Eligible Hospitals - Attestation

Certified EHR Technology

Before an Eligible Hospital can attest to meeting Wisconsin Medicaid EHR Incentive Program requirements, it must acquire or have access to CEHRT.

  • In Program Years 2016 and 2017, Eligible Hospitals can choose to use technology certified to the 2014 Edition, the 2015 Edition, or a combination of the two editions.
  • The standard deduction for Eligible Professional patient volume in Program Year 2016 is 4.65 percent.
  • In Program Year 2018 and subsequent Program Years, all Eligible Hospitals are required to use technology certified to the 2015 Edition.

For more information on CEHRT, including how to obtain the CMS EHR Certification ID used during registration and the Wisconsin incentive application, please refer to the Certified Health IT Product List.

Adopt, Implement, Upgrade

Eligible Hospitals participating in their first year do not have to attest to Meaningful Use; rather, they may demonstrate that they have adopted, implemented, and or upgraded CEHRT.

  • Adopt: Eligible Hospitals must demonstrate acquisition, installation, or contractual proof of an acquisition or future acquisition of CEHRT in the first payment year.
  • Implement: Eligible Hospitals must meet the criteria for adopting CEHRT and demonstrate actual implementation, installation, or utilization of CEHRT.
  • Upgrade: Eligible Hospitals must meet the criteria for adopting and implementing and demonstrate expansion of the CEHRT functionality such as the addition of an e-prescribing functionality or computerized physician order entry.

Meaningful Use

In order for an Eligible Hospital to receive payment in the second year of participation, they will have to attest to the Meaningful Use of CEHRT for a continuous 90-day period. In subsequent years, the Meaningful Use reporting period is the entire Program Year.

The criteria for Meaningful Use will be staged in three steps over the course of the program:

  • Stage 1 sets the baseline for electronic data capture and information sharing.
  • Stage 2 and Modified Stage 2 advances clinical processes. CMS established a modified set of criteria for attestation in Program Years 2015 through 2017, known as Modified Stage 2. Modified Stage 2 replaces the core and menu structure of Stages 1 and 2 with a single set of objectives and measures, and establishes several other changes to the EHR Incentive Program.
  • Stage 3 improves outcomes.

Modified Stage 2 Meaningful Use

The requirements for Modified Stage 2 contain nine objectives for Eligible Hospitals, including one consolidated public health reporting objective. Each objective has one or more measures to which the Eligible Hospitals are required to attest. Since the changes in the final rule occurred after some Eligible Hospitals had already started to work toward Meaningful Use in 2015, there are alternate exclusions and specifications within individual objectives for Eligible Hospitals in Program Years 2015 and 2016.

For more information on the Eligible Hospitals Modified Stage 2 requirements for Program Year 2016, review the Eligible Hospital 2016 Meaningful Use Specification Sheets.

Stage 3 Meaningful Use

The requirements for Stage 3 contain eight objectives for Eligible Hospitals, including one consolidated public health reporting objective.

For information about the objectives and measures for Stage 3, Eligible Hospitals should refer to the Federal Register.

More information on the Eligible Hospital Stage 3 requirements is forthcoming. The CMS Medicare and Medicaid EHR Incentive Program website will be updated to include new information and resources reflecting the latest requirements for participation in Stage 3.

Process for Reporting Public Health Objectives

All Eligible Hospitals, regardless of their stage of Meaningful Use, are required to register with the Wisconsin Department of Health Services (DHS), Division of Public Health (DPH), to initiate an onboarding process for the public health reporting objective. Eligible Hospitals attesting to Modified Stage 2 Meaningful Use are required to register with DPH either before their EHR reporting period starts or within 60 days from the beginning of their EHR reporting period. For current registration information, Eligible Hospitals should refer to the Public Health Meaningful Use website.

2014 Clinical Quality Measures (CQMs)

In addition to meeting Meaningful Use measures, Eligible Hospitals and Critical Access Hospitals are also required to report on the CQMs in order to successfully participate in the program.

Although CQMs are reported separately from Meaningful Use measures, all Eligible Hospitals are still required to report CQMs in order to demonstrate Meaningful Use. The reporting period for CQMs is the same as the Meaningful Use EHR reporting period for that Program Year.

All Eligible Hospitals are required to report on 16 of 29 CQMs finalized in 2014 in the Stage 2 rule. Wisconsin Medicaid recommends Eligible Hospitals report on the priority CQMs identified in Attachment 5 (PDF, 491 KB).

See the CMS page on 2014 Clinical Quality Measures and the CQM Tip-sheet to learn more about CQMs.

Last Revised: September 1, 2016