Monitoring and Maintaining Meaningful Use Measures

How Can You Achieve and Attest to Meaningful Use?

Ron Sterling
Sterling Solutions
Author: Keys to EMR/EHR Success

In order to qualify for the Medicare EHR Incentives, you have to attest that each Eligible Professional (EP) meets the Meaningful Use requirements. The two key issues are how can you get a provider to work up to the MU Measure Requirements and how can you document the same for your Eligible Professionals.

A point of frustration for many providers is that they have to attain all of the core Meaningful Use Measures and 5 Menu items to initially qualify for the incentives and then maintain those levels each year thereafter. CMS can request documentation on Meaningful Use attainment for up to six years after you have attested to CMS. Note that you need to maintain appropriate information for each Eligible Professional: not for the practice.

Attaining MU for Each Provider
In practice, few physicians attain the Meaningful Use measures from day one or at a set date. In actuality, providers work towards Meaningful Use as they become familiar with the EHR specific requirements for each measure.

To help physicians focus, consider waiting until they are familiar using the EHR with patients in order to ease the refinements that may be necessary for the MU Measures. At this point, you should run the MU Measure reports for the physician and analyze the physician performance. Provide feedback to the EP on a weekly or daily basis depending on their progress. Consider more frequent feedback for providers that are not making progress and weekly feedback for providers that are making progress.

When the EP is close or has attained the MU Measures levels for all relevant measures, you can start the 90 day period. Throughout the 90 day period, you should monitor Eligible Professional measures on at least a weekly basis. If you detect some degradation on the measure levels, you should consider more frequent or even daily feedback. Note that some EHR products have a dashboard that provides real time results while other EHRs are limited to daily MU reporting. In either case, you want to monitor the EP in support of their effort to attain MU.

After the 90 day period is completed, continue to monitor the MU Measures at least once a week until the provider is consistent and does not need prompting to accommodate the MU Measure strategy for your EHR. However, you should monitor performance at least monthly and increase the frequency to weekly or even daily to help providers maintain MU performance. Remember that you do not want to have to catch up to a measure that may have little room for error. For example, some measures require fulfillment for at least 80 percent of unique patients.

Maintain Separate Attest Records for Each Eligible Professional
At the completion of each period (initial 90 day or annually), you should accumulate a separate set of documentation for each individual Eligible Professional:

Assure that you have documentation for each MU Measure for each Eligible Professional. For example, generating a list of patients meeting clinical criteria (Stage 1 Menu Measure) should be directed to the specific physician for whom you are compiling information. Similarly, you should perform a test of electronic exchange of clinical information (Stage 1 Core Measure) for the specific Eligible Professional. Documentation should include the relevant support or results that meet the MU Measure.

The security risk analysis will probably be completed for the practice, but will have to be part of the documentation for each EP. You should put a separate copy of the Security Analysis documentation in the documentation for each EP.

Include a copy of the documentation from your EHR on how the MU Reports are generated and the calculation of the MU Measure by the EHR. Note that future MU calculations may change to meet Stage 2, and to account for EHR product changes. If you have made changes to the EHR MU calculation or calculation, you should include supporting documentation for the change and the results.

At the end of the process, you should have a separate set of documentation that fully supports your attestation for the relevant EP.

Attaining MU and maintaining the supporting MU documentation for each Eligible Provfessional is a continuing process that requires consistent monitoring of performance and documentation for each individual provider. Thereby, you will help your providers qualify for the EHR incentives and be able to prove the same if ever challenged by CMS.

This article was originally published on Avoid EHR Disasters. Ron Sterling is author of the HIMSS Book of the Year Keys to EMR/EHR Success. He also hosts The EHR Zone radio show which airs each Wednesday at 4 pm Eastern. He is a nationally recognized EHR expert with the information that you need to improve patient service and performance. For questions or if you are looking to engage him as a speaker, he can be contacted at