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HAP Comment Letter to CMS about Proposed Rule on Modifications to Meaningful Use for 2015–2017

June 15, 2015

Andrew M. Slavitt
Acting Administrator
Centers for Medicare & Medicaid Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W., Room 445-G
Washington, DC 20201

Re: CMS-3311-P Medicare and Medicaid Programs; Electronic Health Record Incentive Program— Modifications to Meaningful Use in 2015 through 2017; Proposed Rule 

Dear Mr. Slavitt:

On 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 Program for 2015 through 2017.

The proposed rule provides significant flexibilities in the reporting period and the definition of meaningful use that are needed for the program to succeed.

However, we do have concerns about the scope of some of the proposed changes in the middle of a program year, which could cause confusion and increase burden for hospitals, particularly for those new to the program.

Changes to the Reporting Period

HAP greatly appreciates the shorter, 90-day reporting period CMS has proposed for eligible hospitals, critical access hospitals, and physicians and other eligible professionals (EP) in 2015. We strongly urge CMS to finalize as quickly as possible the shorter reporting period.

Flexibility in Meaningful Use Requirements

HAP also appreciates the specific proposed changes to meaningful use objectives and measures that would create more flexibility for providers in meeting the modified version of Stage 2 and strongly urges CMS to finalize them as proposed.

Hospitals have found the current set of requirements to be overly prescriptive and difficult to meet. This is particularly true of those items that hold providers accountable for the actions of others that are beyond their control.

The changes in the proposed rule would go a long way toward easing those challenges, while still keeping hospitals on track to deploy advanced EHR functions that support improved care and engaged patients.

Specifically, HAP supports the proposals to:

  • Remove objectives and measures from Stage 2 that CMS believes are “redundant, duplicative or topped out”
  • Change the measures for patient electronic access
  • Change the requirements for the summary of care objective
  • Change the requirement for secure messaging (EP only)

Objectives for Removal

CMS proposes to remove 11 hospital objectives and two hospital measures from Stage 2 that it believes are “redundant, duplicative or topped out.” For EPs, CMS proposes to remove ten objectives and two measures, most of which overlap with the hospital objectives proposed for removal.

While the AHA supports removal of these objectives to simplify the meaningful use requirements, we note that many of these items would still be part of the meaningful use program because they are fundamental pieces of other objectives.

For example, CMS proposes to remove collection of problem lists as a separate objective, but problem lists would be expected to be available through the patient portal.

Patient Electronic Access

The AHA greatly appreciates the proposed changes to this objective and strongly urges CMS to finalize them as proposed. The AHA also encourages all hospitals to continue to actively engage patients through whichever channels patients prefer, whether in person, by telephone, electronically or via other means.

In response to the concerns of hospitals and physicians, CMS proposes to change the requirements on patient engagement for 2015 to 2017. Under the proposed rule, the current requirement to provide patients online access to their health information would remain.

However, the requirement that 5 percent of patients use the patient portal would be modified to at least one patient using the portal. We agree with CMS that this change would ensure the capability is enabled while giving providers and patients more time to incorporate these tools into the care process.

The proposal also would not hold providers accountable if patients choose not to use the portal technology. In many acute care cases, such as a broken arm or a hospitalization for pneumonia, it may well make more sense for patients to access information through their primary care provider, who coordinates all of their care, rather than from the hospital directly.

Furthermore, as currently constructed, the program encourages the proliferation of portals across providers, rather than a consolidation of results and information in one place.

Summary of Care

The AHA appreciates the proposed changes to the summary of care objective, which has been challenging for hospitals to meet, and urges CMS to finalize them. CMS proposes to rename and modify the specifications for the transitions of care objective in the following ways:

  • Remove the current Stage 2 requirement that a summary of care document be sent for 50 percent of transitions and referrals (which could include fax and paper copies), referred to in the rule as Measure 1
  • Keep the requirement that the hospital, critical access hospital, or EP send the summary of care electronically for ten percent of transitions and referrals
  • Remove the requirement to send at least one summary of care record to a provider that uses a different EHR vendor
  • Remove any requirements on the specific methods used to electronically send the summary of care document, such as specifying the use of a certified EHR to do so

Proposals that Would Make Meaningful Use More Difficult or Complicated

HAP believes the proposed rule contains several provisions that would make it more difficult for providers to meet meaningful use. Some of those changes would apply to all providers, while others would accelerate the requirements on providers new to the program. HAP strongly urges CMS to refrain from finalizing proposals that increase the difficulty of meeting meaningful use Stage 2 for all hospitals, including those new to the program.

Consolidation at Stage 2

CMS proposes to create a single, modified Stage 2 definition that all providers would have to meet. For 2015 only, CMS proposes to afford providers meant to be at Stage 1 the option to attest to the Stage 1 objective and measure specifications for all of the objectives of meaningful use that it has retained.

For example, these providers would have to implement only one clinical decision support tool (Stage 1 requirement), rather than five (Stage 2 requirement).

For objectives that did not exist in Stage 1, these providers would have an exclusion in 2015. For example, these providers would have an exclusion from the transitions of care objective because Stage 1 does not have a similar objective.

In 2016 and later, however, CMS would require all providers to meet the same requirements, regardless of when they first enter the program.

HAP opposes the requirement that all providers meet all of the modified Stage 2 requirements in 2016 and later years. We strongly recommend that CMS keep the alternate specifications and exceptions it proposes for 2015 available to providers meant to be at Stage 1 in 2016 and 2017.

e-Prescribing

Under previously finalized rules for Stage 2, e-prescribing of discharge medications was a menu item. In this rule, CMS proposes to require it for all hospitals, with the same threshold of ten percent of hospital discharge medication orders for permissible prescriptions being queried against a drug formulary and transmitted electronically using a certified EHR.

CMS proposes to exclude hospitals from this measure in 2015 only if they did not intend to choose e-prescribing as a menu item. HAP strongly urges CMS to extend that exclusion into 2016 for all hospitals that did not intend to choose e-prescribing as a menu option.

At best, there will be five months between when this rule is finalized and January 1, 2016.

This is far too short a time period for hospitals to make all of the needed changes to implement e-prescribing of discharge prescriptions, which includes purchasing and updating technology, training both clinical and pharmacy staff, educating discharged patients on how e-prescribing will work, and making arrangements with local pharmacies, among other things.

Public Health Reporting

HAP has significant concerns with CMS’ proposals to modify the public health objective by adding new public health measures for hospitals and changing the immunization measure.

Specifically, the agency proposes to add new measures for case reporting, reporting to public health registries and reporting to clinical data registries, as well as changing the immunization measure to involve bidirectional information exchange; that is, both reporting to the registry and receiving forecasts and other information from the registry.

These items were not included in the previously finalized Stage 2 rules, and were not, therefore, anticipated by hospitals. Consequently, these reporting activities are likely not supported by the Certified EHR deployed by a given hospital.

Furthermore, we note that the ability of public health departments to maintain registries other than immunization registries and to accept electronic case reports is highly variable.

Finally, current certification requirements do not include bidirectional exchange with immunization registries; thus, hospitals do not have the capability to conduct bidirectional exchange.

Finally, HAP is concerned that, if CMS chooses to add new public health reporting options, it would greatly increase burden on hospitals. On its face, the idea of adding new options and allowing hospitals to report on three of the six measures would add flexibility to the program.

However, CMS also proposes that an exclusion for a measure would not count toward the total of three measures that must be met by a hospital.

For example, if a hospital qualifies for an exclusion on one measure, the hospital would still need to meet three of the remaining measures. If a hospital qualifies for four or more exclusions, however, the hospital could meet the objective by meeting the two remaining measures and taking one of its four exclusions.

This proposal places tremendous burden on the hospital to investigate and exhaust all possible reporting options, and adds uncertainty about compliance with a program that contains significant penalties for noncompliance.

Therefore, we urge CMS to include only those three public health reporting options for hospitals that have the same measure specifications and exceptions that were previously finalized for Stage 2.

Thank you for your consideration of our comments on this important proposed rule. If you have any questions, please feel free to contact me, or Martin Ciccocioppo, vice president, research, at (717) 561-5363.

Sincerely,

Paula A. Bussard
Chief Strategy Officer

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