Just Do It . . .Right

Consider these strategies for meeting the toughest challenges of meaningful use attestation for your EHR system


Just Do It … Right

Consider these strategies for meeting the toughest challenges of meaningful use attestation for your EHR system.

Jeff Grant, Shell, Wyo.

(Note: Click here for an exclusive online version of this article, which lists all 25 CSMs and MSMs and provides a comprehensive overview of meaningful use attestation information.)

So, you've decided that you're ready to get your EHR for the 2011 payment year. Hopefully, you've already selected one of the certified vendors that offer solutions for optometric practices, or you'll be making your selection very soon. Either way, the time is now to get busy with your implementation planning and process re-engineering to ensure a smooth transition.

One of the key requirements for receiving the EHR incentive payment is to meet the 15 core set measures (CSM) and five of the 10 menu set measures (MSM) set forth by CMS. You'll meet many of these measures simply by using a certified EHR system. However, some measures are more challenging and will require process changes within your practice for compliance.

In this article, I'll discuss some specific strategies you can employ to ensure you meet the criteria of the more challenging measures. Where appropriate, I will note exclusions for measures.

While my comments are “vendor-neutral,” this article is not meant to supplant your vendor's documentation. Therefore, talk to your vendor to ensure that my suggestions align with the way your EHR software functions.

Also, note that many of the measures offer exclusions. Decide whether to exercise one or more of the exclusions and if you choose to do so, you will be required to attest that you meet the requirements of the exclusion(s).

Finally, see “Useful Definitions” (below) for an explanation of some of the more common terms used in this article.

Core set measures

The most challenging CSMs to achieve are:

CSM 1. Use computerized physician order entry for medication orders for 30% of unique (see definition) patients.

Strategy: Simply entering the medication details into the EHR will satisfy this measure for most practices.

Exclusion: If you write fewer than 100 prescriptions during the reporting period.

Staff involved: Clinical

CSM 4. Generate and transmit more than 40% of all permissible prescriptions electronically.

Strategy: All certified EHR systems contain e-prescribing functions. Most of these systems would automatically “count” your e-prescribing actions when you submit the prescription electronically.

Exclusion: If you write fewer than 100 prescriptions during the reporting period.

Staff involved: Clinical

CSM 7. Record demographics for more than 50% of all unique patients. You must record preferred language, gender, race, ethnicity and date of birth.

Strategy: You certainly record patient demographics now, but maybe not all the required values. This is likely something your front desk staff will need to enter, typically after the patient arrives for the visit or with data imported from a patient registration portal.

Exclusion: None

Staff involved: Front desk/check-in/patient registration

Note: Several EHR systems offer patient registration portals where the patient would enter his/her own demographic information. (See “Exciting New Technology: Patient Portals,” below.)

CSM 8. Record and chart changes in the following vital signs: height, weight and blood pressure, display BMI and plot/display growth charts for 50% of all unique patients two years old and older.

Strategy: By far, this measure has caused the most concern and questions. Understand that the measure requires you to “record” changes in vital signs, but it doesn't say “weigh and measure” your patients. Therefore, this data could be self-reported by patients. However, it is my position that you can exercise the exclusion available if you believe that measuring these vital signs falls outside the scope of the your practice. The final decision on the exclusion of this measure is up to you.

Exclusion: Any eligible professional (EP) who either sees no patients age two years or older, or who believes that all three vital signs of height, weight and blood pressure of their patients have no relevance to their scope of practice.

Staff involved: Clinical

CSM 10. Report clinical quality measures (CQM).

Strategy: Become familiar with the Core, Alternate Core, and Specialty-specific options. Chances are that you will report zero (0) for all the Core and Alternate Core measures, but you will definitely need to report on three eyecare-specific measures (one relating to primary open angle glaucoma and two relating to diabetic retinopathy). Your EHR software vendor must generate the information you'll need to enter when you attest.

Exclusion: None

Staff involved: Clinical

Note: For 2011, you will enter your information and attest to the accuracy, but in 2012, you will be required to submit an electronic file containing your CQM information.

CSM 11. Implement one clinical decision support (CDS) rule relevant to your specialty or high clinical priority.

Strategy: The EHR vendors are handling this in different ways and will present the “rule” in different ways. No matter how it is done in your software, you must implement one rule that is relevant to eyecare. For example, the CDS rule, for a given diagnosis, might present alternative drugs, a list of tests that might need to be ordered based on frequency, etc. Once the CDS rule(s) has (have) been presented, the event would be logged in the EHR.

Exclusion: None

Staff involved: Clinical

Note: This is one of the most exciting functions in the latest EHR releases, as the documentation of such rules presents tremendous opportunities to assist EPs, improve patient care and reduce unnecessary services.

CSM 12. Provide an electronic copy of health information within three business days to all patients who request such.

Strategy: Most vendors would use a patient portal to meet this measure. The patient data would be uploaded to the patient portal when requested by the patient, and the event would be logged into the EHR.

Exclusion: Any EP who has no requests from patients or their agents during the EHR reporting period.

Staff involved: Clinical or front desk (depending on how your software generates the summaries and how the software makes them available to patients)

CSM 13. Provide clinical summaries for at least 50% of all office visits within three business days.

Strategy: Different vendors may handle this CSM differently. The measure does not state how these summaries are to be provided, and you're allowed some flexibility. Obviously, these summaries could be printed for and handed to the patient, but most vendors would also offer the option of “providing the summary” to a patient via the patient portal. The patient data would be uploaded to the patient portal at the conclusion of an encounter, and the event would be logged.

Exclusion: Any EP who has no office visits during the EHR reporting period.

Staff involved: Clinical or front desk (depending on how your software generates the summaries and how the software makes them available to patients)

CSM 14. Perform one test of your EHR software's ability to exchange key clinical information (for example, problem list, medication list, medication allergies and diagnostic test results).

Strategy: This is a “baby step” toward exchanging clinical information. Health Information Exchanges (HIE) are functional in only a few areas of the country (but being set up in many others), so most EPs have nowhere to send this information at this time. Therefore, you merely have to test this function to meet the measure. Most vendors would create an electronic Continuity of Care Document (CCD), which is an XML file that can be sent or at least tested to send. Some vendors might actually provide a way for you to send the file to them if no HIE exists in your area. This testing event may or may not be logged in the EHR. Ask your vendor for more information.

Exclusion: None

Staff involved: Clinical or administrative

CSM 15. Conduct a security risk analysis of the certified EHR technology.

Strategy: You are required to comply with all aspects of HIPAA, and this measure specifically requires that you conduct a security risk analysis, and correct any deficiencies. The print version of this article does not allow enough room for a detailed explanation of conducting a risk analysis. So, visit the online version of the article at for some links to helpful information on the subject.

Exclusion: None

Staff involved: Security officer, CEO, administrator and practice owner (complying with HIPAA requires the involvement of everyone in the practice.)

Menu set measures

You must meet at least five MSMs with one of them being one of the two public health-related measures, (unless you're able to exclude certain measures). Below are those that present the greatest challenges or offer an exclusion.

MSM 2. Incorporate lab test results as structured data for at least 40% of clinical lab tests ordered.

Note: For nearly all O.D.s, this measure would be excluded, as lab tests are not commonly performed on each optometric patient.

MSM 4. Send preventive care/follow-up reminders to at least 20% of all patients age 65 or older or age five or younger, according to the patient's preference.

Strategy: Think of this as “recalls” that you've sent in the past, but where they must be sent according to the patient's preference. The patient may want a letter, or maybe this info could be uploaded to the portal, and the patient sent a notification via e-mail. This patient reminder event would be logged into the EHR.

Exclusion: An EP who has no patients age 65 or older or age five or younger with records maintained using certified EHR technology.

Staff involved: Front office

MSM 5. Provide at least 10% of all patients seen by the EP with timely electronic access (within four business days of the data being updated in the EHR) to their health information.

Strategy: Most vendors would be using a patient portal to meet this measure. The patient data would be uploaded to the patient portal and the event logged.

Exclusion: If the EP neither orders nor creates any of the information contained in these measures. This isn't really an exclusion, however, since you would create this information if you try to meet the requirements for the incentive payment.

Staff involved: Clinical, depending on the way your vendor makes this data available to your patients (generally through a patient portal)

MSM 7. If there is a transfer of care, the EP performs a medication reconciliation for more than 50% of those transitions.

Note: Optometrists would generally not be the recipient of a transfer of care (see the definition), so you would probably exclude this measure.

MSM 8. If there is a transfer of care, the EP provides a summary-of-care record for more than 50% of those transitions.

Strategy: Since you'll almost certainly refer a patient to another provider, you will be required to provide a summary of care record.

Exclusion: An EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period.

Staff involved: Clinical

MSM 9. Perform a test of the certified EHR's ability to submit electronic immunization data (public health-related). (See note after MSM 10.)

Note: An optometrist does not administer immunizations, so you would exercise the available exclusion.

MSM 10. Perform a test of the certified EHR's ability to submit electronic syndromic surveillance data (public health-related).

Strategy: Your state may not have an entity where you can test the submission of syndromic surveillance data (diagnosis-specific data). Therefore, you may be able to exclude this measure.

Exclusion: An EP who does not collect any reportable syndromic information on their patients during the EHR reporting period or does not submit such information to any public health agency that has the capacity to receive the information electronically.

Note regarding MSM 9 and MSM 10: The following text from the CMS FAQ on this topic makes it clear that you could skip one of these two measures and attest to an exclusion for the other: “If an EP can be excluded from both public health menu objectives, the EP should claim an exclusion from only one public health objective, and report on four additional menu objectives from outside the public health menu set.”

Hopefully, this information will help you plan for and meet the requirements of each measure. At the very least, it should educate you on exactly what to ask your vendor to ensure you're properly meeting the requirements.

Either way, your ability to earn your incentive money should be greatly enhanced. OM

Exciting New Technology: Patient Portals
The EHR Incentive and EHR software certification program has spurred software developers to build or include some very exciting new functionality that reaches far beyond the requirements for MU. For example, Microsoft and Google offer portals, which allow patients access to their health information. (For a more in-depth explanation of patient portals, visit to view the online version of this article.) While some of the EHR vendors have chosen one of these two portal service providers, other vendors have decided to create their own portals, allowing the vendor complete control over functionality, operation and expense.

Useful Definitions
As you read through the strategies in this article, keep in mind these definitions:

Unique Patient. If a patient is seen by an EP more than once during the EHR reporting period, then for purposes of measurement, they only count once in the denominator for the measure.
Exclusion. An EP will be able to report whether an objective/measure is inapplicable to them because they have no patients or insufficient number of actions that would allow calculation of the meaningful use measure. This will allow an EP to qualify as a meaningful EHR user without being required to meet objectives we have specified as potentially inapplicable.
Transition of Care. CMS defines “transition of care” as the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.

Mr. Grant is founder of HCMA, Inc., which specializes in management, operational and IT consulting for medical practices and offers revenue cycle management services. E-mail him at, or send comments to