As an eligible professional moving forward in the Texas Medicaid EHR Incentive/PI Program from Adopt/Implement/Upgrade stage to Meaningful Use, it is important to maintain auditable records to support your attestation. To receive MU incentives, EPs must show they are meaningfully using the certified EHR technology by reporting on MU and clinical quality measures.
The following are the minimum required documents that must be uploaded into the Texas Medicaid EHR Incentive/PI Program portal at the time of your MU attestation. Based on the data provided during your attestation, you might be asked to submit additional documentation. Note that the documentation you submit during attestation is used for pre-payment review purposes, but it does not preclude a provider from being selected for a post-payment audit after the incentive payment has been disbursed. A post-payment audit is a formal process that requires a provider to submit additional detailed, auditable records to verify all federal eligibility and MU requirements were met when payment was received.
For the numerator/denominator measures, EPs must upload into the portal an EHR-generated summary MU report that shows the numerator and denominator for each measure reported. If some measures are not included in the summary report, other auditable documentation must be uploaded to support those measures, such as detailed data, screenshots or other verification. The report date(s) must match the EP’s EHR reporting period and only include MU data for the attesting provider.
For the yes/no measures, Texas Medicaid requires documentation for the following measures:
- Implement Clinical Decision Support: Provide a screenshot or other documentation showing CDS rule(s) configured during the entire EHR reporting period. For example, you might upload screenshots from your EHR configuration panel showing various CDS rules implemented.
- Drug/drug and drug/allergy interaction checks enabled (Measure 2 of CDS): Provide documentation such as a screenshot or configuration page showing this functionality was fully enabled during the entire EHR reporting period.
- Protect patient health information: Conduct or review a security risk analysis, implement security updates as needed and correct identified deficiencies. Provide a copy or documentation of your security risk analysis.
- Secure electronic messaging: Provide documentation such as a screenshot or configuration page showing this functionality was fully enabled during the entire EHR reporting period.
- Public health reporting: Provide documentation (email, letter, etc.) from the public health agency or clinical data registry acknowledging achievement of “active engagement” with the registry for immunization, electronic lab reporting for hospitals, syndromic surveillance, and specialized registry reporting. Active engagement means the provider is in the process of moving toward sending “production data” to a public health agency or clinical data registry, or is sending production data already. The documentation required will vary based on the active engagement option chosen by the provider during attestation. For the immunization registry, Eps must provide their TXIIS (ImmTrac) ID number.
Clinical Quality Measures
You can upload documentation for your reported CQMs; however, it is not required during attestation.
Keeping Good Records
EPs are required to maintain records to support all aspects of their attestation for six years. Always be sure to save all records, including dated screenshots, reports and communications that support an attestation, so they are available in the event of an audit. Be sure to document your compliance with the requirements during the specific EHR reporting period the EP is attesting to. EPs also can upload additional relevant data and documentation to the attestation portal for safekeeping.