Eligible Providers: Recommended Documents to Retain for MU Audit

Topic/Item / Pertinent Objectives / Location / Notes
General Considerations:
Timing: how long to save / Retain for 6 years post-attestation
Medium / Can be paper or electronic
Payment Calculations / Expected Total Incentive Payment calculations to compare against amount received from CMS after successful attestation.
MU Reports / All Core/Menu/Quality for each Eligible Provider / Retain copies of report(s) that were used to enter the attestation numerators/denominators into the CMS EHR Incentives Attestation website.
Eligible Providers: CORE
EP#1: CPOE / Organizational policies relating to who the organization defines as a “licensed professional”. Policy also includes what to do if a CDS alert is presented.
Definition of which roles (MD/NP/PA/RN/LPN/MA) were used to calculate numerator.
EP#2: Drug-Drug & Drug-Allergy Interaction Checks / Screenshot showing that D-D/D-A checking is turned-on/activated.
EP#3: Problem List / Screenshot showing “no known problems” as a choice
EP#4: e-Rx / Document methodology for inclusion for numerator & denominator
EP#5: Medication List / Screenshot of “no active medications” functionality.
EP#6: Medication Allergy List / Screenshot of “no known medication allergies” option.
Topic/Item / Pertinent Objectives / Location / Notes
EP#7: Demographics /
  • Preferred language, gender, race, ethnicity, date of birth
/ Screenshot of “declined” option.
Screenshot showing ethnicity options
EP#8: Vital Signs /
  • Ht, wt, BP, BMI, growth charts (2-20 yrs)
/ Documentation of which EP’s were planning to claim “exclusion” and why.
EP# 9: Smoking Status (>13 yrs) / Nothing specifically recommended
EP#10: Clinical Quality Measures to CMS / Nothing specifically recommended
EP#11: CDS Rule / Screenshot of CDS rule activated in EHR.
EP#12: e-Copy of Health Information / Report listing which patients requested, when, and “fulfillment” date
Written procedure for accommodating request
EP#13: Clinical Summaries (AVS) / Data dictionary for AVS Fields/Elements
Written procedure/diagram of workflow for each medium supplied (PHR, pt portal, secure e-mail, CD/USB, paper copy)
Ability to document “refused”
EP#14: Clinical Data Exchange / Email from “receiver(s)” stating that they received and were able to open/read the information.
EP#15: Protect PHI (Security Risk Analysis & Plan) / Copy of security risk assessment documenting gaps and how gaps were mitigated prior to reporting period.
Eligible Providers: MENU
EP#1: Drug formulary checks / Document which formulary is being used (internal, external)
Screen shot of formulary check
Topic/Item / Pertinent Objectives / Location / Notes
EP#2: Structured Lab Test Results / Document how data was populated (electronic exchange, manual entry)
Document if standard code set used (LOINC, etc.)
EP#3: List of patients by condition / Copy of report that was generated
EP#4: Pt. reminders / Document which type of reminder was generated (appointment, preventive/follow-up care)
Screenshot of reminder
EP#5: e-Access to Health Information / Document medium (pt. portal, PHR)
EP#6: Pt-specific Education Resources / Document how pt-specific logic is “fired” (problem list, medication list, lab results, others)
EP#7: Med Rec for Transitions of Care / Policy that defines which encounters are considered “transitions of care”
Access to/copy of EHR vendor logic
Organizational policy that states which roles can populate current med list, and that EP has final signature on med rec in EHR.
EP#8: Summary of Care Record for Transitions of Care/Referrals / Documentation of process for generating summary of care
Data dictionary for elements contained in summary of care
Documentation of medium used (paper copy, secure transmission, etc.)
EP#9: Immunization Registry Submission / Screen shot of “upload successful” OR “upload received (but not completely successful)”OR letter/ verification if Public Health agency not ready to receive
Topic/Item / Pertinent Objectives / Location / Notes
EP#10: Syndromic Surveillance Data Submission / Screen shot of “upload successful” OR “upload received (but not completely successful)” OR letter/ verification if Public Health agency not ready to receive

For further information: http://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp

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02.22.2012