May 29, 2015 Centers for Medicare & Medicaid Services Department of Health and Human Services P.O. Box 8013 Baltimore, MD 21244-8013 Attention: CMS-3310-P Re: The Centers for Medicare Medicaid Services (CMS) Proposed Rule-- Medicare and Medicaid Programs: Electronic Health Record Incentive Program Stage 3 To whom it may concern: Community Health Center Network (CHCN) is a partnership of eight federally qualified community health centers with over 75 sites, based in Alameda County, California. Our health centers serve over 175,000 patients with over 850,000 annual encounters. CHCN s mission is to enhance our health centers ability to provide comprehensive, quality health care in a manner respectful of community traditions and values. Together, our clinics represent over 300 eligible providers for Meaningful Use. The vast majority of our sites use NextGen EHR systems and are participating in the Medicaid Meaningful Use program. For 50 years, Community Health Centers have worked to engage patients in a culturally and linguistically competent manner, reduce racial disparities, improve patient safety, coordinate care, improve overall efficiency, and ultimately through this work have improved the health of America s most vulnerable communities. Community Health Centers have been the medical home for low income, uninsured, and medically under served Americans long before the term medical home became popular. The principles used to craft the definition of meaningful use are the same principles that guide healthcare delivery in CHCs today. We appreciate the opportunity to comment on this proposed rule, the outcome of which could greatly affect our member clinics continued participation in the Meaningful Use program. General Comments: 1. Overall, we are supportive of the goals to streamline the Meaningful Use program and reduce provider burden as well as those to promote health information exchange and improve outcomes. We support the alignment of the Meaningful Use program to a single stage, and
believe that starting Stage 3 reporting in 2018 (with an optional year of reporting in 2017) allows for reasonable preparatory time for EPs and organizations. 2. Providers Working at Multiple Locations: CMS should remove the constraints EPs suffer if they work at multiple locations. If an EP works at a location that uses CEHRT where >50% of their encounters occur, they should be able to demonstrate Meaningful Use per the encounters at that one site alone. In the FQHC environment, many providers are part-time and may work for multiple organizations. The requirement for EPs to combine MU data from all organizations with CEHRT where they saw patients is prohibitively difficult. Most often, it is not the EP, but an administrator who is collecting the MU data. Other organizations where the EP may work have no incentive to gather and provide MU data to an unrelated entity. As an example, having the data from a previous employer, that previous employer s CEHRT ID and supporting documentation is a barrier to meeting MU when reporting from multiple locations is required. Implementing this change would likely increase the number of Meaningful Users. To advance the number of meaningful users nationwide, removing all restrictions (applicable to all Stages and all Program Years) that an EP faces if working at multiple locations would benefit many. 3. Reporting Periods 90 Day Reporting Period: For Medicaid EPs in their first year of reporting, we commend CMS for moving away from calendar quarter reporting, in favor of 90 day continuous reporting. However, the 90 day continuous reporting should include an allowance for at least 90 days or 3 calendar months. By doing this, you allow an EP to run reports by month within their EHR system using their Meaningful Use (MU) dashboard, regardless of the number of days in any given month, as long as they capture at least 90 days or 3 calendar months. For example, an EP or administrator can run a report for October through December, which would provide 92 days of data, or February through April which would provide 89 days of data. Full Year Reporting Period: While we greatly appreciate efforts to streamline and align reporting periods, it will be extremely difficult for an Eligible Professional (EP) to meet the full year requirement if the EP has changed place of service (employment) during a reporting year. This is quite common among FQHCs and has resulted in substantial lost revenue when data cannot be collected from a previous employer. We recommend that if a provider has changed place of employment during a year, that they may attest to a reporting period of at least 90 days. We also anticipate it being very challenging for an organization to have documentation of enabled on the first business day following the completion of the preceding reporting period a grace period is recommended for measures that are required to be enabled for the entire reporting period. 4. Removing Topped Out Measures. We applaud the effort to streamline Meaningful Use reporting by removing redundant and topped out measures. However, there needs to be more clarity with respect to how these measures are still required and/or tracked within other
measures such as Summary of Care/CCDA. If meeting Meaningful Use requires digging deep to understand all the various sub-requirements that have been folded into measures, this does not simplify adherence for EPs. In fact, there could be unintended consequences that if subrequirements of a measure are hidden or unclear, EPs could falsely believe they are meeting a measure and then find out at attestation or worse, during an audit post-attestation, that they have missed a minor required detail. We would argue that a great deal of the burden faced by providers and organizations in meaningful use reporting is not based on the number of measures to report on per se, but in understanding the detailed definitions, how they have been interpreted by vendors, and ensuring compliance. Objectives and Measures: Retained Stage 2 Objectives with Small Modifications Objective 1: Protect Patient Health Information a) We suggest that CMS revise the verbiage to include organization or site rather than focusing on the individual provider as often the SRA is not completed by the EP but by the employer. b) We also suggest changing the verbiage to at least annually or once per program year rather than at least once per EHR reporting period as first year MU attesting Medicaid providers will still have 90 day reporting periods. Completion of the SRA during the attestation tail period and prior to submission should also be permitted. Objective 2: Electronic Prescribing (erx) a) Some community health centers have expressed concern that requiring a query of drug formularies undermines the workflow for EPs who are very familiar with drug formularies, and requires them to divert precious provider/patient time towards an unnecessary process. For EPs who work in areas where CEHRT gaps persist, it creates a requirement that cannot be met due to actions beyond the control of the EP. More flexible options that acknowledge gaps in the current system and EPs expertise are recommended. Objective 4: Computerized Provider Order Entry (CPOE) a) It is highly recommended that CMS allow Medical Assistants who were hired and handling the paper based equivalent of CPOE prior to the Stage 2 Final Rules (September 2012), who are still with the same employing organization (as of Sept 2012), be referred to as Veteran MAs and be permitted to enter CPOE for MU. Such MAs have been doing this entry based upon organizational workflow, employee competency, and clinical staff oversight long before new requirements such as credentialed and by an organization other than the employing organization were introduced to the MU rules.
b) The 80% threshold is not realistically achievable if scribes and Veteran MA s are not allowed under CPOE. If they are not deemed eligible, it is recommended that the threshold be reduced to 60% for Measure 1 and 30% for Measures 2 and 3. Objectives with More Expanded Scope Objective 5: Patient Electronic Access to Health Information (VDT) a) Measure 1: Patient Online Access i. It has not been our experience that the current view, download, and transmit functions are widely in use. There is wide variance in the interpretation of what encounters count in current Stage 1 and Stage 2 VDT numerator and denominator. It has been noted during 2014 and 2015 that certified EHRs appear to have different interpretations of what allows a patient s account to appear in the numerator for the comparable Stage 1 and Stage 2 VDT measures. It is recommended that CMS clarify that which counts in the numerator and denominator so that EPs using different EHRs are on the same playing field. Example: Of 500 patients seen during the reporting period, 300 decline or opt out from having their information provided electronically. Is the denominator 200 or 500 (though 500 is the number of unique patients seen during the reporting period)? The objective as proposed in Stage 3 rule making is too complicated, has too many layers, and would continue the trend of different interpretation, resulting in an un-level playing field. ii. Measure 1 should be 50% (and during 2015 17 per the Modification Rule the comparable VDT measure should be 25% as opposed to 50%). This measure should be simplified to a patient s health information is provided via online access, striking VDT. To have two separate Stage 3 objectives ( Patient Electronic Access and Coordination of Care Through Patient Engagement ) that each include VDT is confusing. The importance in meeting this measure is the ability of the EP s EHR in getting the information out, made securely available outside of the EP s EHR and the clinic s 4 walls. The receipt, use, or consumption of that information is addressed in the Coordination of Care Through Patient Engagement objective. A CMS goal should be to simplify yet make meaningful. b) Measure 2: Patient Education i. This measure has not previously (Stage 1, Stage 2) been driven by having education resources provided electronically. The historic measure is that CEHRT is used to identify education resources that should be provided to the patient. Prior to reaching high levels of patient engagement, education material sent electronically will have a likelihood of never being seen by the patient. It is recommended that Measure 2 be that an EP uses clinically relevant information from Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient
(via any means) for more than 35% of all unique patients with office visits seen by the EP during the EHR reporting period. This would encourage meaningful use of technology but avoid the meaningless dissemination of information that is not accessed let alone used by the patient. ii. It should be noted that a significant number of CHC patients opt out of electronic engagement, which makes engaging those patients electronically very difficult. Other patients may opt into electronic engagement, but have sporadic access to the internet. Unlike patients accessing services in the private practice or general hospital settings, low-income patients at CHCs have reduced access to home computers, smart phones, and basic internet services. For these patients, non-electronic engagement is preferred, and should not be dis-incentivized. Objective 6: Coordination of Care through Patient Engagement a) Measure 1: VDT Increased from 5% (or 1 patient, per 2015-2017 NPRM) to 25% i. Per the 2015 2017 Modification NPRM, the Stage 2 baseline of 5% is not expected to be a rule through 2017, but rather at least 1 patient. API is new to meaningful use. We believe that 25% threshold is too high. It is recommended that for Stage 3 EPs, the successful threshold should be 5% or 10%. This change recognizes the challenges faced by CHCs and the patients they serve in accessing technology required to meet this measure. Unlike patients accessing services in the private practice or general hospital settings, low-income patients at CHCs have reduced access to home computers, smart phones, and basic internet services. For these patients, non-electronic engagement is preferred, and should not be dis-incentivized. b) Measure 2: Secure Messaging Increase from 5% (or YES attestation in 2015-2017 NPRM to 35%) i. The revision of secure messaging, that which is initiated by the EP, is a fair revision wherein meeting the measure is not dependent upon patient action only. ii. In the rulemaking, it is suggested or expected that the EP s comments be clinically relevant, however, we cannot impose constraints on the CEHRT with an expectation that this level of input be measured. Examples have been provided by CMS that are helpful, however these examples clearly outline the challenges in how CEHRT would have to differentiate the content of the secure message. Such an expectation is not realistic. iii. The proposed rule references both provider s authorized representative sends a secure message and provider must respond to the patient. CMS should provide clarity with verbiage on who can send out and respond to messages. We proposed that the measure should state provider or authorized representative, including other appropriate clinical staff.
iv. We also believe that an increase to 35% is too high and that threshold for Stage 3 should be at 5% or 10%. c) Measure 3: Patient Generated/Non-Clinical Health Data i. Traditionally, patient-generated health information has not routinely become a part of a patient s medical record, and it should not begin to become part of a patient s electronic medical record simply because we now have the technology to make it a requirement. Information provided by non-clinical settings might be deemed appropriate by clinical staff to include in an electronic record but should be at the discretion of the EP, not the patient, non-clinical personnel, or CEHRT. If approved in the final rule, we do not expect it to be widely adopted. ii. Patient-centered communication between and among providers is a worthwhile objective and despite the above comments related to this proposed measure, should not be discouraged. Technical barriers might easily present towards meeting this measure. The use of customized templates has been imperative for EPs to be able to truly meaningfully use their EHRs. Such customization would likely make the incorporation of health data from patients or non-clinical settings a new burden in meeting MU. iii. We believe an introductory threshold of 15% is not reasonable. It is recommended for Stage 3 EPs, the successful threshold should be 5%. Objective 7: Health Information Exchange (Summary of Care Record) a) Measure 1: Create and electronically exchange a Summary of Care Record--increase from 10% to 50% i. The 50% threshold for this measure is not realistic. While EPs may have the technology to achieve the goal, they cannot force non-ep partners to adopt the appropriate technology, making their task impossible. In addition, some transitions of care do not require, and in fact, should not include a full summary of care, once again reducing opportunities for adherence. We recommend that the threshold be set at a more reasonable 15-20%, or include flexibility options that allow an EP to exclude transitions of care where the receiving entity does not have appropriate technology or does not have a clinical need for a summary of care. b) Measure 2: For more than 40% of transitions of care or referrals received and new patients, EP must incorporate an electronic summary of care record into patient s EHR from another care setting i. The wording of this measure is confusing and it is unclear how exactly CEHRT will capture the data, which could lead to varying interpretations by EHR vendors. If the meaning is to have EPs (or authorized their representatives we would suggest
adding), electronically query for a Summary of Care Record (when possible and technology exists), and incorporate into the EHR at least 40% of those summary of care records received electronically, then the threshold would be possible. It would require the CEHRT to capture a query, electronic receipt of summary of care, and then to calculate the percentage incorporated. The definition of incorporate would need to be better defined to understand if this means incorporating discrete data, or the summary of care as a unique document (or if either would count). ii. However, if the 40% threshold stands regardless of receiving an electronic Summary of Care, this measure would depend on referring providers or other care settings, and would unfairly penalize many of our providers who refer to specialist networks that may not have CEHRT or be participating in Meaningful Use. iii. In addition, as a new measure, and given the complex challenges CHC EPs face in caring for highly transient, vulnerable communities, a 40% attainment threshold is too high. We recommend 15%. c) Measure 3: Clinical Information Reconciliation (CIR) Increased from 50% to 80% and additional requirements added i. Does EP need to perform reconciliation or can the reconciliation be completed by other clinical staff and overseen by the EP and/or at the EP s discretion? If a health care professional is allowed to complete CPOE, are they permitted to complete reconciliations for this measure as well? ii. This rule appears to use the terms Summary of Care document, CCD-A and/or CCDS interchangeably. It would be helpful if CMS clarified the definition of these terms or state that they are synonymous. Objective 8: Public Health and Clinical Data Registry Reporting i. We applaud verbiage change from ongoing submission to active engagement as the definition of ongoing submission was unclear. Additionally, progress around submitting data on an ongoing basis can often be out of the EP s control due to backlogs or technology problems at public health agencies. ii. Public Health measures should be met by site, not EP. Any EP working at a site that meets the requirements should be eligible to attest Yes, regardless of who administers the required therapy or immunization. For example, an EP that is licensed and capable of administering an immunization, but does not in their current scope of work administer immunizations, is still a provider who is available to the security of Public Health should an epidemic present and that EP is called upon to help the system with administering emergent immunizations. It is important the EP s site be capable, not whether the EP actually administers any immunizations during an MU reporting period. It is fair that exclusion for a measure does not count toward the total requirement of three measures.
CHCN appreciates the opportunity to submit this public commentary. Please contact Molly Hart at mhart@chcnetwork.org with any additional questions or clarifications. Sincerely, Molly Hart Healthcare Analytics Strategist Community Health Center Network