The Centers for Medicare & Medicaid Services (CMS) today issued a clarification on the requirements for attestation to the clinical quality measures (CQMs) needed to meet the definition of “meaningful use” under the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The clarification also addresses the documentation needed to demonstrate compliance in this area. The CQMs are only one part of the attestation process.

Hospitals have expressed considerable concern about the accuracy of the CQM data generated by their certified EHR products. Given that the attestation statements for meaningful use require an affirmation that the CQM data are “true and accurate,” it has been unclear what is required for attestation in this area. In response, CMS posted the following listserve message today:

What Does Attestation for the EHR Incentive Programs Entail?
Over 114,000 eligible professionals and hospitals have registered for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. As more hospitals move towards meeting meaningful use and attesting, the Centers for Medicare & Medicaid Services (CMS) wants to make sure everyone understands what attestation entails.

In order to attest, successfully demonstrate meaningful use, and receive an incentive payment under the Medicare EHR Incentive Program, eligible hospitals must indicate that they agree with several attestation statements.

Eligible hospitals must agree that the information submitted:

• is accurate to the knowledge and belief of the hospital or the person submitting on behalf of the hospital.
• is accurate and complete for numerators, denominators, exclusions, and measures applicable to the hospital.
• includes information on all patients to whom the measure applies.
• for clinical quality measures (CQMs), was generated as output from an identified certified EHR technology.

By agreeing to the above statements, the hospital is attesting to providing all of the information necessary from certified EHR technology, uncertified EHR technology, and/or paper-based records in order to render complete and accurate information for all meaningful use core and menu set measures except CQMs.

Attesting to CQM Data’s Validity
CMS considers information to be accurate and complete for CQMs to the extent that it is identical to the output that was generated from certified EHR technology. In other words, the hospital is only attesting that what was put in the attestation module is identical to the output generated by its certified EHR technology. Therefore, the numerator, denominator, and exclusion information for CQMs must be reported directly from information generated by certified EHR technology.

CMS, through meaningful use, does not require any data validation. Eligible hospitals are not required to provide any additional information beyond what is generated from certified EHR technology in order to satisfy the requirement for submitting CQM information, even if the reported values include zeros. If a hospital has concerns about the accuracy of its output, the hospital can still attest but should work with its vendor and/or the Office of the National Coordinator for Health Information Technology to improve the accuracy of the individual product and/or the level of accuracy guaranteed by certification.

CMS recommends that hospitals print out or save an electronic copy of the CQM report used at attestation from their certified EHR. The eligible hospital should retain this copy for its records so that the hospital can show its numbers in the event of an audit. Upon audit, this documentation will be used to validate that the hospital accurately attested and submitted CQMs.

Hospitals have until Nov. 30 to attest to meaningful use and be eligible for a Medicare EHR incentive payment for fiscal year (FY) 2011. They must report on a 90-day reporting period ending on or before Sept. 30 (the last day of FY 2011). For more information about the EHR Incentive Programs, including a description of the CQMs and the other requirements to meet meaningful use, visit the CMS EHR website at http://www.cms.gov/EHRIncentivePrograms.

If you have questions or need additional information, please contact David Ginsberg, Senior Advisor, THE Consortium at dg@coruralhealth.org.