Measures Reporting for Eligible Hospitals

AHIMA Meaningful Use White Paper Series
Paper no. 5b

The fourth paper in this series reviewed the EHR certification requirements related to the final rule on meaningful use. This paper returns the focus to the meaningful use rule, offering an overview of the health IT functional measures for eligible hospitals. A companion paper (5a) offers an overview of the requirements for providers.

Eligible hospitals that intend to qualify for the meaningful use EHR incentive program can apply beginning in January 2011. In the first year, they need only demonstrate meaningful use for a 90-day period. This must occur during the federal fiscal year, which runs through September.

Criteria and Objectives

To qualify as a meaningful user an eligible hospital must meet the program’s objectives and their associated measures. Except as otherwise indicated, the objectives must be satisfied by an individual hospital as determined by its unique CMS certification numbers.

CMS received many comments on its proposed rule, published in January 2010, regarding the need to align the Medicaid meaningful use requirements with those of the Medicare program. CMS agreed with this need; however, it reserved the right to make revisions over time, and it supports the ability of states to reinforce their public health priorities and goals. Because of this CMS is willing to reconsider tailoring of certain public health objectives.

CMS originally put forward 27 required measures in the proposed rule. Based on response to the proposal, CMS made adjustments in the final rule allowing hospitals some flexibility in meeting the reporting requirements.

The measures are largely maintained from the proposed rule, but CMS divided them into two categories—core and menu. Eligible hospitals must successfully meet the measures of each of the core set’s 14 objectives.

The menu set includes 10 additional objectives, of which eligible professionals will choose five. The items not chosen will be deferred to stage 2 of the program. A hospital may choose any five objectives, with the caveat that at least one of the menu objectives includes a population and public health measure. CMS encourages eligible hospitals to implement all of the functionalities listed in stage 1, though this is not mandatory.

The core and menu sets appear in an appendix at the end of this paper, with the changes between the proposed and final rules noted.

In addition, AHIMA offers a comprehensive matrix of the certification criteria and meaningful use objectives mapped against the content exchange standards, implementation specifications, and vocabulary standards. This is a member resource, and log in is required.

CMS anticipates all menu objectives in stage 1 to become a part of the core set in stage 2. In addition, it expects to raise the stage 1 thresholds and add new objectives. New goals will go beyond capturing data in electronic format to include the exchange of the data in structured formats. The intent of escalating measures “is to ensure that meaningful use encourages patient-centric, interoperable health information exchange across provider organizations regardless of provider’s business affiliation or EHR platform,” CMS writes.

Measures of Health IT Functionality

As part of its proposed rule, CMS noted that “without a measure for each objective we believe that the definition of meaningful use becomes too ambiguous to fulfill its purpose. The use of measures also creates the flexibility to account for realities of current HIT products and infrastructure and the ability to account for future advances.”

Many of the measures are percentages for which CMS provides a numerator, denominator, and a percentage threshold. In most instances the numerator is the number of activities or functions performed using an EHR. Denominators are based on either unique patients (regardless of whether maintained in the EHR) or counting actions using patients whose records are maintained using EHRs.

The list of meaningful use objectives and measures contained in the final rule provides further rationale and detail on what must be recorded and reported using certified EHR technology (pp. 44326 -69). Not all of the measures are reported with a percentage. For instance, the requirement for implementation of drug-drug, drug-allergy interaction checks only requires that the eligible hospital attest it has enabled the functionality for the entire reporting period.

Clinical decision support rules are another example of a measure that will require attestation, while certain capabilities such as exchange of electronic information requires attestation that the system has been tested (and not necessarily that an ongoing exchange is under way). Hospitals will have to develop audit trails of these attestations, as it is expected that audits will occur and all meaningful use-related documentation must be kept for six years.

Privacy and Security Requirements

A priority of the meaningful use program is to “ensure adequate privacy and security protections for personal health information.” The measure requires that the hospital complete a security risk analysis as prescribed under the HIPAA security rules and correct identified security deficiencies as part of its risk management process. HIPAA requires that such risk assessments be made periodically.

In this case, such an assessment would not only include security as it relates to the EHR, EHR modules, and other technology, but also the full hospital system that is affected by the increase or introduction of EHR technology as required for meaningful use.

Hospitals should also note that on July 14, 2010, the Office for Civil Rights issued a notice of proposed rulemaking as required under the HITECH proposing modifications to the HIPAA privacy, security, and enforcement rules.

Measures reporting for eligible hospitals is covered in paper 5a of this series.

Download a PDF version of this paper. For more ARRA resources, visit AHIMA’s Advocacy and Public Policy Center.

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The White Paper Series
1. Overview of the Meaningful Use Final Rule 5b. Measures Reporting for Eligible Hospitals
2. Meaningful Use—Provider Requirements 6a. Clinical Quality Measures for Providers
3. Meaningful Use—Payments and Requirements 6b. Clinical Quality Measures for Hospitals
4. Meaningful Use and EHR Certification 7. Qualifying for Meaningful Use
5a. Measures Reporting for Eligible Providers 8. Preparing for Meaningful Use

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