AUDIT – Part 2: Prepare going into Stage 2!

1)    Just prior to attesting, generate a summary report for each Core and Menu measure with a calculated threshold. This will be used to validate the numbers you enter in the attestation portal. Reports should clearly state the Pro EHR version of the CEHRT (certified electronic health record technology) used to generate the report.

a)    Core measures:

i)     CPOE w/ Drug Interaction Checking*, ePrescribe w/ Drug Formulary*, Demographics, Vital Signs, Smoking, View Download, and Transmit (Timely Access and Online Access), Clinical Summaries, Clinical Lab Tests, Patient Reminders, Patient Education, Medication Reconciliation, Summary of Care, Secure electronic messaging, Immunization Registry, Clinical Decision Support

(1)  Summary of Care measure 3 – evidence that a provider that uses a different EHR received a direct message Referral Summary of Care C-CDA document from the practice.
(2)  Patient Lists (the actual de-identified list of patients including the clinical criteria used)
(3)  Protect electronic health information (Security Risk Assessment): Documentation demonstrating your Security Risk Assessment review for that reporting year and any educational or process changes which occurred during the reporting year to make sure you are maintaining the security of your data. This assessment is outside of the EHR an ideally includes an action plan with responsible parties. It needs to be reviewed and updated regularly within your reporting period. A tip sheet can be located here on the CMS website.

ii)    Qualifying for an exclusion for a core measure is the same as successfully meeting the measure; however, you should still be able to prove why you qualify for the exclusion.

b)    Menu Measures – the three you have chosen from the following:

i)     Electronic Notes, Imaging, Family Health History, Syndromic Surveillance+, Cancer Registry - or Specialized Registry  - .

ii)  -  Not supported by Allscripts Professional EHR as of this posting date. Supplemental certified software would be needed to choose these as menu measures.

+ Most states do not accept syndromic surveillance data from ambulatory providers. 

2)    Optional reports in support of the Yes/No attestation measures

i)     The Non-calculated measure report provides support for the Yes/No attestation answers. Services that are enabled, such as: CDS Recommendations, Drug Interaction Checking, Drug Formulary, Immunization Registry and Syndromic Surveillance* are indicated on this report. You can use this report for validating these measures where on for the duration of the reporting period or screen shots from the product demonstrating the use of these services.

ii)    The CDS recommendations report will validate the provider has chosen at least five recommendations and the associated clinical quality measure number. This report should also validate that these measures correlate with a minimum of four of the nine Clinical Quality Measures chosen.

3)    Clinical Quality Measures – 9 clinical quality measure attestation reports and evidence of submission per CMS direction should be included with this documentation.

4)    Keep this documentation for at least SIX YEARS in at least two formats (saved on your computer, flash drive, external hard drive, printed copy – these are examples of different formats referenced here.

If you think Stage 2 is impossible, please call, it certainly is possible and you shouldn't leave your money on the table!