Gulf Coast Regional Extension Center

Hospital Services

Promoting Interoperability Requirements for Eligible Hospitals, CAHs, and Dual-Eligible Hospitals Attesting to CMS


Hospitals and CAHs that are eligible to participate in both the Medicare and Medicaid EHR Incentive Programs:

  • Medicare Eligible Hospitals and Critical Access Hospitals
  • Medicaid Eligible Hospitals and Critical Access Hospitals
  • Dually Eligible Hospitals and Critical Access Hospitals

Eligible hospitals, CAHs, Dually eligible or new hospitals attesting to CMS for both the Medicare and Medicaid EHR Incentive Programs will register and attest for the Medicare program in the QNet system. The Registration and Attestation System is available for Medicaid-only hospitals and CAHs.

EHR Reporting Period in 2018

For 2018, the EHR reporting period for all participants is a minimum of any continuous 90 days from January 1 through December 31, 2018.

Modified Stage 2 Objectives and Measures in 2018:

The following seven Modified Stage 2 objectives, which eligible hospitals and CAHs attesting to CMS must meet in order to successfully demonstrate meaningful use for an EHR reporting period in 2018.

  • Protect Patient Health Information
  • Electronic Prescribing
  • Health Information Exchange
  • Patient Specific Education
  • Medication Reconciliation
  • Patient Electronic Access
  • Public Health Reporting

For detailed objective descriptions, measure specifications, and options to attest with CEHRT, contact GCREC for further information.

Stage 3 Objectives and Measures:

Six objectives are required in 2018 for eligible hospital, critical access hospitals , including Dual-Eligible hospitals.

  • Protect Patient Health Information
  • Electronic Prescribing
  • Patient Electronic Access to Health Information
  • Coordination of Care Through Patient Engagement
  • Health Information Exchange
  • Public Health and Clinical Data Registry Reporting

Providers attesting to Stage 3 objectives and measures, have the options regarding the use of their EHR technology that support the functionalities, objectives, and measures for Stage 3.

Clinical Quality Measures:

In addition to reporting on the Modified Stage 2 or Stage 3 set of objectives and measures, eligible hospitals and CAHs must report clinical quality measures (CQMs) via the QualityNet portal. Eligible hospitals and CAHs that do not successfully report are subject to Medicare payment adjustments. Experienced GCREC consultants can make sense of these CMS reporting requirements and assist in navigating the QNet portal, whose password must be renewed every 60 days.

Hospitals may also meet CQM reporting requirements by participating in the Hospital Inpatient Quality Reporting (IQR) Program. The data collected through this program are available to consumers and providers on the Hospital Compare website.

Removal of Objectives and Reductions in Thresholds

CMS continues to update program objectives and reporting requirements. For Modified Stage 2, CMS reduced the threshold for one measure in 2018. For Stage 3, CMS reduced the thresholds for four measures in 2018. To stay abreast of these changes, contact GCREC for program specifics.