NY Medicaid EHR Incentive Program

Public Health Frequently Asked Questions (FAQs)

  • FAQs is also available in Portable Document Format (PDF)

Updated January 2022

MU Public Health Objective Support Team
MUPublicHealthHELP@health.ny.gov
1-877-646-5410 Option 3

Contents

Disclaimer

This document serves as an informational reference for Eligible Providers participating in the NY Medicaid or Medicare EHR Incentive Programs. Although reasonable effort has been made to assure the accuracy of the information within these pages at the time of posting, it is the responsibility of each provider to comply with the current policies and requirements of the program.

1. MEANINGFUL USE PUBLIC HEALTH REPORTING MEASURES

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1.3 If an Eligible Provider qualifies for an exclusion from a Public Health Reporting Measure, does excluding count as meeting that measure for the Meaningful Use (MU) Public Health Reporting Objective?

Published: 09/28/2015

Updated: N/A

No, an exclusion from a Public Health Reporting Measure does not count as meeting that measure for the Meaningful Use (MU) Public Health Reporting Objective. If the Eligible Provider qualifies for multiple exclusions and the remaining number of measures available to the Eligible Provider is less than the number of measures the Eligible Provider is required to meet for the MU Public Health Reporting Objective, then the Eligible Provider should meet any Public Health Reporting Measures for which they are qualified and claim the proper exclusions for the remaining measures.

Ex. If an Eligible Professional (EP) in Modified Stage 2 qualified for an exclusion from one of three available public health measures, then the EP would be required to meet the two remaining available measures. However, if the EP qualified for an exclusion from two of the three available public health measures, then the EP would only be required to meet the one remaining available measure.

For additional information on exclusion criteria for each Public Health Reporting Measure, please review the detailed registry information at the Meaningful Use Public Health Reporting Website.

Additional Resources:

1.4 Our Eligible Hospital´s (EH) laboratory unit does not perform laboratory tests for reportable conditions. All laboratory tests for reportable conditions are outsourced to an external laboratory and the laboratory results are then sent directly from the laboratory to NYSDOH. Will the EH meet the Electronic Reportable Laboratory Result Reporting measure requirements to attest to Meaningful Use?

Published: 08/20/2014

Updated: 9/26/17

The EH can be excluded from the Electronic Reportable Laboratory Result Reporting measure if no reportable laboratory testing is performed in the Hospital setting. This guidance may be subject to change based on Public Health Law and/or Public Health reporting policies.

An EH that can be excluded, for the reason stated above, should indicate the following exclusion in MEIPASS when attesting:

  • 1.4.1 Meaningful Use Stage 1 and Stage 2:
    • Operates in a jurisdiction for which no public health agency is capable of accepting the specific ELR standards required to meet the CEHRT definition at the start of their EHR reporting period.
  • 1.4.2 Meaningful Use Modified Stage 2 or Stage 3:
    • Does not perform or order laboratory tests that are reportable in their jurisdiction during the EHR reporting period.

Additional Resources:CMS FAQ

1.6 When should an Eligible Provider engage in registration and onboarding or claim an exclusion for a given Public Health Reporting Measure?

Published: 07/08/2014

Updated: 09/28/16

A Public Health registry´s policies may restrict a provider from onboarding beyond initial registration, however it is the NY Medicaid EHR Incentive Program´s stance that all Eligible Providers who have appropriate data should register intent to submit data before or within 60 days of the start of their EHR Reporting Period. Based on the registry´s onboarding policies Eligible Providers may not be invited to further participate in the onboarding process, but they will have successfully met the Public Health Reporting Measure requirement by achieving the status Active Engagement Option 1 - Completed Registration to Submit Data.

Eligible Providers who do not have appropriate or relevant data to submit to Public Health should instead claim an exclusion or pick another Public Health Reporting Measure.

Note: It is highly recommended that all providers review a Public Health Reporting Measure´s exclusions to see if they appropriately meet the exclusion criteria.

1.7 As an Eligible Provider, I would like to submit data to a registry outside of the New York State Department of Health (NYSDOH) and New York City Department of Health and Mental Hygiene (NYC DOHMH) Public Health Agencies to satisfy the Meaningful Use Measures. Is this allowed in the NY Medicaid EHR Incentive Program?

1.7.1 Modified Stage 2 (2015-2017)

Published: 03/16/2015

Updated: 01/13/16

The Centers for Medicare and Medicaid Services (CMS) Meaningful Use Stage 3 and Modifications to Meaningful Use in 2015 Through 2017 Final Rule DOES NOT restrict Eligible Providers from working with specialized registries outside of the NYSDOH and NYC DOHMH Public Health Agencies to satisfy the Meaningful Use Specialized Registry Reporting measure.

CMS has stated in the CMS Meaningful Use Stage 2 Final Rule Comments, "We are purposefully general in our description of specialized registry because we do not wish to exclude certain registries in an attempt to be more specific. The only limitation we place on our description of specialized registries is that the specialized registry cannot be duplicative of any of the other registries included in other meaningful use objectives and measures." (CMS Meaningful Use Stage 2 Final Rule, Vol. 77/No. 171/54030)

In the Stage 3 and Modification to Meaningful Use in 2015 Through 2017 Final Rule, CMS states, "We further note that we have previously supported the inclusion of a variety of registries under the specialized registry measure...We agree that a variety of registries may be considered specialized registries, which allows providers the flexibility to report using a registry that is most helpful to their patients. Therefore, we will continue to allow these registries to be considered specialized registries for purposes of reporting the EHR Reporting period in 2015, 2016, and 2017." (CMS Stage 3 and Modifications to Meaningful Use in 2015 Through 2017 Final Rule, Vol. 80/No. 200/62822-62823)

Does the Specialized Registry need to be operated by the NYSDOH and NYC DOHMH Public Health Agencies or a national medical specialty organization?

CMS further explains in the Meaningful Use Stage 2 Final Rule Comments, "... Specialized registries that can be used to satisfy the measure...are not limited only to reporting to registries operated by Public Health Agencies or national medical specialty organizations. Specialized registries operated by patient safety organizations and quality improvement organizations also enable knowledge generation or process improvement regarding the diagnosis, therapy and prevention of various conditions that affect a population." (CMS Meaningful Use Stage 2 Final Rule, Vol. 77/No. 171/54030)

What support services do the NY Medicaid EHR Incentive Program and Public Health Objective Support Teams offer to Eligible Providers working with Public Health Registries outside the NYSDOH and NYC DOHMH Public Health Agencies?

The NY Medicaid EHR Incentive Program and Public Health Objective Support Teams do not provide registration, administrative onboarding, compliance, or audit support to Eligible Providers satisfying a Public Health Reporting Measure when leveraging a registry outside the NYSDOH and NYC DOHMH Public Health Agencies.

Please be aware that as an Eligible Professional, you are responsible for:

  • Meeting Public Health Reporting Objective onboarding deadlines such as registering intent to submit data within 60 days of the start of one´s EHR Reporting Period.
  • Securing documentation such as registration, testing and submission of production data confirmations from each registry to support any potential pre-payment and/or post-payment audits.
  • Engaging and testing with the registry to achieve the submission of production data.
  • Saving audit documentation for up to six years after an EHR Incentive Payment is approved.

Additional Resources:

1.7.2 Stage 3 (2017-2021)

Published: 09/28/2016

Updated: N/A

For Stage 3, Specialized Registry Reporting has been categorized into two separate measures, Public Health Registry Reporting and Clinical Data Registry Reporting. See the definitions below of a Public Health Registry and Clinical Data Registry:

  1. Public Health Registry: A registry that is administered by, or on behalf of, a local, state, territorial, or national public health agency and which collects data for public health purposes.
  2. Clinical Data Registry: A registry that is administered by, or on behalf of, other non-public health agency entities.

The Centers for Medicare and Medicaid Services (CMS) Meaningful Use Stage 3 and Modifications to Meaningful Use in 2015 Through 2017 Final Rule DOES NOT restrict Eligible Providers from working with public health registries outside of the NYSDOH and NYC DOHMH Public Health Agencies to satisfy the Meaningful Use Public Health Registry Reporting Measure.

Currently, the 2015 ONC Final Rule has defined specific certification criteria for Transmission to Cancer Registries, Transmission to PHA - Health Care Surveys, and Transmission to PHA - Antimicrobial Use and Resistance. In addition to reporting cancer cases to the New York State Cancer Registry (NYSCR), Eligible Providers can report to the CDC for National Health Care Surveys and Antimicrobial Use and Resistance.

In addition, please see the MU Stage 3 - Public Health Registry Reporting Grandfathering Regulation for information on meeting the Public Health Registry Reporting Measure through submitting production data to a Specialized Registry.

Please note that the NY Medicaid EHR Incentive Program and Public Health Objective Support Teams do not provide registration, administrative onboarding, compliance, or audit support to Eligible Providers satisfying a Public Health Reporting Measure when leveraging a registry outside the NYSDOH and NYC DOHMH Public Health Agencies.

Please be aware that as an Eligible Provider, you are responsible for:

  • Meeting Public Health Reporting Objective onboarding deadlines such as registering intent to submit data within 60 days of the start of one´s EHR Reporting Period.
  • Securing documentation such as registration, testing and submission of production data confirmations from the respective Public Health Registry to back any potential pre-payment and/or post-payment audits.
  • Engaging and testing with the Public Health Registry to achieve the submission of production data.
  • Saving audit documentation for up to six years after an EHR Incentive Payment is approved.

Additional Resources:

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3. REGISTRIES & CERTIFIED EHR TECHNOLOGY (CEHRT)

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3.1 The healthcare practitioners in our practice or hospital system immunize across New York State and New York City Public Health jurisdictions, which registry do I report to?

Published: 01/05/2016

Updated: 05/12/2016

If a healthcare practitioner immunizes across New York State and New York City Public Health jurisdictions then it is required under Public Health Law Article 21, Title 6, (3a) that immunizations be reported to the respective registries in which the immunizations have taken place.

  • Immunizations performed outside the five boroughs of New York City will be reported to the New York State Immunization Information System (NYSIIS).
  • Immunizations performed inside the five boroughs of New York City will be reported to Citywide Immunization Registry (CIR).

If you are a healthcare practitioner who performs immunizations across jurisdictions, please refer to Public Health FAQ #2.5 for details on how to register when the organization spans jurisdictions.

3.2 Do I need to report immunization data for 19 years and older patients to be deemed a "Meaningful User" of Certified EHR Technology?

Published: 05/10/2013

Updated: 12/11/2015

To be considered a Meaningful User of Certified EHR Technology (CEHRT), the NY Medicaid EHR Incentive Program requires that a provider reports all immunizations data for persons less than 19 years of age and for those 19 years of age or older when the express verbal or written consent is given by the vaccinee.

The NY Medicaid EHR Incentive Program requests that providers offer verbal or written "Consent for Participation" to vaccinees´ 19 years of age or older. If consent is granted, the vaccinee´s immunization data and history must be submitted to the correct immunization registry.

19 Years of Age or Older Consent Forms

Immunization Reporting Resources

3.3 I am an Eligible Professional (EP) who treats adult patients and rarely administers immunizations. Should I plan to attest "yes" to the Meaningful Use Immunization Registry Reporting measure or claim an exclusion under the criterion "the EP does not administer any immunizations to any of the populations for which data is collected by their jurisdiction´s immunization registry or immunization information system during the EHR reporting period"?

Published: 07/08/2015

Updated: 09/28/2016

In order to determine whether it would be appropriate to attest "yes" or claim an exclusion to the Immunization Registry Reporting measure, the NY Medicaid EHR Incentive Program suggests you consider the following questions:

  1. Will the EP administer any immunizations during the EHR Reporting Period?
    • If NO: If the EP does not administer any immunizations during the EHR Reporting Period, he/she is eligible to claim an exclusion.
    • If YES: If the EP does administer immunizations during the EHR Reporting Period, continue to question 2.
  2. If the EP will administer immunizations during the EHR Reporting Period, will the immunizations be administered to patients who are 18 years of age and younger, or 19 years of age and older?
    • If 18 years of age and younger: If the EP does administer immunizations during the EHR Reporting Period to patients who are 18 years of age or younger, the EP cannot claim an exclusion and Public Health Law requires that the immunization be reported to the Citywide Immunization Registry (CIR) if administered within the five boroughs of New York City or to the New York State Immunization Information System (NYSIIS) if administered outside of the five boroughs.*
    • If 19 years of age and older: CIR and NYSIIS also accept immunization records for patients who are 19 years of age or older as long as the patient gives consent for the immunization to be reported and consent is captured in the record. Continue to question 3.
  3. If the EP will be administering immunizations to patients aged 19 years and older, is there a process in place to seek patient consent to report the immunization record and does the Certified EHR Technology (CEHRT) capture that consent?
    • If YES: If the EP does administer immunizations during the EHR Reporting Period to patients who are 19 years of age or older, receives patient consent to report the immunization, and records consent in the CEHRT, the EP cannot claim an exclusion. Such immunization records are accepted by the CIR and NYSIIS.*
    • If NO: If the EP only administers immunizations to patients aged 19 years or older and patient consent is not sought and captured, such immunization records are prohibited from being reported, and the EP may claim an exclusion.

* Please note, EPs who intend to attest "yes" to any Public Health Reporting Measure must register their intent before or within 60 days of the start of the EHR Reporting Period in the Meaningful Use Registration for Public Health (MURPH) System.

Additional Resources:

3.4 We are using Certified EHR Technology (CEHRT) to generate HL7 messages for submission to a public health registry. We use an interface engine or other intermediary such as a health information exchange (HIE) to modify messages to meet the registry´s requirements. Does the interface engine or HIE need to be certified by ONC in order for us to be in compliance with the public health reporting objective?

Published: 10/22/2014

Updated: N/A

If the HL7 message is generated by CEHRT and slight modifications are made by the interface engine or health information exchange (HIE) to meet requirements of the public health registry (ex: including a calculated value from a field or including a field that is required by the public health registry, but is optional in the national implementation guide), the intermediary technology does not have to be certified by ONC in order for the message to be in compliance with Meaningful Use requirements.

However, if the Hl7 message is generated by CEHRT and the message is modified by the interface engine or health information exchange (HIE) such that the message structure no long adheres to the national implementation guide/certification standards, the message produced would not be in compliance with Meaningful Use requirements.

In an alternate scenario, if an HL7 message is generated by non-certified EHR technology and transformed by an intermediary to meet the public health registry´s requirements, the intermediary must be certified by ONC in order for the message to be in compliance with Meaningful Use requirements.

Additional Resource: ONC Regulations FAQ #18

3.5 What data are collected by Eligible Professionals who intend to meet the Syndromic Surveillance Reporting Measure?

Published: 02/12/2016

Updated: 9/26/2017

As of the start of 2016, the New York City Department of Health and Mental Hygiene (NYC DOHMH) collects Syndromic Surveillance data from Eligible Professionals (EPs) practicing at an urgent care center within the five boroughs of NYC. The data must be structured in accordance with NYC-specific HL7 v2.5.1 message requirements, which are based largely on the PHIN Messaging Guide for Syndromic Surveillance.

The surveillance data collected by NYC DOHMH include the following syndromes: respiratory, vomiting, diarrhea, influenza-like-illness, fever, and asthma.

As of the January 1, 2017, the New York State Department of Health (NYSDOH) collects Syndromic Surveillance data from EPs practicing at an urgent care center outside the five boroughs of NYC. The data must be structured in accordance in accordance with New York State HL7 Message Requirements for Syndromic Surveillance Reporting.

The NYSDOH collects syndromic surveillance data from EPs, which includes the following syndromes: asthma, carbon monoxide, drug overdose, fever, gastrointestinal infection, heatwave, heroin overdose, hypothermia, neurological, rash, respiratory, and synthetic drugs.

Additional Information: CMS FAQ

3.6 I am an Eligible Professional (EP) who has previously met the Syndromic Surveillance Reporting Measure by reporting aggregate count influenza-like-illness (ILI) data to the Primary Care Information Project (PCIP), a bureau of the New York City Department of Health and Mental Hygiene (NYC DOHMH). However, CMS FAQ states that NYC DOHMH is now collecting Syndromic Surveillance data from EPs at urgent care centers in order to satisfy the measure. How does my reporting aggregate count ILI now count towards the Meaningful Use Public Health Reporting requirements?

Published: 02/12/2016

Updated: 09/28/2016

In October of 2012, PCIP began collecting aggregate count ILI data from EPs demonstrating Meaningful Use (MU) who practice within the five boroughs of NYC. Engagement with PCIP - including the submission of one or more test messages, additional testing and validation, or the submission of production ILI data - satisfied the Syndromic Surveillance Reporting Measure for MU Stage 1, MU Stage 2, and Modified Stage 2 in 2015.

To align with the CMS definition of EP Syndromic Surveillance included in the Stage 3 Final Rule, in January of 2016 the NYC DOHMH began accepting Syndromic Surveillance data from EPs demonstrating MU who practice at an urgent care center within the five boroughs of NYC. Engagement with the NYC DOHMH towards the submission of production ambulatory Syndromic Surveillance data (including registering intent within 60 days of the start of the EP´s EHR Reporting Period) or the submission of production ambulatory Syndromic Surveillance data will satisfy the Syndromic Surveillance Reporting Measure for Modified Stage 2 in 2016 and future years.

For EPs demonstrating MU who practice within the five boroughs of NYC and have been submitting production ILI data or wish to begin submitting ILI data, engagement with the NYC DOHMH Population Health Registry will satisfy the Modified Stage 2 Specialized Registry Reporting Measure in 2016 and 2017. EPs who achieve Active Engagement Option 3 - Production under the Modified Stage 2 Specialized Registry Reporting Measure may be eligible to continue to count this engagement towards Meaningful Use Stage 3 Public Health Reporting requirements.

Additional Information:

3.7 What is the Population Health Registry?

Published: 06/21/2016

Updated: 01/04/2019

The Population Health Registry is a specialized registry used by the New York City Department of Health and Mental Hygiene to support public health, epidemiologic, quality, and utilization programs. The registry data is used to assess acute and chronic health conditions and disparities across the NYC population. Eligible Professionals (EPs) who practice in the 5 boroughs of New York City may report data to the Population Health Registry to meet the Specialized Registry Reporting Measure under the Meaningful Use Public Health Reporting Objective.

As of December 31, 2018, the Population Health Registry stopped accepting registrations and onboarding EPs. The registry continues to collect data from EPs who were already submitting production level data.

Additional Resources:

3.8 What data are collected from Eligible Professionals who are or intend to be engaged with the Population Health Registry at the New York City Department of Health and Mental Hygiene (NYC DOHMH) in order to meet the Specialized Registry Reporting Measure?

Published: 06/21/2016

Updated: N/A

Eligible Professionals (EPs) who practice in the 5 boroughs of New York City may report data to the Population Health Registry to meet the Specialized Registry Reporting Measure. The Population Health Registry currently recognizes the following reporting options and transmission standards. If new transmission options are added, providers will be given sufficient time to work with their EHR vendor to demonstrate active engagement for their required reporting period.

  1. Aggregate influenza-like-illness (ILI) surveillance data
  2. EPs using eClinicalWorks electronic health record (EHR) can join the Macroscope/Hub Population Health Network for no cost. Membership includes feedback on performance of key health conditions. See the NYC Macroscope Website for more information. This option is not available to EPs using other EHR vendors.

Additional Resources:

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4. MU PUBLIC HEALTH REPORTING STATUS & COMPLIANCE

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4.2 How does an Eligible Provider determine one´s current status when engaged in the registration and onboarding process?

Published: 07/08/2014

Updated: 01/07/2022

An Eligible Provider´s onboarding status will be tracked by each registry. The registries will send notifications to the provider as the status updates or changes. These notifications should be kept for at least 6 years within the provider´s supporting documentation file.

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5. ARCHIVED PUBLIC HEALTH FAQS

Please see the Archives section of the website for all of the archived FAQs.

6. CMS PUBLIC HEALTH FAQS

Below is a list of CMS FAQs related to Public Health Reporting. These have been compiled for quick reference, but all of the below CMS FAQs are referenced from the FAQ document on the CMS website, which is located here.

DISCLAIMER: As a reminder, that although reasonable effort has been made to assure the accuracy of the information below, it is the responsibility of each provider to comply with the current policies and requirements of the program.

Content

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6.1 Public Health and Certified EHR Technology

6.1.1 CMS FAQ 2809 What is the purpose of certified electronic health record (EHR) technology?

Certification of EHR technology will provide assurance to purchasers and other users that an EHR system or product offers the necessary technological capability, functionality, and security to help them satisfy the meaningful use objectives for the Medicare and Medicaid EHR Incentive Programs. Providers and patients must also be confident that the electronic health information technology (IT) products and systems they use are secure, can maintain data confidentially, and can work with other systems to share information. Confidence in health IT systems is an important part of advancing health IT system adoption and realizing the benefits of improved patient care.

6.1.2CMS FAQ 2811 How do I know if my electronic health record (EHR) system is certified? How can I get my EHR system certified?

The Medicare and Medicaid EHR Incentive Programs require the use of certified EHR technology, as established by a new set of standards and certification criteria. Existing EHR technology needs to be certified by an ONC Authorized Testing and Certification Body (ONC-ATCB) to meet these new criteria in order to qualify for the incentive payments. The Certified Health IT Product List (CHPL) is available at http://www.healthit.hhs.gov/CHPL.

This is a list of complete EHRs and EHR modules that have been certified for the purposed of this program. A provider may use a single product or a combination of products and/or models to meet the requirements.

6.1.3 CMS FAQ 2893 Must providers have their electronic health record (EHR) technology certified prior to beginning the EHR reporting period in order to demonstrate Meaningful Use under the Medicare and Medicaid EHR Incentive Programs?

No. An EP or hospital may begin the EHR reporting period for demonstrating Meaningful Use before their EHR technology is certified. Certification need only be obtained prior to the end of the EHR reporting period. However, Meaningful Use must be completed using the capabilities and standards outlined in the ONC Standards and Certification Regulation for certified EHR technology. Any changes to the EHR technology after the beginning of the EHR reporting period that are made in order to get the EHR technology certified would be evidence that the provider was not using the capabilities and standards necessary to accomplish Meaningful Use because those capabilities and standards would not have been available, and thus, any such change (no matter how minimal) would disqualify the provider from being a meaningful EHR user. If providers begin the EHR reporting period prior to certification of their EHR technology, they are taking the risk that their EHR technology will not require any changes for certification. Any changes made to gain certification must be done prior to the beginning of the EHR reporting period during which Meaningful Use will be demonstrated. This does not apply to changes made to EHR technology that were not necessary for certification.

6.1.4 CMS FAQ 3369 If my certified electronic health record (EHR) technology is capable of submitting batch files to an immunization registry using the standards adopted by the Office of the National Coordinator of Health Information Technology, is that sufficient to meet the Meaningful Use objective "submit electronic data to immunization registries" for the Medicare and Medicaid EHR Incentive Programs?

Submitting batch files to an immunization registry, provided that they are formatted according to the standards adopted by the Office of the National Coordinator of Health Information Technology, is sufficient to meet the Public Health Reporting objective measure 1, Immunization Registry reporting. However, if a provider within the group does not administer immunizations, they should not attest to meeting the measure; they must instead claim the exclusion. If a provider within the group does administer immunizations, but did not have any for a particular EHR reporting period, they are not required to claim the exclusion as long as they have done any necessary registration and testing and are reporting when they do have the data to report. (See FAQ #11984)

6.1.5 CMS FAQ 11982 If an eligible professional (EP) or hospital meets an exclusion for a public health objective, does the EP or hospital need to have CEHRT that meets the certification criteria related to that public health objective?

If the EP or hospital qualifies for and attests to an exclusion for a public health measure, they would not need to have CEHRT that meets the certification criteria related to that public health objective. For example, if an EP does not give any immunizations during their EHR reporting period, they would not need to have CEHRT that meets the certification criteria related to the immunization reporting objective in order to attest to the exclusion. However, if the EP or hospital qualifies for an exclusion, but elects to try to meet objective, they would need to have and use CEHRT that meets the certification criteria for the objective.

6.2 Meeting Meaningful Use Public Health Reporting Measures

6.2.1 CMS FAQ 2883 If an eligible professional (EP) is unable to meet the measure of a Meaningful Use objective because it is outside of the scope of his or her practice, will the EP be excluded from meeting the measure of that objective under the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs?

Some Meaningful Use objectives provide exclusions and others do not. Exclusions are available only when our regulations specifically provide for an exclusion. EPs may be excluded from meeting an objective if they meet the circumstances of the exclusion. If an EP is unable to meet a Meaningful Use objective for which no exclusion is available, then that EP would not be able to successfully demonstrate Meaningful Use and would not receive incentive payments under the Medicare and Medicaid EHR Incentive Programs.

6.2.2 CMS FAQ 6097 I entered numerator and denominator information during my Medicare Electronic Health Record (EHR) Incentive Program attestation from my certified EHR technology, but subsequently discovered that the method of calculation included in the software was flawed. The software vendor has updated the reports. If CMS audits me, will I be held responsible for the difference between what I reported and what the updated software calculates?

CMS does not plan to conduct an audit to find providers who relied on flawed software for their attestation information. We realize that providers relied on the software they used for accuracy of reporting, and we believe that most providers who were improperly deemed meaningful users would have met the requirements of the EHR Incentive Programs using the updated certified EHR technology.

6.2.3 CMS FAQ 11964 To meet public health objectives in the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs, must providers register their intent to submit data for Stage 2 of Meaningful Use during each year of participation to meet the measure?

No. Providers only need to register once, with the Public Health Agency (PHA) or other body to whom the provider will be submitting data, to indicate their intent to initiate ongoing submission of data to meet a public health objective. If in subsequent years of participation, providers have not progressed into testing and validation or ongoing submission (i.e. production) status, the documentation of the initial registration of intent may be used for attestation. PHAs may periodically ask providers to verify or update the information from the initial registration. PHAs use the information collected to manage communication and prioritization of their onboarding processes.

6.2.4 CMS FAQ 11978 For the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs that require submission of electronic data to Public Health Agencies (PHA), can a provider meet the objective even though they may not have successfully submitted data to the PHA for their entire EHR reporting period?

Eligible professionals (EP) and hospitals may satisfy these objectives if they meet one of the four criteria for ongoing submission: 1. Ongoing submission was already achieved for an EHR reporting period in a prior year and continues throughout the current EHR reporting period. 2. Registration with the PHA or other body to whom the information is being submitted or intent to initiate ongoing submission was made by the deadline (within 60 days of the start of the EHR reporting period) and ongoing submission was achieved. 3.Registration of intent to initiate ongoing submission was made by the deadline and the EP or hospital is still engaged in testing and validation of ongoing electronic submission. 4. Registration of intent to initiate ongoing submission was made by the deadline and the EP or hospital is awaiting invitation to begin testing and validation. Providers that meet the last two of these criteria would not have achieved ongoing submission during their EHR reporting period. In addition, providers that meet the second criteria may not have ongoing submission for their entire EHR reporting period. In order to meet the objective, providers who have been invited by the PHA to begin the onboarding process must participate in that process. Providers who fail to participate in the onboarding process as demonstrated by failure to respond to the PHA written requests for action within 30 days on two separate occasions during their EHR reporting period would not meet the objective

6.2.5 CMS FAQ 11984 If an eligible professional (EP) in the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs is part of a group practice that has achieved ongoing submission to a public health agency (PHA), but the EP himself/herself did not administer any immunizations to any of the populations for which data is collected by their jurisdiction´s immunization registry during their EHR reporting period, can he/she attest to meeting the measure since they are part of the group practice that is submitting data to the registry?

If a provider does not administer immunizations, they should not attest to the measure; they must claim the exclusion. If a provider does administer immunizations, but did not have any for a particular EHR reporting period, they are not required to claim the exclusion as long as they have done any necessary registration and testing and are reporting when they do have the data to report.

6.2.6 CMS FAQ 12657 What if your product is decertified?

If your product is decertified, you can still use that product to attest if your EHR reporting period ended before the decertification occurred. If your EHR reporting period ended after the decertification occurred, you can apply for a hardship exception. If the decertification occurs after the hardship exception period has already closed for the payment adjustment year which would be applicable for your reporting period, please contact CMS Hardship Coordinator at EHRinquiries@cms.hhs.gov to apply for a hardship exception under the Extreme and/or Uncontrollable Circumstances category per CMS discretion to allow such an application. Also, if you are a first time participant at a group practice which is switching products and the product is decertified after the hardship deadline, contact CMS at EHRinquiries@cms.hhs.gov.

6.2.7 CMS FAQ 13413 Does integration of the PDMP (Prescription Drug Monitoring Program) into an EHR count as a specialized registry?

If the PDMP within a jurisdiction has declared itself a specialized registry ready to accept data, then the integration with a PDMP can count towards a specialized registry. The EHR must be CEHRT, but there are no standards for the exchange of data.

6.2.8 CMS FAQ 13653 What can count as a specialized registry?

A submission to a specialized registry may count if the receiving entity meets the following requirements: The receiving entity must declare that they are ready to accept data as a specialized registry and be using the data to improve population health outcomes. Until such time as a centralized repository is available to search for registries, most public health agencies and clinical data registries are declaring readiness via a public online posting. Registries should make this information publicly available for potential registrants. The receiving entity must also be able to receive electronic data generated from CEHRT. The electronic file can be sent to the receiving entity through any appropriately secure mechanism including, but not limited to, a secure upload function on a web portal, FTP, or Direct. Manual data entry into a web portal would not qualify for submission to a specialized registry. The receiving entity should have a registration of intent process, a process to take the provider through test and validation and a process to move into production. The receiving entity should be able to provide appropriate documentation for the sending provider or their current status in Active Engagement. For qualified clinical data registries, reporting to a QCDR may count for the public health specialized registry measure as long as the submission to the registry is not only for the purposes of meeting CQM requirements for PQRS or the EHR Incentive Programs. In other words, the submission may count if the registry is also using the data for a public health purpose. Many QCDRs use the data for a public health purpose beyond CQM reporting to CMS. A submission to such a registry would meet the requirement for the measure if the submission data is derived from CEHRT and transmitted electronically.

6.2.9 CMS FAQ 13657 What steps does a provider have to take to determine if there is a specialized registry available for them, or if they should instead claim an exclusion?

The eligible professional (EP) is not required to make an exhaustive search of all potential registries. Instead, they must do a few steps to meet due diligence in determining if there is a registry available for them, or if they meet the exclusion criteria. An EP should check with their State* to determine if there is an available specialized registry maintained by a public health agency. An EP should check with any specialty society with which they are affiliated to determine if the society maintains a specialized registry and for which they have made a public declaration of readiness to receive data for meaningful use no later than the first day of the provider´s EHR reporting period. If the EP determines no registries are available, they may exclude from the measure. The provider may meet the specialized registry measure up to 2 times. This can be done through reporting to:

  • Two registries maintained by one or more specialty societies
  • One registry maintained by a public health agency and one maintained by a specialty society
  • One registry maintained by a public health agency and one exclusion
  • One registry maintained by a specialty society and one exclusion

PLEASE NOTE: In 2015, providers may also simply claim an alternate exclusion for a measure as defined in CMS FAQ.

*If you report to an entity other than a State as your reporting jurisdiction (such as a county) you may elect to check with them.

6.2.10 CMS FAQ 14117 What steps do eligible hospitals and Critical Access Hospitals need to take to meet the specialized registry objective? Is it different from EPs?

For an eligible hospital or Critical Access Hospitals (CAHs), the process is the same as for an EP. The eligible hospital or CAH should check their State* and any such organization or specialty society with which they are affiliated to determine if that entity maintains a specialized registry and for which they have made a public declaration of readiness to receive data for meaningful use no later than the first day of the provider´s EHR reporting period. However, we note that eligible hospitals or CAHs do not need to explore every specialty society with which their hospital-based specialists may be affiliated. The hospital may simply check with their State* and any such organization with which it is affiliated, and if no registries exist, they may simply exclude from the measure. For further information please see CMS FAQ.

The provider may meet the specialized registry measure up to 3 times. This can be done through reporting to:

  • Three registries maintained by a public health agency
  • Three registries maintained by one or more specialized societies
  • One or two registries maintained by a public health agency and two or one maintained by a specialty society
  • Two registries maintained by a public health agency and one exclusion
  • Two registries maintained by a specialty society and one exclusion
  • One registry maintained by a public health agency and one registry maintained by a specialty society and one exclusions*
  • One registry maintained by a public health agency and two exclusions*
  • One registry maintained by a specialty society and two exclusions*

*In these cases, the exclusion which overlaps a category of registries would be based on there being no additional option for reporting beyond those already selected by the eligible hospital or CAH. In 2015, providers may also simply claim an alternate exclusion for a measure as defined in CMS FAQ.

*If you report to an entity other than a State as your reporting jurisdiction (such as a county) you may elect to check with them.

6.2.11 CMS FAQ 14393 Can a provider register their intent after the first 60 days of the reporting period in order to meet the measures if a registry becomes available after that date?

If a registry declares readiness at any point in the calendar year after the initial 60 days, a provider may still register their intent to report with that registry to meet the measure under Active Engagement Option 1. However, a provider who could report to that registry may still exclude for that calendar year if they had already planned to exclude based on the registry not being ready to allow for registrations of intent within the first 60 days of the reporting period.

6.2.12 CMS FAQ 14397 What should a provider do in 2016 if they did not previously intend to report to a public health reporting measure that was previously a menu measure in Stage 2 and they do not have the necessary software in CEHRT or the interface the registry requires available in their health IT systems? What if the software is potentially available but there is a significant cost to connect to the interface?

In the 2015 EHR Incentive Programs Final Rule, we stated that we did not intend for providers to be inadvertently penalized for changes to their systems or reporting made necessary by the provisions of that regulation. This included alternate exclusions for providers for certain measures in 2016 which might require the acquisition of additional technologies they did not previously have for measures they did not previously intend to include in their activities for meaningful use (80 FR 62945). Therefore, in order that providers are not held accountable to obtain and implement new or additional systems, we will allow providers to claim an alternate exclusion from certain public health reporting measures in 2016 if they did not previously intend to report to the Stage 2 menu measure.

Additional Information:

6.2.13 CMS FAQ 14401 For 2016, what alternate exclusions are available for the public health reporting objective? Is there an alternate exclusion available to accommodate the changes to how the measures are counted??

We do not intend to inadvertently penalize providers for changes to their systems or reporting made necessary by the provisions of the 2015 EHR Incentive Programs Final Rule. This includes alternate exclusions for providers for certain measures in 2016 which might require the acquisition of additional technologies they did not previously have or did not previously intend to include in their activities for meaningful use (80 FR 62945). For 2016, EPs scheduled to be in Stage 1 or Stage 2 must attest to at least 2 measures from the Public Health Reporting Objective Measures 1-3 and eligible hospitals or CAHs scheduled to be in Stage 1 or Stage 2 must attest to at least 3 public health measures from the Public Health Reporting Objective Measures 1-4. We will allow providers to claim an alternate exclusion for the Public Health Reporting measure(s) which might require the acquisition of additional technologies providers did not previously have or did not previously intend to include in their activities for meaningful use. We will allow Alternate Exclusions for the Public Health Reporting Objective in 2016 as follows:

  • EPs scheduled to be in Stage 1 and Stage 2:
    • Must attest to at least 2 measures from the Public Health Reporting Objective Measures 1-3
    • May claim an Alternate Exclusion for Measure 2 and Measure 3 (Syndromic Surveillance and Specialized Registry Reporting).
    • An Alternate Exclusion may only be claimed for up to two measures, then the provider must either attest to or meet the exclusion requirements for the remaining measure described in 495.22 (e)(10)(i)(C).
  • Eligible hospitals/CAHs scheduled to be in Stage 1 and Stage 2:
    • Must attest to at least 3 measures from the Public Health Reporting Objective Measures 1-4
    • May claim an Alternate Exclusion for Measure 3 (Specialized Registry Reporting)
    • An Alternate Exclusion may only be claimed for one measure, then the provider must either attest to or meet the exclusion requirements for the remaining measures described in 495.22 (e)(10)(ii)(C).

6.3 General Public Health Related Questions

6.3.1 CMS FAQ 2793 What is meaningful use, and how does it apply to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs?

Under the Health Information Technology for Economic and Clinical Health (HITECH Act), which was enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), incentive payments are available to eligible professionals (EPs), critical access hospitals, and eligible hospitals that successfully demonstrate are meaningful use of certified EHR technology. The Recovery Act specifies three main components of meaningful use: The use of a certified EHR in a meaningful manner (e.g.: e-Prescribing); The use of certified EHR technology for electronic exchange of health information to improve quality of health care; The use of certified EHR technology to submit clinical quality and other measures. In the final rule Medicare and Medicaid EHR Incentive Program, CMS has defined stage one of meaningful use. To view the final rule, please visit: http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf.

6.3.2 CMS FAQ 2807 Where can I get answers to my privacy and security questions about electronic health records (EHRs)?

The Office for Civil Rights (OCR) is responsible for enforcing the Privacy and Security rules related to the HITECH program.

6.3.3 CMS FAQ 3605 Where can I find a list of public health agencies and immunization registries to submit my data as required by the public health objectives for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs?

For information and/or instructions on where to submit your public health-related data, please contact your local or state public health agencies and immunization registries. For more information on specialized registry, see CMS FAQs.

6.3.4 CMS FAQ 3615 For the meaningful use objective "Capability to submit electronic syndromic surveillance data to public health agencies," what is the definition of "syndromic surveillance?"

Syndromic surveillance uses individual and population health indicators that are available before confirmed diagnoses or laboratory confirmation to identify outbreaks or health events and monitor the health status of a community.

6.3.5 CMS FAQ 9204 If an eligible hospital (EH) or critical access hospital (CAH) does not have any reportable lab results during the EHR reporting period (for example, the EH or CAH outsources all lab testing to a commercial lab or does not perform any lab tests for conditions that are reportable in their jurisdiction) can they be excluded from the requirement in the Electronic Health Records (EHR) Incentive programs to submit reportable lab results to a public health agency?

The EH or CAH should indicate the following exclusion when attesting yes; Does not perform or order laboratory tests that are reportable in their jurisdiction during the EHR reporting period (80 FR 62824).

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