RE: CMS-3310-P Electronic Health Record (EHR) Incentive Programs Stage 3

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1 May 29, 2015 Andy Slavitt Acting Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services Hubert H. Humphrey Building, Room 445 G 200 Independence Avenue, SW Washington, DC Karen B. DeSalvo, MD, MPH National Coordinator for Health Information Technology Office of the National Coordinator for Health Information Technology U.S. Department of Health and Human Services Hubert H. Humphrey Building, Suite 729D 200 Independence Avenue, SW Washington, DC RE: CMS-3310-P Electronic Health Record (EHR) Incentive Programs Stage 3 Dear Acting Administrator Slavitt and Dr. DeSalvo: The Society for Vascular Surgery (SVS), a professional medical society composed of over 5,000 specialty-trained vascular surgeons and other medical professionals who are dedicated to the prevention and cure of vascular disease, offers comments on the proposed rule published March 30, 2015, Electronic Health Record Incentive Programs- Stage 3. Our members have, like the physician community at large, broadly adopted electronic health records and embraced the underlying principles of patient safety, improved health outcomes, and value in care delivery. Overarching Concerns Streamlining of Programs SVS commends CMS for its commitment to simplifying reporting and harmonizing EHR requirements with those of other concurrent programs such as the Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM), Accountable Care Organization (ACO), and others. The careful selection of measures and ongoing streamlining process will assume additional importance with the implementation of P.L , the Medicare Access and CHIP Reauthorization Act of 2015 and the incorporation of existing programs into the Merit-Based Incentive Payment System 1

2 (MIPS). In addition, SVS strongly urges CMS to coordinate Stage 3 rulemaking with the anticipated requirements of the MIPS program and to delay finalization of the Stage 3 rule if necessary to accomplish this. Focus on Value SVS would encourage CMS to focus on objectives that add value and on essentials of the core physician-patient interaction. There is well-justified concern in the physician community about the cost and productivity impact of both initial EHR adoption and ongoing Meaningful Use (MU) compliance. SVS appreciates CMS recognition, in the proposed rule published April 15, 2015, Electronic Health Record Incentive Program- Modifications to Meaningful Use in 2015 Through 2017, that the Congressional Budget Office has found, on review of data on EHR cost benefits, the highest gains accruing to large provider systems and groups and claims that office-based physicians may not realize similar benefits from purchasing health IT products. At this time, there is limited data regarding the efficacy of health IT for smaller practices and groups. SVS has in the past supported a small practice exemption from the EHR Incentive Program penalty and would continue to urge CMS to carefully consider the cost and benefits of all aspects of the EHR program across a wide variety of provider types and practice sizes. Fundamentally, the requirements of the program must be examined in the context of the original purpose and priorities of the HITECH Act and carefully tailored to achieve the greatest impact on patient safety, the quality of care, and cost containment through the elimination of waste and harm while avoiding the imposition of excessive cost and productivity burdens on physicians in a manner that expends resources that would otherwise be applied to providing and improving care. Reporting Period SVS strongly supports the retention of the 90-day reporting period in 2015 and urges CMS to continue this approach at least through the 2019 implementation of MIPS. Additionally, SVS would urge adoption of an approach that addresses the multitude of situations that render full year reporting impracticable, including adopting either full reporting exemptions or permitting 90-day reporting for providers newly entering practice, those participating in the program for the first time, and when a provider changes practice or EHR vendor or product, events requiring significant transition time. Specific Stage 3 Objectives Objective 2: Electronic Prescribing SVS would urge a flexible approach to the inclusion of controlled substances in the denominator of Measure 1, noting that some states may have enacted legislation to permit electronic prescribing of controlled substances but have not yet finalized the process by which providers may be approved to do so or approved providers under such a process. We would support permitting providers practicing in one of these environments to elect 2

3 to exclude controlled substance prescriptions from the denominator measure and would also support offering providers the ability to exclude from the measure s denominator prescriptions provided in paper form at the request of the patient. SVS also supports maintenance of the current exclusions from this measure. Objective 3: Clinical Decision Support SVS expresses concern about Measure 1, requiring implementation of five separate clinical decision support (CDS) interventions related to four or more Clinical Quality Measures (CQMs) or, in the absence of four relevant CQMs, high-priority health conditions. It is important that the tools of EHR be applied in a manner that is relevant to a provider s practice. SVS supports permitting satisfaction of this requirement through participation in a clinical data registry. Objective 4: Computerized Provider Order Entry SVS supports the broader approach proposed here which permits medication, laboratory, and diagnostic imaging orders to be entered by a licensed healthcare professional, credentialed medical assistant, or medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant who can enter orders into the medical record per state, local, and professional guidelines. Objective 5: Patient Electronic Access to Health Information SVS supports the flexible approach to permitting the use of either a traditional EHR portal or an Application Program Interface (ABI) in Measure 1, and would also encourage retention of a longer time frame for the release of health information both for technical reasons and to permit sufficient time for physician review of records and results. With regard to Measure 2, SVS would note that there has been no demonstration that electronic access to patient-specific education materials is superior to providing these materials in paper form and would, therefore, urge CMS to eliminate the 35 percent threshold and preserve the ability to meet this requirement using paper-based resources. Many practices have developed proprietary educational materials that are specific to the particular practice and carefully tailored to institutional clinical pathways and local resources and may expend significant expense and effort to attempt to satisfy this requirement by tailoring commercial EHR products to substitute these practice-specific materials for the more generic pre-made educational content in their repositories. Objective 6: Coordination of Care through Patient Engagement While SVS appreciates CMS s acknowledgement of broad concerns within the provider community with regard to the patient engagement measures, we view the proposed measures with grave concern. The most direct and effective way to engage patients in their own health is through directing incentives and disincentives at patients, themselves, rather than providers. (Emanuel, Ezekiel, How to Solve the ER Problem, NY Times, May 6,

4 problem.html) Low rates of patient engagement, as measured in the EHR program, may reflect demographic factors such as socioeconomic status, geography, or educational level, which are beyond the control of providers and may penalize those who serve disadvantaged communities. In addition, the failure of patients to utilize EHR features may reflect a perception that they do not value features broadly offered by vendors in current EHR versions. In this case, incentives and disincentives may be more productively applied to software developers and vendors who are in a position to respond to the demands of the patient-consumer. In addition, current EHR products require patients to establish separate access and passwords to utilize EHR features if they see multiple providers who are not members of a group that shares a common EHR. Providers in small or single-specialty groups will tend to be disadvantaged as patients may not find the value of establishing this separate, duplicate process to access EHR features associated with a single provider s records where the majority of their records may reside elsewhere. As with providers, patient adoption of EHR technology, whether the VDT or API access contemplated by Measure 1 or the secure messaging addressed in Measure 2, will be driven by either a perceived value or the application of direct incentives or disincentives. With regard to Measure 3, SVS expresses concern that while the ability to incorporate patient-generated health data or data from a non-clinical setting holds potential, the 15 percent threshold is arbitrary and premature. As cooperative agreements among providers often strictly limit the ability of outside physicians to interact with the EHR in a nonread-only manner over concerns about data accuracy, it is clear that similar discussions about how patient-generated or non-clinical data should be incorporated into the record must occur before this measure becomes mandatory. To the extent that the efforts of providers to encourage patient engagement are captured as metrics, these should focus exclusively on more appropriate measures such as whether providers offer EHR-based services found to be valued by patients such as the ability to request prescription refills, to request or view appointments, and whether providers respond to patient communications in a timely fashion. SVS strongly opposes holding physicians responsible for patient behavior. Objective 7: Health Information Exchange (HIE) SVS would encourage CMS to ensure that Measure 1 permits transitions of care and referrals to a practice group rather than a particular provider, as this reflects typical practice and workflow in many cases. We support the concept introduced in the proposed rule of clinical relevance with regard to the summary document itself. SVS seeks guidance from CMS with regard to the anticipated incorporation of the FDA Unique Device Identifier (UDI) as one of the Consolidated Clinical Document Architecture (CCDA) elements in the summary of care document. Objective 8: Public Health and Clinical Data Registry Reporting 4

5 SVS supports broader application of clinical data registry (CDR) reporting to satisfy both PQRS and MU quality reporting, consistent with the stated goal of streamlining quality reporting. The Vascular Quality Initiative (VQI), developed by SVS, is a state-of-theart clinical registry relevant to the practice of SVS members, permitting participants to collect and analyze data on patient comorbidities, intra-procedural variables, and postprocedural outcomes and, through the work of the associated AHRQ-listed SVS PSO, to support best practices in the care of our patients. SVS strongly urges CMS to continue to support specialty- and practice-appropriate quality improvement through supporting the incorporation of VQI and similar CDRs in current and future quality programs. With regard to the timelines anticipated in these measures, SVS would urge CMS to carefully examine technical and vendor-related barriers to electronic reporting to public health and clinical data registries and to consider additional exclusions or the preservation of alternative methods of reporting or transmission. The Society for Vascular Surgery remains committed to providing safe, high-quality, effective, and efficient care to our patients and looks forward to continuing to work with CMS to improve the functionality of the EHR through iterative improvements to the Meaningful Use program. SVS appreciates the opportunity to provide comments on this proposed rule. If you have any questions or need additional information, please contact Pamela Phillips, Director of the SVS Washington Office at or Sincerely, Peter F. Lawrence, MD President Society for Vascular Surgery Robert M. Zwolak, MD Health Policy Adviser Society for Vascular Surgery Sean P. Roddy, MD Chair, Health Policy Committee Society for Vascular Surgery 5

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