Eligible Hospitals - Attestation

  • Attention Program Year 2015 Applicants: Due to pending federal regulations on Program Year 2015, the Wisconsin Medicaid EHR Incentive Program is currently processing only adopt, implement, and upgrade (AIU) applications for incentive payments. Eligible Professionals and Medicaid Only Hospitals applying for Meaningful Use are advised that Meaningful Use applications are not being processed for incentive payments at this time.
    • Meaningful Use applications will be accepted at a later date, which is dependent on pending federal regulations and subsequent attestation system changes to comply with those new requirements.
    • Once the regulations have been finalized later this year the Wisconsin Medicaid EHR Incentive Program will communicate information on the launch of Meaningful Use.

Adopt, Implement, Upgrade (AIU)

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 certified EHR technology (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

Eligible Hospitals that are adopting, implementing, or upgrading CEHRT are required to attest using 2014 Edition CEHRT. For more information on CEHRT, please refer to the Certified Health IT Product List.

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.

  • Note: The reporting period for Program Year 2014, regardless of attestation stage, will be 90 consecutive days for all providers.

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 advances clinical processes.
  • Stage 3 improves outcomes. Stage 3 is expected to be implemented in Program Year 2017.

Stage 1 Meaningful Use

In Stage 1, Meaningful Use includes both a core set and a menu set of objectives that are specific to Eligible Hospitals. To qualify for an incentive payment, Eligible Hospitals must meet 16 of the 21 Meaningful Use objectives identified by CMS:

  • There are 11 required core objectives.

  • The remaining 5 objectives may be chosen from the list of 10 menu set objectives.

For more information on the Eligible Hospital Meaningful Use Objectives and Measures review the Stage 1 EHR Meaningful Use Specification Sheets for Eligible Hospitals.

Stage 2 Meaningful Use

For Stage 2 Meaningful Use, there are a total of 22 Meaningful Use objectives for Eligible Hospitals. Eligible Hospitals must meet 19 of the 22 Meaningful Use objective identified by CMS:

  • There are 16 required core objectives.

  • The remaining 3 objectives may be chosen from the list of 6 menu set objectives.

For more information on Stage 2 requirements, please refer to the Stage 2 Page on the CMS Website.

Process for Reporting Public Health Objectives

Beginning October 1, 2013, all Eligible Hospitals, regardless of their stage of Meaningful Use, will be required to register with the Wisconsin Department of Health Services (DHS), Division of Public Health (DPH), to initiate an onboarding process for any of the public health objectives. Eligible Hospitals attesting to Stage 2 Meaningful Use are required to register with the 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 at www.dhs.wisconsin.gov/ehealth/PHMU/index.htm.

2014 Clinical Quality Measures (CQMs)

In addition to meeting the core and menu objectives, Eligible Hospitals and CAHs are also required to report 2014 clinical quality measures (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, regardless of whether they are in the Stage 1 or Stage 2 of Meaningful Use, 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: January 8, 2016