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June 15, 2015SENT VIA ELECTRONIC MAIL
Andrew M. Slavitt, Acting Administrator Centers for Medicare & Medicaid Services U.S. Department of Health and Human Services Attention: CMS-3311-P
P.O. Box 8013
Baltimore, MD 21244-8013
RE: Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Modifications to Meaningful Use in 2015 Through 2017
Dear Administrator Slavitt:
The North American Spine Society (NASS) appreciates the opportunity to comment on CMS’ proposals related to the Electronic Health Record Incentive Program-Modifications to Meaningful Use in 2015 through 2017. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several
disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.
NASS applauds CMS for proposing several changes to the program’s requirements for 2015-2017 that will likely improve the participant’s ability to meet meaningful use requirements during this
timeframe, and we encourage CMS to more closely align the Stage 3 Rule with changes outlined in this proposal. NASS also recommends that CMS assess the impact of these proposals on the Meaningful Use program before moving to Stage 3. Despite some flexibility offered under this proposal, there are still ongoing concerns and complexities associated with the Meaningful Use program. Below you will find our comments on specific proposals in this proposed rule.
Stages of Meaningful Use
CMS proposes to require all providers to attest to a single set of objectives and measures finalized in the Stage 2 final rule beginning with the 2015 reporting period. While CMS has outlined
accommodations for newer participants, including retaining specifications that align with Stage 1 and Stage 2 and offering exclusions in 2015, NASS disagrees with this proposal. CMS has noted their intent to create a new progression for this program, and NASS views this proposal as an attempt to
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further accelerate the timeline of this program. NASS cannot overemphasize the need for CMS to preserve a more gradual and staged process that recognizes the various situations of practicing professionals and provides support and encouragement to those with less experience with EHR implementation. Without the option of staged participation, new participants and those not yet participating in the EHR Incentive Program will become further removed.Elimination of 90-day Reporting Period
NASS is very concerned with CMS’ proposal to eliminate the 90-day reporting period for new participants to the program and requiring all eligible professionals to attest to meaningful use for a full year beginning in 2017. CMS already reversed its original 365 day reporting period ruling back to a 90 day reporting period under Stage 2 criteria due to shortfalls in reporting. Granting flexibility and an incremental approach will ensure that more eligible professionals meet meaningful use. All new participants to the program have traditionally been given the option to report for a 90-day period to allow them to get acclimated to the program, and this exception should be extended into the future. Additionally, CMS proposes to allow new entrants in the Medicaid program the shorter, 90-day reporting period, and this flexibility should be extended to ALL new entrants in the program, including Medicare providers. Elimination of the initial 90-day reporting period will create an enormous barrier for new participants and likely discourage new entrants in the program. Full year reporting does not give eligible providers and practices sufficient time to identify meaningful use shortcomings and implement corrective procedures before the next reporting year. CMS has the authority to define and implement shorter reporting periods, and we encourage CMS to allow this flexibility, at least for new participants.
Structural Changes to Meaningful Use
NASS appreciates CMS’ intent to streamline the program’s requirements and to ultimately minimize administrative complexity by proposing a single set of objectives and measures. In 2015-2017, eligible professionals would have to meet 9 required objectives using Stage 2 objectives, with available exclusions and other accommodations in 2015 for Stage 1 providers. While a single, more streamlined set of objectives may reduce complexity, it would also further limit the applicability of the objectives across specialties, practice types, and patient populations. Since the inception of this program, NASS has voiced concern that the objectives and measures are almost exclusively focused on primary care, not specialty care, which puts specialists at a disadvantage in terms of qualifying under the program. NASS continues to believe that the program should rely on a wider assortment of menu objectives (versus a more limited set of core objectives, all of which are required) and that EPs should have the flexibility to choose which objectives are most appropriate for their practice and most relevant to their patient population. This may require more work on behalf of the professional, initially, but ultimately provide for more meaningful reporting options, which would encourage greater participation.
Specific Comments Related to Meaningful Use Objectives
Electronic Prescribing
Proposed EP Measure: More than 50% of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT.
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Proposed Alternate EP Measure (for 2015 only): More than 40% of all permissibleprescriptions written by the EP are transmitted electronically using Certified EHR Technology. NASS recommends that the 40% threshold be preserved beyond 2015, at least for first year
participants. The majority of spine care specialists write very few prescriptions, and the prescriptions they do write are often only for controlled substances. Although controlled substances may be included as permissible prescriptions under Stage 3 objectives, providers still face significant barriers in transmitting these prescriptions even if their state permits it, including security compliance, provider authentication, pharmacy inability to electronically accept these prescriptions, and other regulatory barriers. The lower threshold will allow more flexibility to those providers trying to meet this objective.
Clinical Decision Support
Proposed Measure 1: Implement 5 clinical decision support interventions related to 4 or more CQMs at a relevant point in patient care for the entire EHR reporting period. Absent 4 CQMs related to an EP’s scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions. It is suggested that one of the 5 clinical decision support interventions be related to improving healthcare efficiency. Proposed Alternate Measure 1 (for 2015 only): Implement one clinical decision support rule
relevant to specialty or high clinical priority, or high priority hospital condition, along with the ability to track compliance with that rule.
Proposed Measure 2: The EP, eligible hospital or CAH has enabled and implemented the functionality for drug-drug and drug allergy interaction checks for the entire EHR reporting period.
NASS believes that the alternate measure for 2015 is reasonable and recommends that this flexibility also be offered to first time participants in 2016 and 2017.
Patient Engagement
CMS proposes to modify the current patient engagement objectives under the Patient Electronic Access (VDT) and Secure Messaging Objectives:
Remove the 5 percent threshold for Measure 2 from the EP Stage 2 VDT objective. Instead require that at least 1 patient seen by the provider during the EHR reporting period views, downloads, or transmits his or her health information to a third party.
Convert the measure for the Stage 2 EP Secure Electronic Messaging objective from the 5 percent threshold to a yes/no attestation to the statement: "The capability for patients to send and receive a secure electronic message was enabled during the EHR reporting period." NASS applauds CMS for heeding the medical community’s concerns regarding the difficulty of
meeting patient engagement objectives for meaningful use. Physicians are growing increasingly frustrated with being held accountable for measures out of their control, and NASS continues to reject any requirements that place this type of accountability on the eligible provider or hospital. We strongly support the proposed modifications under this objective.
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Public Health and Clinical Data Registry Reporting
Under this objective, EPs would be required to successfully attest to any combination of two measures out of five. Measures 4 and 5 may be counted more than once, if more than one public health or clinical data registry is available.
Measure Option 1: Immunization Registry Reporting: The EP is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).
Measure Option 2: Syndromic Surveillance Reporting: The EP is in active engagement with a public health agency to submit syndromic surveillance data from a non-urgent care
ambulatory setting for EPs
Measure Option 3: Case Reporting: The EP is in active engagement with a public health agency to submit case reporting of reportable conditions.
Measure Option 4: Public Health Registry Reporting: The EP is in active engagement with a public health agency to submit data to public health registries.
Measure Option 5: Clinical Data Registry Reporting: The EP is in active engagement to submit data to a clinical data registry.
For 2015 and beyond, CMS proposes to consolidate all of the public health reporting measures into one new objective, which includes public health and clinical data registry reporting. Of the five measures available for eligible providers for this objective, NASS believes that Measure 5 would likely be the most relevant to spine care specialists. For the purposes of meeting the clinical data registry reporting measure, eligible providers would have to demonstrate that they are in “active
engagement” with a registry. CMS proposes 3 options for demonstrating “active engagement.” While NASS appreciates CMS’ flexibility under this measure, we’re concerned that these options may not be sufficient enough to accommodate this new measure. Under “active engagement” Option 1, the most flexible option, registration with a registry must be completed within 60 days after the start of the EHR reporting period and the eligible provider should be awaiting invitation from a registry (within this time frame) to begin testing and validation. The 60-day timeframe is overly restrictive and NASS is concerned that EHR and registry vendors will be overwhelmed with an onslaught of new requests and unable to accommodate. NASS also questions how situations where the testing and validation process fails would be handled? This is beyond the control of the eligible provider; therefore, an additional option or exclusion is needed to ensure that eligible providers are not held accountable in this situation.
Due to these complexities and lack of advanced notice, NASS recommends that the clinical data registry reporting requirement be optional, at least for 2015. Additionally, NASS recommends that the definition for “active engagement” under Option 1 be modified to “initiating contact with the clinical data registry via email or written notice within the EHR reporting period.” Going forward, NASS urges CMS to lower the threshold of this objective so that providers are only required to satisfy one of the 5 measures. One registry should be enough to satisfy this measure and is often all that is available for some specialists who do not treat conditions that would warrant communication with a public health registry on a regular basis.
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Conclusion
Thank you for considering our comments and concerns related to changes proposed for years 2015-2017 of the EHR Incentive Program. NASS looks forward to working with CMS to work through the ongoing challenges cited in this letter so that spine care specialists and their patients can realize the true value of health information technology. Should you have any questions, please contact Karie Rosolowski, Senior Manager of Research & Quality Improvement, at 630-230-3692 or
Sincerely,
Heidi Prather, DO President
