? 495.24(d)-Objectives/Measures (EPs)

https://www.qualitynet.org/

Registration & Attestation User Guide
For Eligible Hospitals and Critical Access Hospitals

Medicare EHR Incentive Program
Registration Information & Disclaimer
Attestation Information & Disclaimer

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CONTENTS
Step 1 – Getting Started

3

Step 2 – Quality Net Secure Portal

4

Step 3 – My Tasks Page

5

Step 4 – Meaningful Use Registration

6

Step 5 – Provider Selection Page for Admin Users

7

Step 6 – Registration Status Summary Page

8

Step 7 – Registration Information Data Entry Page

9

Step 8 – Registration Questions Answered

10

Step 9 – Registration Information Completed

12

Step 10 – Business Address & Phone Number

13

Step 11 – Registration Disclaimer

16

Step 12 – Attestation/Disclaimer Selection

17

Step 13 – Attestation Information

18

Step 14 – Attestation Disclaimer

22

Questions/Help

24

Acronyms

25

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Step 1 - Getting Started
This guide will assist in navigation throughout the Hospital Quality Reporting (HQR) Web-Based
Data Collection Tool application. It contains the steps needed to use this application in the
QualityNet Secure Portal to begin entering Meaningful Use (MU) Web-Based data, specifically,
the Registration and Attestation forms. This document will not cover the data entry for
Meaningful Use Objectives or Meaningful Use Clinical Quality Measures. These topics are
discussed in a separate user guide.
No PHI or PII will be displayed within this document. All names are either ficticious or blurred.
Eligible hospitals and Critical Access Hospitals (CAHs) can receive incentive payments and
avoid penalties through the CMS Medicare and Medicaid Electronic Health Records (EHR)
Incentive Programs by demonstrating their meaningful use of Certified Electronic Health
Records Technology (CEHRT) to improve patient care.
Hospitals wanting to take part in the program will use this HQR web-based system to register
and demonstrate effective and meaningful use of Certified Electronic Health Records
Technology (CEHRT) by providing the following information:


Meaningful Use Registration/Disclaimer



Meaningful Use Attestation Information/Disclaimer



Meaningful Use Objectives

Depending on your Attestation Information, you might also have to provide the following:


Meaningful Use Clinical Quality Measures (CQMs)

You must complete the Registration and Attestation process before you are allowed to enter
either Meaningful Use Objectives or Meaningful Use Clinical Quality Measures. Error messages
will warn you if you have not completed the Registration and Attestation pre-requisites.
Registration is a onetime process. To complete it successfully, you must enter information for
three pieces of information: Registration Information, Business Address & Phone Number, and
Registration Disclaimer.
The Registration data submission period opens January 2, 2018, Pacific Time and does not
close. Users can continue to register through the EHR Registration & Attestation website (NLR)
prior to this date. Registration data can be modified at any time once it is submitted.
This guide will demonstrate how to complete the Registration and Attestation forms available
through the Hospital Quality Reporting system’s QualityNet Secure Portal (QNet), Web-Based
Data Collection Tool application.

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Step 2 – Quality Net Secure Portal https://www.qualitynet.org/
This guide begins with the screen that immediately appears after you have successfully logged
in to the QualityNet Secure Portal with your appropriate credentials. https://www.qualitynet.org/
If you need assistance with logging into the QualityNet Secure Portal, please refer to the
QualityNet Secure Portal User Guide.
After you log in to the QualityNet Secure Portal with appropriate credentials, select the Hospital
Quality Reporting IQR, OQR, ASCQR, IPFQR, PCHQR link (circle 1) from the Quality
Programs (arrow 1) dropdown on the QualityNet page.

After Logging In, Choose HQR

Your My Tasks page will appear. Depending on your assigned role(s) you may see different
selection options on this page. Click the View/Edit/Structural/Web-Based Measures/Data
Acknowledgement (DACA) link name under Manage Measures (circle 1).

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Step 3 - My Tasks Page

The Program Selection page will appear. Again, Depending on your assigned role(s), you may
see more or fewer selection options. Click the desired program link name, in this case,
Meaningful Use Registration/Disclaimer (circle 1). You may return to this page to select
another different option at any time, by clicking the Start option (arrow 1) in the upper left
corner of the screen. This option is always available.

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Step 4 – Meaningful Use Registration

When you are logged in as a Provider user, you have access only to your organization’s data.
After you click Meaningful Use Registration/Disclaimer the Registration Status Summary
page will appear.
When you are logged in with administrative privileges, you have access to multiple providers
and will be presented with a Provider Selection page after clicking Meaningful Use
Registration/Disclaimer. You must identify the providers you want to work with by selecting
one or more (circle 1) from the drop-down. Providers may be selected in any order, or you can
select the All option (arrow 1) and work with every one of them.
Should you need to return to the Program Selection page, click the Back button (arrow 2).
After you have selected the providers you want, click Continue (arrow 3)

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Step 5 - Provider Selection Page for Admin Users

This will take you to the Registration Status Summary page.
This Registration Status Summary page example is the result of multiple-provider selections.
A single provider user will see only a single status row. Nevertheless, the Status Summary page
operates the same way for all users.
On this screen, you will see the MU Registration/Disclaimer link names are across the top of the
summary grid (circle 3). You will also see Provider IDs on to the left of the grid (arrow 1),
shown as is the CMS Certification Number (CCN). Statuses are shown under the link names
and across from the Provider ID. Prior to January 2018, these statuses will be marked “Not
Available” and registration should continue to be done using the NLR site. Beginning January 2,
2018, HQR system MU Registration/Disclaimer statuses will be either “Incomplete” or
“Completed” (circle 2).
Users will be able to view detailed information regardless of whether the status is listed as
“Incomplete” or “Completed” “Incomplete” is the default status when the submission period
opens. The status will remain in an “Incomplete” status until the registration data is successfully
submitted. Registration Information, Business Address and Phone, and Disclaimer data is
accessed by clicking the link within the top row (circle 3).

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Step 6 - Registration Status Summary Page
Multi -Provider Registration Status Summary

Below is an example of the single provider’s Registration Status Summary page. All statuses
in this example are marked “Incomplete” (circle 1).
Though information can be completed in any order, we will proceed left to right starting by
clicking on Registration Information (arrow 1).

Single Provider Registration Status Summary

Data entry pages appear after you click a link name. The provider is identified at the top of the
page (circle 1), above the questions.
Please note the additional functionality, for multiple provider users, within the data entry pages.
Multiple provider users can stay with one data field and move to another provider using the
Previous Provider or Next Provider links (circle 2) at the bottom of the data entry page.
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These links, however, are available only when there is a previous or next provider to move to.
When you start a section, only the Next Provider link is available. When you reach the last
provider, only the Previous Provider link is available.

Step 7 - Registration Information Data Entry Page
Registration Information has a question hierarchy. This means that additional required
questions may appear depending on how you answer the initial questions.
You are unable to determine the question hierarchy by simply looking at a data entry page. You
could determine the hierarchy once you start answering questions. However, if you want to
know in advance, you can find each question documented in the Online Help, Appendix B,
along with the conditions under which the question is required.

Once you answer all required questions (circle 1), you may then click the Submit button (arrow
3) to save your information. If there are no errors, a successfully saved message (arrow 1) will
appear above the name. This will be considered “Completed” and you will see this status on the
Registration Status Summary page after you click the Back button (arrow 2).
The Print button (arrow 4) does not print what is on your screen. It prints only saved or
submitted information. If you click Print before any information has been submitted, you will see
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all the questions regardless of hierarchy, without answers, including in this case the CEHRT
question.
Pages printed from saved/submitted information are generated in a separate window and you
must use your browser’s print option to send it to your printer. When you are done, close the
Print-button generated window.

Step 8: Registration Questions Answered
Registration Questions Answered -No CEHRT entered

In the next screen, you will see what the page looks like if you answer that you do have a
CEHRT number You can see that “Yes” was answered (arrow 1) to the question “Do you have
a certified EHR Number?” and, so the user has been prompted to enter their CEHRT number
(arrow 2).
CEHRT numbers require the entry of 15 alpha-numeric characters. Users whose CEHRT
numbers contain characters 14E, 15E, or 15H in character positions three, four, and five will
later be allowed to enter information for Meaningful Use Objectives. See the Meaningful Use
Objectives and Clinical Quality Measures (CQMs) training video.
In our Registration Information example here, the information was successfully saved (arrow
3).

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Step 8 Continued:
Registration Questions Answered, with CEHRT

Please note the following about data entry pages. Outside of clicking the Print button, if you
leave a data entry page prior to clicking Submit and saving the information, any data you have
entered will be lost. To prevent this, regardless of whether any changes were made, there will
always be an informational warning message to which you must respond OK (arrow 1) in order
to leave a page.

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Step 9 - Registration Information Completed

To return to the Registration Status Summary page, click the Back button then the OK button.
Notice that Registration Information is now marked “Completed” (arrow 1).

Once you click the Business Address & Phone Number (arrow 2) link name, the data entry page
appears. These questions are not hierarchical.
The address and city questions (circle 1) are free-text fields. Select your state from the
dropdown (arrow 4). Your phone number (arrow 5) must be formatted with hyphens after both
the area code and the first three digits of the phone number. Your email address must be
correctly formatted and confirmed (arrow 6).
Information is required in all fields except “Enter Address Line 2” (arrow 1) and the ZIP Code
extension field associated with “Enter Zip+4” (arrow 2), as is seen by those questions not
having a red asterisk.
After all the required fields have been entered, click Submit to save your data.

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Step 10 - Business Address & Phone Number

The application displays a message that the questions have been successfully saved (arrow 1).
Note the placement of hyphens in the phone number (arrow 2).

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Step 10 - Continued

Once we return to the Registration Status Summary page, you will notice that the Business
Address & Phone Number field is now marked “Completed” (arrow 2). Now let’s select (arrow
1) and complete the Disclaimer.

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Step 10 – Continued
Business Address & Phone Number Completed

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Step 11 - Registration Disclaimer

Read the Disclaimer form, click the “Yes, I Acknowledge” button (arrow 1), and enter a
description of your position. Click Submit. Once the Disclaimer is successfully saved, you will
see the successfully saved message near the top of this page. Note: You cannot deselect “Yes,
I Acknowledge” once the data is saved. Only the “Position” information can be changed and resubmitted/saved if needed.
You now need to return to the Program Selection page to enter Attestation data. Click the
Start option in the upper left corner (arrow 2). Remember, you can click the Start option in the
upper left corner of any screen you are on to return to the Program Selection page.

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Step 12 - Attestation/Disclaimer Selection

On the Program Selection page click the Meaningful Use Attestation/Disclaimer link (circle
1). Once you select this Program, the Program Year Selection page will appear.

Program Year Selection Page

Unlike Registration, Attestation requires the selection of a Program Year (arrow 1). Click the
dropdown and select 2017 (arrow 1). It is currently the only year available.

You will be allowed to enter Attestation data for Program Year 2017 only during the data
submission period January 1, 2018, through February 28, 2018, Pacific Time. Other years will
be added in the future.
Click Continue (arrow 2).
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Step 13 - Attestation Information
As with Registration, single provider users will immediately see an Attestation Status
Summary page, while multi-provider users will have to choose providers from a dropdown list.
For single and multi-provider users, the Attestation Status Summary page operates like it did
in Registration. Providers are identified on the left of the summary grid (arrow 1), measure links
are displayed across the top of the summary grid (circle 2), and statuses are within the grid
itself. There are important differences, too.

Data submission and reporting periods (circle 1) are identified near the top. There are two
additional statuses as well, “Not Available” and “Rejected”.
“Not Available” is displayed under both Attestation Information and Disclaimer when the current
date is prior to the submission period start date. “Rejected” is a status that can only displays
only under Attestation Information.
Note that the Submission Period date range displayed here (arrow 2) is not available in
production. This Submission Period was extended back into 2017 to allow us to test the
software and to complete this training video. The Submission Period available for any given
Program Year is January 1 through the end of February.
Once you select the Attestation Information link, you will see the data entry page. The Provider
is identified at the top (circle 1) along with the Submission Period and Reporting Period (circle
2). All eight questions must be answered (circle 3), but they can be answered in any order.

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Step 13 – Continued Attestation Information Data Entry Page

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You will again enter your 15 alpha-numeric character CEHRT number (arrow 1). The Reporting
Period for MU Objectives dates (arrow 2) must span a minimum of 90 consecutive days within
the associated Reporting. The Reporting Period for MU CQMs dates (arrow 3) must span a
minimum of 90 consecutive days with the associated reporting period for first time Meaningful
Use providers. The Reporting Period for MU CQMs dates would need to span the entire
reporting year for returning providers.
When the EHR Reporting Period start and end dates (circle 1) do not meet the minimum
requirements within the Reporting Period window, an error message (arrow 1) will appear after
you click the Submit button. Your information will not be saved until you correct the date
ranges.

Step 13 – Continued
Completed Attestation Status, Rejected

When one or more answers to a question under Attestation Statements (arrow 1) is “No”
(arrow 2), the Attestation Information will be saved when you click Submit, but the status will be
reflected on the summary page as rejected.

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Step 13 – Continued
Attestation Statement with No as Answer

The Attestation Status Summary page will reflect this (arrow 1) and you will not be allowed to
enter Meaningful Use Objectives or Clinical Quality Measures data.

Attestation Information, Rejected

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Step 14 - Attestation Disclaimer
The Attestation Disclaimer functions the same as the Registration Disclaimer form. After you
read it, click the “Yes, I Acknowledge” (arrow 1) and enter a description of your position. Your
information is saved when you click Submit (arrow 2).

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Step 14 – Continued
Previously Completed Disclaimer Information
When you bring up a previously completed Disclaimer information at the bottom (circle 1)
identifies when the Disclaimer was completed and by whom.
If you need to change the Position description information, click the Update Acknowledgement
button. (Arrow 1). However, you will not be allowed to deselect the acknowledgement.

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Questions and Help
Resources:


Questions about the Web-Based Data Collection Tool application and help with technical
issues:



QualityNet Help Desk at [email protected]



1 (866) 288-8912.



The QualityNet Help Desk is available by selecting the Help Desk link at the bottom of
any page throughout this application.

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Acronyms
Centers for Medicare and Medicaid (CMS)
Critical Access Hospital (CAH)
CMS Certification Number (CCN)
Certified EHR Technology (CEHRT)
Electronic Health Record (EHR)
Hospital Quality Reporting (HQR)
Inpatient Prospective Payment System (IPPS)
Inpatient Psychiatric Prospective Payment System (IPF PPS)
Meaningful Use Quality Reporting (MU)
Office of the National Coordinator (ONC)
Center for Clinical Standards and Quality (CCSQ)
Outpatient Prospective Payment System (OPPS)
Payment File Development Contractor (PFDC)
Quality Management Value and Incentives Group (QMVIG)
QualityNet Secure Portal (QNet)

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