Hospitals Beware: Modified Stage 2 and Meaningful Use Audits

Jim TateBy Jim Tate, EMR Advocate
Meaningful Use Audit Expert
Twitter: @JimTate, eMail:

Meaningful use audits against 2015 attestations are currently underway. Through our work at we have found that there are specific areas of attestation documentation that are particularly difficult for Eligible Hospitals (EH) and Critical Care Hospitals (CAH). The release in October 2015 of the Modified Stage 2 requirements caught many hospitals by surprise with the removal of the Core and Menu set concepts. In addition, there were changes to some specific objectives as well as to the reporting period timeline. Strategies related to exclusions and other issues had to be modified quickly to be able to attest by February 29, 2016.

[tweet_box design=”default” float=”none”]Last minute regulatory changes to 2015 #meaningfuluse has opened the door to attestation errors @JimTate @CMSGov[/tweet_box]

It is no surprise that there may be some gaps in the underlying documentation that will be required in the case of an audit. Since the audit can take place up to 6 years after attestation it is a good idea to plug those holes sooner than later. Let’s take a look at just two of the potential documentation problem areas for EPs and CAHs in their 2015 attestations:

  • Objective 2: Clinical Decision Support – Stage 2 Measure 1 requirement: “Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four clinical quality measures related to an eligible hospital or CAH’s scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions.” Suggested documentation: There must be documentation to both the presence of CDS rules as well as proof they were active. “For Measure #1- Documentation which proves that five clinical decision support interventions exist in the CEHRT system (i.e. audit trail, screenshots from the system, letter/e-mail from the vendor, etc.) and that they remained active throughout the EP’s reporting period (i.e. a schedule of alerts related to clinical decision support interventions that fired during the reporting period or an indication that the interventions cannot be turned off).”
  • Objective 9: Public Health Reporting – Stage 2 requirement: “Eligible Hospitals and CAHs scheduled to be in Stage 2 in 2015 must meet three measures.” There are four Public Health Measures (Immunization Registry Reporting, Syndromic Surveillance, Specialized Registry Reporting, Electronic Reportable Laboratory Result Reporting) and Stage 2 hospitals needed to meet three of those four. Suggested documentation: If the EH/CAH cannot meet at least three of the Public Health objectives then exclusions must be claimed and documentation must be obtained in cased of an audit. For objectives that are not excluded, there must be proper documentation of “active engagement” with a Public Health Agency. A relevant tip sheet that covers required documentation for both excluded and met measures is available from CMS.

From a risk standpoint the last minute regulatory changes to 2015 meaningful use (MU) requirements opened the door to attestation errors based on confusion, knowledge gaps, and missing documentation. As the acknowledged experts on MU audits, appeals, and mock audits we are ready to assist hospitals in the protection of incentives based on the CMS EHR Incentive programs. References documenting our extraordinary work on behalf of hospitals are available here. Please contact us at

Jim Tate is known as the most experienced authority on the CMS Meaningful Use (MU) audit and appeal process. His unique combination of skills has brought successful outcomes to hospitals at risk of having their CMS EHR incentives recouped. He led the first appeal challenge in the nation for a client hospital that had received a negative audit determination. That appeal was decided in favor of the hospital.