Comment Letter to CMS on Proposed Changes to EHR Incentive Programs for 2014
for Medicare & Medicaid Services
of Health and Human Services
B. DeSalvo, M.D., MPH, MSc
Coordinator for Health Information Technology
of Health and Human Services
Independence Avenue, S.W.
Re: Medicare and
Medicaid Programs; Modifications to the Medicare and Medicaid
Record Incentive Programs for 2014; and Health Information Technology:
Revisions to the Certified EHR Technology Definition
Ms. Tavenner and Dr. DeSalvo:
behalf of The Hospital & Healthsystem Association of Pennsylvania (HAP),
which represents approximately 240 member institutions, including 125
stand-alone hospitals and another 120 hospitals that comprise 32 health systems
across the state, we appreciate this opportunity to comment on the proposed
changes to the requirements for the Medicare and Medicaid Electronic Health
Records (EHR) Incentive Programs for 2014.
HAP greatly appreciates the increased
flexibility the Centers for Medicare & Medicaid Services and Office of the
National Coordinator for Health Information Technology (ONC) have proposed for
eligible hospitals, critical access hospitals (CAH), and physicians and other
eligible professionals (EP) in 2014.
The flexibility offered in the
proposed rule would support continued adoption of EHRs; without it, many Pennsylvania
providers are likely to conclude that they cannot meet meaningful use this year
and abandon the program. That would be an unfortunate outcome for health care
in the commonwealth, and unfair to providers, given that they would miss out on
promised incentives despite their ongoing investments and be subject to future
payment penalties for failure to meet meaningful use.
We strongly urge you to finalize, as quickly
as possible, the proposal to expand providers’ choice of certified EHR
technology (CEHRT) to be used in 2014. The proposed flexibility is much
needed and would offer more choice in the specific meaningful use requirements
they must meet in 2014 (Stage 1 or Stage 2).
However, HAP is concerned that the
extremely late release of the proposed rule will limit its benefit to
recommend that the agencies:
greater flexibility in the electronic clinical quality measures reported
and simplify how the rule would be implemented
that 2015 also will be a transition year
from Stage 2 before finalizing the start date for Stage 3
that the specific proposed changes to regulatory text support the intended
hospitals have invested tremendous financial and human resources to accelerate
the widespread adoption and use of EHRs to improve health and health care to
make them reality. Our hospitals also work every day to ensure privacy and
security for patients and their health information. However, the complexity
2014 CEHRT criteria has limited the EHR
vendors’ ability to bring functional certified 2014 products to market
in time for safe provider adoption.
Further, the scope of Stage 2 meaningful
use requirements, especially those dependent on external players, have severely
hampered our providers’ ability to meet Stage 2 requirements in FY 2014. According
to data from CMS, as of mid-May 2014, fewer than 10 hospitals and 50 EPs had
attested to Stage 2.
HAP appreciates the flexibility afforded in the proposed rule and urges CMS and
ONC to finalize the provisions on choice of the CEHRT used without any changes
that would narrow the flexibility proposed. The late timing of the proposed
rule poses significant risk and operational challenges to hospital leaders, who
must make significant and consequential decisions about what actions to take to
meet meaningful use during the last possible reporting period for FY 2014 (July–September
2014) without the certainty afforded by a final rule.
believes that hospitals should have more flexibility in the eCQMs they choose
to report, regardless of the specific stage of meaningful use they meet.
Specifically, hospitals using a combination of 2011 and 2014 Edition CEHRT
should be able to report either set of eCQMs, regardless of the stage of
meaningful use met.
recommends that CMS remove the proposed limitation on providers’ ability to
take advantage of the proposed flexibility. The proposed rule would limit the
selection of an alternative approach to attesting in a manner consistent with
the existing rules to hospitals that “could not fully implement 2014 Edition
CEHRT to meet meaningful use for the duration of an EHR reporting period in
2014 due to delays in 2014 Edition CEHRT availability.”
HAP members have
expressed considerable concern that this limitation creates uncertainty that could
limit the benefit of the proposed flexibility. At a minimum, the agency should
make clear in the final rule that many different scenarios could prevent a
provider from fully implementing a 2014 Edition CEHRT, even beyond those
specifically mentioned in the proposed rule.
The agency also should carefully
instruct its meaningful use auditors that a full range of individual
circumstances can be expected to qualify a provider for this flexibility,
including some that may not be foreseen by our comments or agency staff.
proposed rule states that, beginning in FY/CY 2015, all eligible hospitals and
professionals will be required to use 2014 Edition CEHRT to report meaningful
use, consistent with current rules. The reporting period would be 365 days for all
providers, except the limited number in their first year of meaningful use, for
whom the reporting period will be 90 days. Thus, the vast majority of hospitals
will be expected to meet Stage 2 criteria no later than October 1, 2014.
strongly recommends that CMS shorten the reporting period for 2015 to 90 days
for all hospitals, CAHs and EPs. As acknowledged in the proposed rule, a
central reason for the challenges being faced today is the requirement for a
nation-wide, simultaneous upgrade to a new certification level for EHR
The flexibility in 2014 is helpful, but in reality provides only
three months of additional time for providers to get up and running with Stage
2 requirements using the 2014 Edition technology. It takes 19 months to
efficiently and safely move from having the software to being able to attest to
the next stage of meaningful use— assuming a three-month reporting period. Most
hospitals received their 2014 Edition CEHRT in spring or summer 2014 (with some
still waiting), and will need until summer 2015 to complete their transition.
believe a 90-day reporting period would keep all providers moving forward to
meet Stage 2, while giving them additional time to undertake the many workflow
and other changes required by Stage 2. We prefer any continuous 90 days in the
fiscal year to a period matching a fiscal year quarter because it allows more
flexibility in when providers begin their reporting period. In addition, it
allows vendors to better manage the large number of providers seeking support
as they begin and end their reporting periods by spreading these dates over the
year, and not bunching them into four specific days (the start and end of the
addition, the Stage 2 rules are very challenging to meet, and while the
proposed rule does not address the definition of Stage 2, we continue to
believe that CMS should provide additional flexibility for Stage 2.
Specifically, the rules make unwarranted assumptions about the level of
information exchange that is possible by specifying “view, download, and
transmit” and “transitions of care” requirements that are beyond the capacity
of today’s exchange infrastructure. Hospitals are successfully using EHRs to
improve the quality of patient care and reduce medical errors.
rate of adoption has been less robust among other care settings—such as skilled
nursing facilities and home health agencies—that are logical recipients of
hospital data. Similarly, patients are just beginning to use tools, such as patient
portals, that hospitals make available to allow direct, electronic access to
their medical records, but the practice is not yet commonplace. While we
continue to believe that the Stage 2 requirements that make hospitals’ success
contingent on the actions of others should be removed, a 90-day reporting
period in 2015 would at least afford hospitals more time to develop the
relationships and information exchange structures to engage their external
insists that it is too soon to finalize the start date of Stage 3 as FY 2017
for hospitals, as proposed. Instead, CMS should specify that the 2014 Stage 1
and Stage 2 criteria will be effective until updated by future rulemaking. This
approach is consistent with the policy CMS adopted in the 2010 Meaningful Use
Final Rule, which made the Stage 1 criteria effective until updated by future
Rushing toward another aggressive deadline for Stage 3 could
jeopardize program success. Furthermore, no one, including CMS and ONC, can
judge readiness for providers to meet Stage 3 in the absence of the specific
criteria that will be required. It would, therefore, be more appropriate to
wait until the Stage 3 rules themselves are finalized to codify the start date
in regulation. CMS and ONC should take the time to thoroughly evaluate
experience under Stage 2 before moving on to Stage 3.
HAP requests that CMS carefully assess whether additional changes to the
regulation text at Part 495 are needed to explicitly authorize the practical
use of the full array of options discussed in the proposed rule. Following such
an assessment, if the agency concludes that additional regulatory changes are
not required, we ask that the final rule preamble explicitly acknowledge that
this is the case and explain CMS’s rationale for this conclusion. Our goal is
to ensure that eligible hospitals, CAHs, EPs and other stakeholders have a
clear understanding of the options for meeting EHR meaningful use requirements
in FY or CY 2014.
Thank you for the opportunity to provide comment on this important
proposed rule. If
you have any questions, please feel free to contact me at (717) 561-5344, or Martin Ciccocioppo, vice president,
research, at (717) 561-5363.
and Regulatory Advocacy