. Once he got the required billables, the payment was processed automatically and sent to the clinic in a timely manner. The best way avoid this problem is to make sure you're picking the best EHR incentive program for your practice (so, for example, says Esker, if you're an OB/GYN and cannot reach $24,000 in Medicare billable services, you may not want to opt for the Medicare EHR incentive program). Otherwise, be prepared for the possibility of a pro-rated check that's less than what you expected.

• Getting audited. Just like with your taxes, your attestation for meaningful use is subject to audits. CMS and its contractors will perform audits on Medicare and dually eligible (Medicare and Medicaid) providers, while states and their contractors will perform audits on Medicaid providers. To prepare, CMS suggests providers retain all relevant supporting documentation (in either paper or electronic format used in the completion of the attestation module responses) for six years post-attestation. Providers should also retain documentation to support payment calculations (such as cost-report data). If, based on an audit, a provider is found not to be eligible for an EHR incentive payment, the payment will be recouped. A spokesman for CMS confirmed to Physicians Practice that additional information on the appeals process, when available, will be posted to CMS' website.

Getting ahead

EHR-equipped physicians can reduce stress and complications on attestation day by making sure they have everything ready to go days or weeks in advance, says Stefanie Strinko, an implementation specialist with KY REC, the regional extension center for Kentucky. Strinko suggests getting all of the pertinent numbers and passwords you need and putting them in one place.

The list of things to have ready before attestation includes the provider NPI, registration ID, 90-day reports with volume breakdowns, CMS EHR Certification ID, signed AIU contract (for Medicaid attestation), as well as the meaningful use reports providers will be using during attestation, says Strinko.

"It takes about 20 to 30 minutes to go through the attestation process for each provider, so having this information at hand helps the provider get through the process in a timely manner," she says. "Also, by having all needed documents ready, providers know they will not forget a critically important document."

Practices might also want to conduct a pre-attestation check with their physicians.

By doing just that, Miller's practice made unexpected discoveries. Among them: Physicians who were supposed to be e-prescribing 80 percent of the time were e-prescribing 40 percent of the time.

"We had to do a gap analysis where we had to go through each one of our objectives and then go through our reports to make sure we met each of the metrics," says Miller. "I think practices need to go through a methodical, step-wise [process] to understand the objective, to understand the measure, to measure their success in obtaining the measure, and then determining what processes need to be changed to meet the measure."

Marisa Torrieri is an associate editor with Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

This article originally appeared in the January 2012 issue of Physicians Practice.