DATE: May 24, 2010
TO: Jessica Kahn
[email protected]
Maria Durham
[email protected]
Centers for Medicare and Medicaid Services
RE:
REQUEST FOR CLARIFICATION
FROM: Multi-State Collaborative for Health Systems Change to Address Tobacco Use
The Multi-State Collaborative for Health Systems Change [to address tobacco use], together with four
organizations that have co-signed this letter, respectfully request that Centers for Medicaid and
Medicare (CMS) review our interpretation that referrals made by eligible providers and hospitals to
state-based quitlines meet several meaningful use core and menu set measures, as enumerated and
discussed below. The Multi-State Collaborative is an association of 20 state-level tobacco control
programs and New York City and four national organizations working to increase integration of tobacco
interventions in healthcare, including referrals to quitlines. These are questions of high interest among
both health care providers and tobacco control programs across the country. The Collaborative recently
hosted a webinar on Meaningful Use tobacco measures, which attracted over 250 registrants from 44
states. This webinar can be accessed at our website
www.multistatecessationcollaborative.org
.
Background on Quitline Referral Programs
Quitlines have been adopted as a core component of all state-level tobacco control programs in the
United States, aided by several factors, among them a strong body of research that demonstrates the
efficacy of quitlines. Further, most state quitlines also offer a quitline referral program for providers and
healthcare facilities (e.g. CHCs, hospitals, practices, outpatient clinics). These referral programs
proactively link providers and their patients who use tobacco to the state’s quitline services. When a
provider referral is received, the quitline conducts outreach to engage the referred patient in a screener
call and one or more telephone counseling sessions before, during, and after a quit attempt. Some
quitlines also offer free nicotine patches or other medications, self-help materials, and access to website
resources. Most quitlines conduct evaluation calls after six months to assess the client’s quit status.
Typically, feedback reports are transmitted back to referring providers on patient contact, services
accepted and quit status.
In most cases, quitline referrals can be made from the electronic health records (EHR) and may be
transmitted by various methods to the quitline service provider. Similarly, feedback reports may be
faxed, emailed or transmitted electronically via an interface program back to the referring provider. In
Massachusetts, Rhode Island, and New Hampshire the quitline referral program, named QuitWorks, has
succeeded in implementing a fully electronic, bi-directional service, in HL7 format. This program was
featured on the Department of Health and Human Services Health Information Technology blog recently
(see attached).
Request for Clarification on Four Measures
Below are seven meaningful use measures related either to tobacco or to the quitline. Those for which
we seek clarification are in bold and relate to the quitline. For these four, we reference key language in
the specifications for which we seek clarification and include logic and supporting text to our
interpretation for your review and clarification
.1.
Record Smoking Status (eligible providers and hospitals) – CMS clarification not needed
2.
Clinical Quality Measures (eligible providers and hospitals)- CMS clarification not needed
3.
Clinical Decision Support Rule (eligible providers and hospitals) – CMS clarification requested
4.
Electronic Exchange of Patient Information (eligible providers and hospitals) – CMS clarification
requested.
5.
Patient Lists (eligible providers and hospitals)- CMS clarification requested
6.
Patient Specific Education Resources (eligible providers and hospitals) – CMS clarification
requested
7.
Tobacco Use Assessment and Cessation Intervention (eligible providers) - CMS clarification not
needed.
The Multi-State Collaborative, the North American Quitline Consortium, Quality Partners of Rhode
Island, John Snow, Inc. and the other four cosigners below appreciate CMS attention to our request. If
there are questions, please contact Donna Warner, Managing Partner, at 508-340-9924 or email
[email protected]
. Ms. Warner will coordinate communications with the experts who
prepared this request for clarification, Michael Stelmach, Consultant, John Snow Inc. and Brenda
Jenkins, Quality Partners of Rhode Island, and the North American Quitline Consortium, as needed.
Thank you,
Donna Warner, MBA, MA Managing Partner
Thomas Land, PhD, Chief Scientist
Caroline Cranos, MPH, Coordinator
Multi-State Collaborative for Health Systems
Change
www.multistatecessationcollaborative.org
PO Box 88
Groveland, MA 01834
508-340-9920
Linda A. Bailey, JD, MHS
President and CEO
North American Quitline Consortium
1300 Clay Street, Ste 600
Oakland, CA 94612
Michael P. Stelmach
Health IT Projects Director
JSI Research & Training Institute, Inc.
44 Farnsworth Street
Boston, MA 02210-1211
Brenda Jenkins RN, D.Ay., CPEHR
Senior Program Administrator
Quality Partners of Rhode Island
235 Promenade Street
Suite 500 Box 18
Providence, RI 0290
8
Susan M. Kansagra, M.D., M.B.A.
Assistant Commissioner
Attachments(2):
Requests for Clarification
DHHS/Blog
ATTACHMENT: FOUR REQUESTS FOR CLARIFICATION
REQUEST #1
Clinical Support Decision Rule
- Eligible Provider Core Set Measure 11 of 15 (10 for EHs)
Objective:
Implement one clinical decision support rule relevant to specialty or high clinical priority
along with the ability to track compliance with that rule.
CMS Inquiry
The Multi-State Collaborative interprets this to mean that an eligible provider or eligible hospital that
has identified a tobacco user through their EHR and,
as a result of an EHR alert or clinical decision
support rule,
refers the patient to the quitline program by any means (e.g. fully electronic, secure fax or
email, telephone) meets the requirement of this core measure (Clinical Decision Support Rule).
“Clinical Decision Support” in this context refers to the EHRs capacity to provide persons involved in care
processes with general and person-specific information, intelligently filtered and organized, at
appropriate times, to enhance health and health care. Although the wording of the definition of the
“clinical decision support” term is vague, it is inferred that a clinical workflow associated with smoking
assessment and subsequent patient referral to a quitline alone is insufficient. Rather, the quitline
referral must be triggered by an EHR alert or decision support rule.
Furthermore, CMS allows providers to decide which clinical decision support process to implement
taking into account their workflow, patient population, and quality improvement efforts.
We request that CMS confirm or refute our contention that an eligible provider or eligible hospital’s
referral to a Quitline as described above meets the meaningful use requirement for this measure,
provided that the referral is prompted or cued in the EHR or a clinical decision support rule.
REQUEST #2
Electronic Exchange of Clinical Information
- Eligible Provider Core Set Measure 14 of 15 (13 for
EHs)
Objective:
Capability to exchange key clinical information (for example, problem list, medication list,
medication allergies, and diagnostic test results), among providers of care and patient authorized
entities electronically.
CMS Inquiry
The Multi-State Collaborative interprets this to mean that an eligible provider or eligible hospital’s ability
to provide an electronic referral (eReferral) to a quitline from their EHR and/or receive an electronic
referral update (eReferral update) from a Quitline to their EHR meets the requirement of this core
measure.
The CMS technical specification for this measure offers both supporting and disqualifying language. For
example, supportive language would include the statement that the data must be exchanged between
providers and “patient authorized entities”. This term seems to open the door to a Quitline as patient
consent is part of the Quitline referral process. The guidance also specifies that data must be shared
between a certified EHR system and “other system capable of receiving the information”. Again, this
language seems to open the door to a Quitline. Other supporting language provides significant latitude
regarding what information is shared (a Quitline referral for example).
Disqualifying language also exists however. For example, the information exchanged must be shared
between different legal entities with distinct certified EHR technology. Quitlines typically do not have
certified EHR technology. However, this requirement seems to contradict the supportive guidance
shown in the paragraph above.
There is further disqualifying language that Office of the National Coordinator for Health IT data
exchange standards must be met, not the capabilities of uncertified or other vendor-specific alternative
methods. Quitline systems are not typically certified to these standards. However, if a health
information exchange network (HIEN) serves as an intermediary between the certified EHR and Quitline
systems, and the HIEN supports HL7 messaging, code set standards and HIPAA related security and
privacy standards, the ONC data exchange standards may be met.
We request that CMS confirm or refute our contention that an eligible provider or eligible hospital’s
involvement with a Quitline as described above meets the meaningful use requirement for this measure
.
REQUEST #3
Patient Lists
- Eligible Provider Menu Set Measure 3 of 10 (4 for EHs)
Objective:
Generate lists of patients by specific conditions to use for quality improvement, reduction of
disparities, research, or outreach.
CMQ Inquiry
The Multi-State Collaborative interprets this to mean that an eligible provider or eligible hospital’s ability
to generate patient lists by smoking status meets the requirement of this menu set measure (Patient
Lists).
The technical specification doesn’t indicate which report(s) must be generated. CMS guidance specifies
that the eligible provider/eligible hospital is best positioned to determine which reports are most useful
to their care efforts.
We believe that the eligible provider and hospital’s ability to generate a list of patients by smoking
status and the subsequent use of that information for quality improvement would meet this
requirement as long as the patient’s smoking status is listed on the patient’s problem list.
We request that CMS confirm or refute our contention that an eligible provider or eligible hospital’s
involvement with a Quitline as described above meets the meaningful use requirement for this measure.
REQUEST # 4
Patient Specific Education Resources
-
Eligible Provider Menu Set Measure 6 of 10 (5 for EHs)
Objective:
Use certified EHR technology to identify patient-specific education resources and provide
those resources to the patient if appropriate.
CMS Inquiry
The Multi-State Collaborative interprets this to mean that an eligible provider or eligible hospital’s ability
to refer patients to the Quitline program meets the requirement of this menu set measure (Patient
Specific Education Resources).
The measure indicates that eligible providers and hospitals must use certified EHR technology to identify
patient-specific education resources and provide those resources to the patient if appropriate.
The measure indicates that patient-specific education resources must be identified through logic built
into certified EHR technology, but that the education resources do not have to be part of or stored
within the EHR.
Using this guidance, the Multi-State Collaborative believes the measure will be met as long as the
following conditions are met:
•
The smoking assessment process and subsequent referral process are incorporated into the EHR
supported clinical workflow.
•
The quitline can be considered as providing “patient-specific education resources” which
includes, in addition to telephonic quit coaching, electronic and print materials (mailed to all
referred patients) about the state’s quitline services, cessation medications, quitting methods
and advice.
We request that CMS confirm or refute our contention that an eligible provider or eligible hospital’s
involvement with a Quitline as described above meets the meaningful use requirement for this measure
.
Submitted by:
Multi-State Collaborative for Health Systems
Change
P.O. Box
Groveland, MA
www.multistatecessationcollaborative.org
Contact: Donna D. Warner, Managing Partner
Ph: 508-340-9924
Home > Beacon Communities >
An Innovative, Community-based Approach to Smoking Cessation
An Innovative, Community-based Approach to Smoking Cessation
March 10, 2011, 5:27 pm / Jason Kunzman and Aaron McKethan /
Beacon Communities Project Officer and
Beacon Communities Program Director
One of the criteria set forth in Stage One Meaningful Use guidelines pertains to capturing information at the point of care about patients’ smoking status, and as relevant, offering counseling to help patients quit smoking. While
attending the Rhode Island Statewide Patient Centered Medical Home Learning Collaborative on February 5, we
learned about the kinds of innovations that this aspect of meaningful use may inspire and make more widespread in the future.
Terri Mrozak of Quality Partners of Rhode Island introduced us to a comprehensive smoking cessation strategy
that makes the best available use of health information technology (health IT) to support patients seeking to quit smoking across three states. She explained that quitting smoking is often the single most important thing one can do to improve their health, and that it takes most smokers as many as eight quit attempts before they are able to
quit permanently.1
Terri then told us about QuitWorks – RI , a free stop-smoking service sponsored by the Rhode Island Department
of Health and based on a program created by the Massachusetts Tobacco Control Program in 2002. Since its
inception, providers in three states (Massachusetts, New Hampshire, and Rhode Island) have referred more than 30,000 patients to QuitWorks, and nearly one in every five patients contacted has quit smoking within six months
after enrolling in the program.2 More than a telephonic quit line, which are widely available across the country,
QuitWorks combines traditional telephonic care management with a health IT-enabled referral management system.
According to Donna Warner, QuitWorks founder in Massachusetts, patients interested in smoking cessation resources can be electronically referred to the QuitWorks program through their physicians’ electronic health records (EHRs) with the patient’s medical ID attached. This automatically triggers a follow-up telephonic referral to a trained quitline counselor who will reach out to the patients and offer targeted education and coaching.
Importantly, status reports can be provided back to physicians directly into their EHR system, which allows physicians to follow up with patients and monitor their progress as they seek to quit. As part of the program, Quality Partners of Rhode Island also helps physician practices develop the workflow changes needed in their office to support approaches to tobacco-dependence treatment. While QuitWorks itself pre-dates the meaningful use rule, the combination of well-established tobacco counseling approaches with health IT linking patients’ data back into referring physicians’ EHRs represents the kind of innovation that meaningful use may support more broadly.
1
Massachusetts Office of Health and Human Services 2
