by J. Gordon Wright, MD, FACS, RVT

How this series of articles is organized:

The simple and superficial instructions (think of checklists) appear at the very beginning, with more in-depth details coming later. In this way, those of you who just want the short story can find it in Part 1, then quit reading when you are clear on the instructions. Those of you who want a more detailed explanation will find it in Part 2, which will include the rationale for some of the recommendations and advice given in Part 1. Finally, Part 3 will provide the reader with a discussion of the exemptions and will contain references and links to useful and authoritative websites.

Executive Summary of the EHR Incentive Program in less than 150 words.

It is known that you have to own “Certified Technology” before you can achieve Meaningful Use (MU). It is also common knowledge that “Certified Technology” can be acquired in one of two ways: either (1) you purchase an EMR that is Certified by the ONC -HIT as a Fully Certified EHR or (2) you purchase a conglomeration of EHRs that are Certified by the ONC -HIT as Modular (i.e. partially) Certified EMR s, the sum of which add up a Fully Certified EHR . In addition to simply owning an EMR , you need to use it for at least 90 consecutive days (called your “Reporting Period”). You need to use it in a way our Federal Government has defined as “Meaningful”. You need to register for the program, which you can do at any time (even before you install your EMR ), up until 60 days after your RP. After registration and after your RP, you can “attest” to your experience which is done on a CM S website. Then you simply wait for your check to arrive in about 6-8 weeks.

Teacher, will this be on the test?

Now there are lots of nuances, caveats, and details I am leaving out both above and below, but you do not need to know this trivia. As a matter of fact, you do not need to know anything in this entire article, assuming you purchased an EMR that has so-called “Meaninful Use Support Features”, designed to help you with meaningful use, AND assuming your vendor knows what they are talking about and are willing to help you.

As part of the certification process, all EMR s are required to produce an on-demand report for you that will provide all the numerators and denominators and other data you need to successfully achieve meaningful use. It is interesting to note that the certification process does NOT require that the report (or any other part of the EMR ) is well organized or provides you with any additional information or help that will make the process of attestation easier. This is why it is important to select an EMR that is looking out for your best interest and understands the nuances of a phlebology practice. You want a vendor who has put a tremendous amount of effort into educating, coaching and providing you with printed materials, worksheets and software help in the form of MU alerts, alarms, prompts and defaults to help make the MU journey a successful and profitable one.

OK, then what WILL be on the test? - or - What do I Really have to do?

It is amazing to me that in the hundreds of articles I have studied in the last year on this topic, none of them ever provided much of a practical list of things to do. Here is the skinny:

1. Read something short and sweet that describes the objectives. A spreadsheet that makes clear what has to be done and who should do it is very helpful (see below). The information contained there should suffice. If not, your vendor should research other resources for you and make them available. Regardless of how you do this, you should educate yourself on the topic of MU BEFORE your GoLive training so you can provide the leadership needed for successful Attestation of MU.
2. Work on your staff and with your staff. They will actually be doing most of the MU work, not you. They need your guidance, leadership, coaching and encouragement.
1. a. The best time to start to prepare your staff is about two months before your GoLive training date. If you have missed that deadline, then the second best time to start to prepare your staff is TODAY.
2. b. GET A POSITIVE ATTIT UDE : If you show the slightest frustration or doubt about the EMR being the best thing for the practice and your patients, your staff will pick up on it and amplify it tenfold. Any negative attitude on your part can ruin the implementation of what might be the most important tool in your practice after your ultrasound and endovenous machine.
3. c. Show them, tell them, write to them. Explain what they need to do, why, and when, and hold them to it. Remember what Dr. Samuel Johnson said: “People need to be reminded much more often than they need to be instructed.”
3. Monitor your progress by running a MU Report once a week. Look for problems, (i.e., MU requirements that you have failed to pass) find out who the guilty parties are (i.e., who should have collected this data), and fix the problem ASAP.
4. There are several things that you will attest to with a simple “Yes,” like, “Did you do a security risk analysis in the last year?” These are things you can do before the start of your reporting periods: Some of them can be done even before your software is installed. My recommendation is to start doing them now. A good vendor will supply you with a simple but adequate checklist so you can document and prove that you performed a HIPPA compliant security risk analysis.
5. It is highly recommended that for those “Yes” attestations you have some kind of paper documentation that is signed and dated, showing that you did not just say “Yes” when you really did not do what you are attesting to. You should take all those documents, along with the final MU Report you printed out from your EMR and screen shots of your final Attestation web page, put them in a folder and keep them for at least six years in case you are ever audited by CM S and have to prove that you did what you said you did.
6. Remember that using the EMR so that it achieves the MU objectives should NOT be very difficult. The recommendations above are simply intended to make what should be an easy task a little easier.
7. MAKE SURE YOU SPEND TIME WITH YOUR EMRPRE -IMPLEMENTATION -PLANNING LIASON TO GET YOUR DE FAULTS AND ALERTS SET TO YOUR LIKING. This is probably the single most important step you can do to make the achievement of Meaningful Use as effortless as possible.
8. Print out a copy of your MU report, go to the CMS website, login, attest, then wait for your $18,000 check!

Before we start discussing some details, we need to get clear on the definition of some Meaningful Use terms:

Within the 857 pages of the federal legislation known as the “EHR Incentive Program,” which has spawned tens of thousands of web pages and millions of opinions and comments regarding the Program, I have found that the Program’s rules and regulations are often vague and at times outright contradictory (like many legislative documents). Therefore, it is not surprising that misconceptions abound, even among some socalled experts. I have found it tremendously useful to get clear on some of the commonly used terms before we start drawing conclusions about the most common question, “What exactly do I have to do in order to achieve Meaningful Use?”

What you have to Attest to, and what you do NOT have to do:

It is important to get this straight because it will clarify a lot of confusion and anxiety about the attestation process. All Fully Certified EMR s are required to produce one or more “Meaningful Use Report(s)” that lists all of the 25 MU Objectives plus nine CQMs with their numerators, denominators, and exclusionary data. Eligible Providers are required to attest to what is on the report that comes out of their EMR , and little more. If your EMR was designed properly, it will provide you with a clear and comprehensive report that you will print out and use when you go to the CM S website for attestation. You are NOT required to review your charts, tally the data or calculate the percentages, or even know what is being measured. You are simply required to take the report and hammer it into the Attestation Website. The ONC -HIT recommends that you keep a paper copy of the EMR Meaningful Use report(s) and file them away in case you are ever asked to document your attestation. If what you Attested to matches what is on the EMR s Meaningful Use Report(s), you will pass your audit. If it does not match, you will fail your audit. It is as simple as that.

More details regarding the CQMs:

Each of the three CQM sub-sub-categories has three specific CQMs for a total of nine CQMs. I have found it extremely useful (for descriptive purposes) to “lump” the first two sub-sub-categories of Core and Alternate CQMs into a sub-category that has no official name, but I will call the Core-Alternate Pair.

Just FYI , there are actually 44 CQMs in total. Fortunately, for the purposes of the Program, the six CQMs for the Core-Alternate Pair have been selected for you by the Federal Regulations, and the three CQMs for the Additional CQMs have been selected for you by your EMR vendor, giving you a list of nine CQMs.

When attesting, you will report on at least six, and no more than all of the nine CQMs. All of the variation in the number of CQMs you attest to has to do with how many (zero through three) of the Alternate CQMs you will be required to report. The number of Alternate CQMs you will be required to report will be equal to the number of Core CQMs with a zero in their denominator.

You MUST report on all three Core CQMs, even if they have a zero in the denominator. IF any of the Core CQMs are reported with a zero in the denominator then an Alternate CQM must be reported. Therefore, if none of the Core CQMs have a zero in the denominator, you will not need to report on any of the Alternate CQMs. If all the Core CQMs have a zero in the denominator, then you will need to report on all three of the Alternate CQMs. Personally, I have found this explanation to be a little confusing, so I will explain it again in a slightly different way in the next two paragraphs.

If you already feel like you understand enough about the CQM details, then you can skip to “What is Required for Attestation?” below.

These categories, sub-categories and sub-sub categories have the following rules for what you must attest to:

1. When attesting, you must report both the numerator and the denominator as supplied by your EMR S Meaningful Use Report for ALL required CQMs; even if one or both of the numerator or the denominator are a zero (0).
2. For each Core CQM with a zero in its denominator, you must select an Alternate CQM as its replacement, rovided the Alternate has a non-zero denominator.
3. In other words, three of the six CQMs in the so-called Core-Alternate pair MUST HAVE A NON -ZERO DENOMINATOR . If you do not have this during your reporting period, you will have to re-apply. IF you cannot find any 90 day reporting period during which you satisfy this criteria, you will not be able to achieve meaningful use.
4. You must report the numerator and denominator reported by your EMR for all three of the so-called “Additional” CQMs which have been selected for you by your EMR .
5. THERE ARE NO REQUIRED “THRESHOLDS” FOR THE CQMs EXCEPT THAT A CORE -CQM WITH A ZERO IN THE DENOMINATOR REQUIRES AN ALTERNATE AS A SUBSTITUTE. BEYOND THAT, ALL REPORTED CQMS COUNT AS SATISFYING THE MU REQUIREMENTS, EVEN IF THEY HAVE A ZERO IN THE NUMERATOR!

So if we put this into a structured formula, with the number of specific MU objectives or CQMs for each category and sub-category in the denominator, the number of required MU objectives or CQMs in the numerator, and the number you must satisfy in the numerator parenthesis, the number of required might look like this:

I. Meaningful Use (MU) objectives

A . MU Core objectives (15/15) [5/15 are “Yes” attestations, 10 are N/D%]
B. MU Menu objectives (5/10) [4/10 are “Yes” attestations, 6 are N/D%]

II . M U Clinical Quality Measures (CQMs). (6/9, 7/9, 8/9 or 9/9) [0 are “Yes”, all require N/D%]

A . Pick three of six, giving preference to the Core CQMs

1 CQM-Core (0/3, 1/3, 2/3 or 3/3)
2 CQM-Alternate (0/3, 1/3, 2/3 or 3/3)

Fraction of Core + Fraction of Alternate = 3/3

B. CQM-Additional (3/3)

Another way to break down the MU objectives is by Threshold Measures or Yes/No Measures. Most of the MU objectives are based on a numerator and a denominator, representing the number of patients or encounters that fit certain requirements during your reporting period. These MU objectives could be called “Percentage objectives, “Num/Denom objectives”, or “Threshold objectives”. I will call them “N/D%” objectives.

Two choices to make on the process

There are a large number of choices that CM S has left open to physicians participating in this program. In fact, there are so many choices, that the task of making the best choices can often seem overwhelming. For Phlebologists, there are really just two choices to focus on; and they both have to do with what needs to be reported.

1. For CQMs, the choice is really made for you by the regulations, however, you do have the choice as to how hard (or not) you will try to make sure you have a non-zero denominator for all three Core-CQMs. As described in the section above entitled: “The Clinical Quality Measures" (CQMs), are broken down into three sub-sub-categories,” found on page 4. It is the strong advice of VT S and VeinDraw that you try to get a nonzero denominator for all three Core-CQMs, because it is much easier to report; and if you end up with a zero in the denominator of all three of the Alternate CQMs, you might fail to achieve Meaningful Use! This is where it is very helpful to have a software vendor who will help you make these decisions (or make them for you) while you are winding your way through the maze of Meaningful Use. Achieving Meaningful Use (MU) is not as hard as it seems at first glance, (mainly because in reading this, you have made the decision to trust VeinDraw and the staff at Vein Technology Solutions (VT S) to help guide and coach you through the Meaningful Use maze.) We believe we have made this as easy as possible for you. We will get you through this in six easy steps.
2. The other choice you have to make has to do with the so-called Menu-Objectives, in which you get to choose five to report on and five to skip. It is the strong advice of VT S and VeinDraw that you choose the five easiest (i.e. least bothersome or least disruptive) choices for you and your staff among the ten MU Menu-Objectives. At VT S, we have a clear set of strong suggestions for these choices and we think that 95% of the phlebologists will agree with these suggestions. But if your particular needs are such that different choices make better sense, then we will coach you through these choices.

In addition to making these two choices, you then have the following important step to accomplish, and this is probably the most important thing you will do during the entire MU process: Let your staff know what they have to do in order for you to achieve Meaningful Use. We will help you coach them through this process before, during and after their GoLive training, and we recommend that you start working with your staff and on your staff about two months before your GoLive training.

Finally, you have to do these four things after your GoLive training:Use VeinDraw for at least 90 consecutive days, during which ime you will

1. M onitor your progress with MU requirements using the reports built into VeinDraw. When you have achieved MU, then
2. Print a MU report, and use it to:
3. Attest; then wait for your $18,000 check to arrive!

Step #1 – Choose what I want to attest to, what I want to exclude, and what I want to skip.

The 26 things mentioned above are listed in the following tables, along with the recommendations from VT S as to what you should exclude, defer, attest to, and why these choices are legitimate; but also the way most phlebology practices can achieve MU with the minimal amount of effort and change in practice patterns. In this table, the first column to the left contains a code name for each of the Meaningful Use requirements, using an unofficial, but commonly used coding system, which is explained below. But first, I want to outline the basic strategy used in selecting which MU requirements to exclude, which to avoid, and which things you should do “partly” in order to make your “journey to payment” as easy as possible. THE RECOMMENDATIONS HERE EXPLAIN THE MINIMUM REQUIRED EFFORTS IN ORDER TO ACHIEVE MEANINGFUL USE. FOR EXAMPLE, IN TOBACCO CESSATION, WE RECOMMEND DISCUSSION WITH THE PATIENT, TELLING THEM THEY HAVE TO QUIT. THERE ARE THREE OTHER THINGS AN EP CAN DO (PRESCRIBE MEDICINE, GROUP OR INDIVIDUAL COUNSELING) BUT WE LEAVE THOSE THREE OTHER THINGS OUT OF OUR ADVICE HERE BECAUSE THEY SEEM TO BE HARDER TO DO THAN JUST TELLING THE PATIENT THEY SHOULD REALLY, REALLY, QUIT.

An Overview of MU Strategy in making choices relevant to the Core-Set of Measures and the Menu-Set of Measures in the incentive program.

The strategy that makes most sense when dealing with most of the choices that are offered to the Phlebologist participating in the CM S EMR Incentive Program are counter-intuitive and probably the opposite of what most Phlebologists would choose. The main choices regarding the MU Measures (NOT the CQMs) are as follows:

1. Can I qualify for the Medicaid program? I will not go into those requirements here because I am certain that over 95% of phlebologists will NOT qualify, but if you can, you should apply for the Medicaid program ASAP.
2. During the first reporting period, which is only 90 days, can I get by writing less than 100 prescriptions? I feel that most phlebologists can do this. If you cannot, you should probably contact the VT S staff to discuss options. This decision is huge because it impacts on three of the 15 MU measures you must attest to (20% in one fell swoop!).
3. Are you willing to attest “that all three vital signs of height, weight, and blood pressure have no relevance to the scope of your practice”? This decision is important because it impacts on three MU requirements. I believe that most phlebologists will say that they can look at a patient and know if their obesity is impacting on their venous health, and that measuring their height, weight and BP will have no impact on their recommendations. If that is true, then it is reasonable to say that NOT all three vital signs are relevant. It is also important to note that if you do attest that the exclusion described in the first sentence of this paragraph applies to you, then you are not prohibited from recording vital signs. This is also important because one of the easier clinical quality measures (CQM-C1, Hypertension: Blood Pressure Measurement) requires that you at least record the fact that the patient carries the diagnosis of hypertension. If you do not do this as part of your routine history taking then you should record the BP of at least one patient who will be in to see you at least twice during your RP. PLEA SE NOTE THAT FOR THE CORE SET AND MEN U SET OF MU RE QUIREMENT S (but NOT for CQMs) AN EXCLUDED RE QUIREMENT COUNT S AS BEING AC HIEVED . This is also a little counter-intuitive, so you will often have to keep reminding your self of this fact as we go through the logic of this strategy.
4. The next question you have to ask yourself is this: During the first reporting period, which is only 90 days, can I get by ordering ZERO lab tests that have their results expressed as positive/negative or numeric values? The most common lab tests of this sort that phlebologists will order are Factor V Leiden tests (reported as positive or negative), other clotting functional tests (also reported as positive or negative) or INR tests (numeric). Holding off on ordering these kinds of tests during the 90 day reporting period can be thought of as a safety net for the 5 “Menu Set” of MU requirements; since one of the Menu Set of MU requirements can be excluded (4M , Incorporate clinical lab-test results as structured data) if no such tests are ordered, and as mentioned above, an excluded requirement counts as being achieved. This is not a large-impact choice, so if it is going to be difficult to avoid ordering such labs, please read the further notes on Exclusions regarding this MU requirement below.