Step 10: Attest for the Security Risk Analysis Meaningful Use Objective

Think of “Meaningful Use” as the federal government’s proverbial carrot-or-stick approach to driving a data-driven electronic health system.

The carrot: Those who meet benchmarks for Meaningful Use will be eligible for incentives payments for Medicare and Medicaid. And the stick: Those who fall short may face penalties. And what is the end goal? The push is for comprehensive data that can quantify best outcomes, and create standards of care. That is why the rules place so much attention on capturing gritty details of patient care and outcomes.

2015 is the first year of EHR reporting to the Centers for Medicare and Medicaid Services (CMS). Under rule modifications announced in October, providers may, in 2015 only, submit reports reflecting data for any continuous 90-day period – not the full year, as previously announced. Providers may select an EHR reporting period of any continuous 90 day period from January 1, 2015 through December 31, 2015. Eligible hospitals may select an EHR reporting period of any continuous 90 day period from October 1, 2014 to December 31, 2015. A Beginner Reporter Toolkit is included in the resources below.

Meaningful Use objectives are grouped according to five policy-driven priorities:

Improve Quality, Safety, and Efficiency
Engage Patients and Families
Improve Care Coordination
Improve Public and Population Health
Ensure Privacy and Security for Personal Health Information

In applying for incentives, you must legally attest you have met requirements, including the protection of ePHI. The 10 Step Plan from HHS includes this caution:

Do not register and attest for an EHR Incentive program until you have conducted your security risk analysis (or reassessment) and corrected any deficiencies identified during risk analysis.
Document any changes or corrections. Providers participating in the EHR Incentive Program can be audited.

Objectives and Measures

All providers are required to attest to a single set of objectives and measures. For providers, there are 10 objectives, including one public health reporting objective. For eligible hospitals, there are 9 objectives, including one public health reporting objective. In 2015, providers must attest to objectives and measures using EHR technology certified to the 2014 Edition. To assist providers who may have already started working on meaningful use in 2015, changes to the rule include:

Allowing providers who were previously scheduled to be in a Stage 1 EHR reporting period for 2015 to use a lower threshold for certain measures.
Allowing providers to exclude Modified Stage 2 measures in 2015 for which there is no Stage 1 equivalent.

HHS says to start its 10 step plan at least 90 days before the day you you start the EHR incentive program. Click here for the government’s certified product listings to make sure you are using applications that qualify you for incentives.

Tools and Resources for Step 10

Understanding the Incentive Programs

Specification sheets on the requirements:

For Healthcare Providers For Hospitals

HHS tipsheets on 2015 Requirements for the Incentive Programs:

EHR for Eligible Professionals Tipsheet

EHR Incentive Programs Factsheet

View a 3-minute video introduction to EHR Incentive Programs.

EHR Incentive Program Video

More expansive resources

An 85-page guide titled An Introduction to the Medicare EHR Incentive Program for Eligible Professionals. The table of contents includes:

Program Basics:
- What is the EHR Incentive Program?
- What requirements do you have to meet?
Program options:
- How To Participate
Eligibility
Registration
Meaningful Use
- What do you have to do for meaningful use?
- How will certified EHR help you?
- Core Objectives
- Menu Objectives
Clinical Quality Measures
Attestation: How you report to CMS
- What is attestation?
- Steps to Follow
- After you attest
Resources Library

Introduction to Medicare EHR Incentive Program

A 94-page guide titled An Introduction to the Medicaid EHR Incentive Program for Eligible Professionals. Table of Contents includes:

Program Basics:
- What is the Medicaid EHR Incentive Program?
- What requirements do you have to meet?
- What is meaningful use?
How To Participate
Eligibility
Registration
Meaningful Use
- First year participants
- What do you have to do for meaningful use?
- Core Objectives
- Menu Objectives
- Clinical Quality Measures
- How will certified EHRs help you?
Attestation: How You Report to Your State
- What is attestation?
- Steps to follow
- After you attest
Resources Library