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The Strategic View of Modified Stage 2 Meaningful Use: Part 5Objective 9 Public Health Reporting/Measure Option 1—Immunization Registry Reporting

Hess, Cathy Thomas BSN, RN, CWCN

Advances in Skin & Wound Care: May 2016 - Volume 29 - Issue 5 - p 240
doi: 10.1097/01.ASW.0000482433.24556.70
DEPARTMENTS: PRACTICE POINTS

Cathy Thomas Hess, BSN, RN, CWCN, is Vice President, Chief Clinical Officer for Wound Care, Net Health. Ms Hess presides over Professional Services, which offers products and solutions to optimize process and workflows. Address correspondence to Ms Hess via e-mail: cthess@nhsinc.com.

As in subsequent columns, we are continuing to review the objectives and measures for Modified Stage 2 Meaningful Use set forth from 2015 through 2017. In this column, you will find information detailing Objective 9: Public Health Reporting. You will note there are 3 Measure Options within Objective 9. Measure Option 1, which is available on p. 20 at http://go.cms.gov/25GPZcI, focuses on Immunization Registry Reporting. Measure Objective 2: Syndromic Surveillance Reporting and Measure Objective 3: Specialized Registry Reporting will be discussed in future columns. The specific Public Health Reporting Measures provide epidemiological statistics and help to monitor population health more accurately. There are different options for reporting each select measure, and the eligible professional (EP) should research his/her Public Health Reporting Options from the state in which they are attesting.

The Centers for Medicare & Medicaid Services provided a detailed explanation (FAQ 2985)1 for reporting the measures:

“In the final rule at 80 FR 62788, we discuss our final policy to allow for alternate exclusions and specifications for certain objectives and measures where there is not a Stage 1 measure equivalent to the Modified Stage 2 (2015 through 2017) measure or where a menu measure is now a requirement. This includes the public health reporting objective as follows.

First, EPs scheduled to be in Stage 1 may attest to only 1 public health measure instead of 2, and eligible hospitals or critical access hospitals (CAHs) may attest to only 2 public health measures instead of 3.

Second, we will allow providers to claim an alternate exclusion for a measure if they did not intend to attest to the equivalent prior menu objective consistent with our policy for other objectives and measures as described at 80 FR 62788.

We will allow Alternate Exclusions for the Public Health Reporting Objective in 2015 as follows:

EPs scheduled to be in Stage 1: Must attest to at least 1 measure from the Public Health Reporting Objective Measures 1 to 3

  • May claim an Alternate Exclusion for Measure 1, Mea-sure 2, or Measure 3.
  • An Alternate Exclusion may be claimed only for up to 2 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).

EPs scheduled to be in Stage 2: Must attest to at least 2 measures from the Public Health Reporting Objective Measures 1 to 3

  • May claim an Alternate Exclusion for Measure 2 or Measure 3 (Syndromic Surveillance Measure or Specialized Registry Reporting Measure) or both

Eligible hospitals/CAHs scheduled to be in Stage 1: Must attest to at least 2 measures from the Public Health Reporting Objective Measures 1 to 4

  • May claim an Alternate Exclusion for Measure 1, Measure 2, Measure 3, or Measure 4
  • An Alternate Exclusion may be claimed only for up to 3 measures, then the provider must either attest to or meet the exclusion requirements for the remaining measure described in 495.22 (e)(10)(ii)(C).

Eligible hospitals/CAHs scheduled to be in Stage 2: Must attest to at least 3 measures from the Public Health Reporting Objective Measures 1 to 4

  • May claim an Alternate Exclusion for Measure 3 (Specialized Registry Reporting Measure)”

Cheers to diligent documentation!

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References

1. Centers for Medicare & Medicaid Services. Frequently asked questions. https://questions.cms.gov/faq.php?id=5005&faqId=12985. Last accessed March 22, 2016.
2. Centers for Medicare & Medicaid Services. EHR Incentive Programs: 2015 through 2017 (Modified Stage 2) Overview. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage3Overview2015_2017.pdf. Last accessed March 22, 2016.
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