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 Year 2017, Eligible Hospitals can choose to use technology certified to the 2014 Edition, the 2015 Edition, or a combination of the two editions.

    Note: If attesting to Stage 3 requirements in 2017, Eligible professionals must use technology certified to the 2015 Edition. An Eligible Professional who has technology certified to a combination of the 2015 Edition and 2014 Edition may potentially attest to the Stage 3 requirements, if the mix of certified technologies would not prohibit them from meeting the Stage 3 measures. An Eligible Professional who has technology certified to the 2014 Edition only, may not attest to Stage 3.
  • 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 for a copy of and the Wisconsin incentive application, 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, 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.

For more information on the Eligible Hospitals Modified Stage 2 requirements for Program Year 2017, review the Eligible Hospital 2017 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 more information on the Eligible Hospitals Stage 3 requirements for Program Year 2017, review the Eligible Hospital 2017 Meaningful Use Specification Sheets.

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. 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.

All Eligible Hospitals are required to report on 16 of the 29 available CQMs.

See the CMS Clinical Quality Measure Basics page on the CMS website to learn more about reporting CQMs. For a complete listing of available CQMs, refer to the eCQM Library on the CMS website. Wisconsin Medicaid recommends Eligible Hospitals report on the priority CQMs identified in Attachment 5 (PDF).

Clinical Quality Measure Reporting Periods

The following date ranges are the Clinical Quality Measure (CQM) reporting periods for Meaningful Use for Program Year 2017:

  • The CQM reporting period for Eligible Hospitals who are attesting to Meaningful Use criteria for the first time is any continuous 90-day period between January 1, 2017, and December 31, 2017.
  • The CQM reporting period for Eligible Hospitals who have successfully demonstrated any stage of Meaningful Use in a prior year is the full calendar year from January 1, 2017, through December 31, 2017.

Note: In prior years, the reporting period for CQMs was the same as the Meaningful Use EHR reporting period for that Program Year. The policy for Program Year 2017 is different because Eligible Hospitals who have successfully demonstrated any stage of Meaningful Use in a prior year have a CQM reporting period of a full calendar year and an EHR reporting period of only 90 days.

Last Revised: June 19, 2017