January 14, To Whom It May Concern:

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1 CENTRAL OFFICE: 260 South Broad Street, 18th Floor, Philadelphia, PA Phone WASHINGTON DC OFFICE: 620 Michigan Avenue, NE, Gowan Hall #152, Washington, DC Phone Office of the National Coordinator for Health Information Technology Department of Health and Human Services Patriots Plaza III, 355 E. Street SW Washington DC, Submitted via regulations.gov January 14, 2013 Re: Health Information Tecnology Policy Committee Request for Comment Regarding the Stage 3 Definition of Meaningful Use of Electronic Health Records (EHRs) To Whom It May Concern: On behalf of the National Nursing Centers Consortium (NNCC), I thank you for the opportunity to comment on the Stage 3 Definition of Meaningful Use for Electronic Health Records (EHRs). This comment addresses the Medicaid EHR Incentive Program established by the American Recovery and Reinvestment Act (Pub. L ). The NNCC is a non-profit member organization of nonprofit, nurse-managed health clinics (sometimes called nurse-managed health centers or NMHCs). The Affordable Care Act (P.L ) defines the term nurse-managed health clinic as a nurse-practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center (FQHC), or independent nonprofit health or social services agency. 1 Although recent estimates indicate that there are approximately 500 nurse-managed clinics nation-wide that include birthing centers and schoolbased clinics, 250 of these practices are primary and preventive care NMHCs. These primary and preventive care NMHCs provide a full range of health services, including primary care, health promotion, and disease prevention, to low-income, underinsured, and uninsured clients. Approximately 58% of NMHC patients are either uninsured, Medicaid recipients, or self-pay. Because many NMHCs are affiliated with schools of nursing, NMHCs help to build the capacity of the health care workforce by acting as teaching and practice sites for nursing students and other health professionals. Also, several NMHCs are FQHCs. Outcome data from managed care organizations and academic research journals show that NMHCs provide accessible high quality care that is also cost effective. The nurse practitioners in NMHCs can manage 80-90% of the care provided by primary care physicians 1 42 U.S.C.A. 254c 1a(a)(2) (West 2012).

2 without referral or consultation. 2 Also, according to a 2011 meta-analysis of peer-reviewed articles regarding the quality of nurse practitioner-provided care, primary care nurse practitioners continually produced patient health outcomes comparable to those of primary care physicians. 3 In terms of cost effectiveness, NMHC patients experience higher rates of generic medication fills and lower hospitalization rates than patients of similar providers. 4 Additionally, elderly and disabled people with access to NMHCs visit emergency rooms less often than those without access. 5 Comments I. Meaningful Use Objectives and Measures a. Improving Quality, Safety, and Reducing Health Disparities SGRP 118: NNCC feels that one barrier to implementing this standard would be electronic storage limitations and the ensuing cost of storing image files. We encourage ONC to consider cost when implementing standards using image files. b. Engage Patients and Families in their Care SGRP 207: As expanded upon in our comments on privacy in section III, below, NNCC is concerned that new technology is unavailable and/or inaccessible to many NMHC patients. While we recognize that access to electronic messaging is increasing, particularly through cell phones and smart phone, 6 many vulnerable populations are still removed from this form of communication. For example, some of our NMHCs principally serve homeless individuals who do not possess smart phones or personal laptops. Consequently, NNCC recommends that ONC assess providers level of success in achieving Stage 2 to determine if even 10% of patients will utilize electronic messaging, before planning this measure for Stage III. Barring evidence-based research to the contrary, NNCC believes that a 30% threshold is unattainable for the populations served by most safety-net clinics. We suggest that ONC use Stage 2 as an opportunity to study to what extent patients utilize electronic messaging before establishing the MU standard. c. Information Exchange IEWG 103: NNCC recommends that ONC require EHR systems have a feature allowing for transferability of data at no cost. Providers who need to switch vendors will have already 2 Mundinger, M.O. (1994). Advanced-practice nursing -- good medicine for physicians? New England Journal of Medicine, 330(3), Newhouse N.P., Stanik-Hutt J., White, K.M., Johantgen, M., Bass E.B., Zangaro G., Wilson R.F., Fountain L., Steinwachs D.M., Heindel L., Weiner J.P. (2011). Advanced practice nurse outcomes : a systemic review. Nursing Economic$, 29(5) Published Online Before Release, available at: 4 Hansen-Turton, T. (2005). The nurse-managed health center safety net: a policy solution to reducing health disparities. Nursing Clinics of North America, 40, Glick, D. F., Thompson, K. M., & Ridge, R. A. (1999). Population-based research: The foundation for development, management, and evaluation of a community nursing center. Family & Community Health, 21(4), Fox, S. & Duggan, M. (2012). Half Of Smartphone Owners Use Their Devices To Get Health Information and One- Fifth Of Smartphone Owners Have Health Apps, Mobile Health 2012, available at: 2

3 spent most of their incentive funds establishing the original EHR system and need free access to their data in an easily exported/imported form. II. Quality Measures NNCC does not have any specific comments related to quality measures at this time. We continue to believe that EHR systems that work correctly are excellent quality indicators when efficient and appropriately configured. III. Privacy and Security NNCC acknowledges that importance of developing technology that advances the National Strategy for Trusted Identities in Cyberspace (NSTIC) and our member clinics comply with the Health Insurance Portability and Accountability Act (HIPAA) by using encryption, multifactor authentication, and the like. Aside from these technological considerations, NNCC would like to share some privacy concerns of our clinicians on behalf of their patients. First, we understand that remote access can be useful for many individuals, but many of the patients served by NMHCs do not have ready access to private computers. Those patients will therefore be using public and shared computers and may have privacy concerns based on their location or shared access. Similarly, the digital divide still affects many NMHC patients who lack a level of computer literacy to sufficient to allow for use of remote access features. These patients are unlikely to benefit from remote services and remote access could even compromise their privacy if they seek help from others. Thus, as ONC continues to develop the privacy technology to protect patient health records, NNCC advises ONC to consider all kinds of patients daily lives when evaluating both the feasibility and the potential benefit to patients of implementing meaningful use objectives. Lastly, because much of this technology is relatively new and it is unclear what privacy breaches could result, NHMC clinicians are wary of sharing information through these new means (e.g. text messaging) for fear that they may expose their patient s private health information. NNCC recommends that ONC provide detailed guidance to clinicians about what type of information they can communicate and by what means. Our member clinics are also concerned about what can be lost in trying to make messages short and succinct enough for text message communication, and also ask that ONC consider the possibility of miscommunication using this communication medium. IV. General Comments NNCC appreciates that ONC seeks achievable objectives in increasing the level of certain Stage 2 measures for Stage 3. In that vein, we suggest that ONC not rush Stage 3 implementation. Resource-strapped clinics serving vulnerable populations already struggle to meet current objectives and the speeds with which these goals are advancing have prompted several concerns. First, as various EHR vendors enter (and leave) the market, clinics take risks when choosing a system. The free market may ultimately reveal the best EHR system, but we have yet to reach that point. Clinics are ill suited to bear the cost of failed EHR systems or systems that prove difficult to utilize in trying to reach MU. We are concerned that if ONC rushes through the meaningful use stages, the systems implemented will not be as efficient or effective 3

4 as intended. Additionally, we fear that EHR vendors may sacrifice quality in their attempt to attain certification functionality quickly. NNCC recommends delaying Stage 3 at least a year or so to allow the EHR market to stabilize before raising the performance bar for health clinics. Similarly, NNCC recommends that ONC fund evidence-based research to assess the effectiveness of the EHR systems. While the comment and response method of implementation will reveal some issues, developing solid research demonstrating the efficacy of EHRs for Medicaid providers will encourage providers to invest in these systems. NNCC believes that pairing evidence-based research with financial incentives to subsidize the cost is the most effective way to not only implement the new system but to ensure that it is creating the desired outcomes. NNCC recommends that ONC require certified EHR vendors to achieve the necessary functionality in accordance with the attestation period for providers. For providers to achieve MU, EHRs should not only meet standards for certification but also the MU standards demanded of providers. When providers lack the technology to comply with MU, they suffer the lost incentive and bear the cost if they need to change to a vendor with the needed functionality in place. NNNC applauds both Congress and the ONC for including nurse practitioners (NPs) and nurse midwives (NMs) in the definition of eligible provider for the Medicaid EHR Incentive Program (Incentive Program). 7 As reviewed above, nurse-managed care plays a particularly important role in improving access to and quality of healthcare for vulnerable populations. By recognizing the contributions of nurse-managed care, the ARRA establishes a model list of essential providers for similar healthcare initiatives. Many NMHCs want to improve patient services through meaningful use of EHRs. Unfortunately, while NPs are eligible for the Medicaid Incentive Program, many NMHCs that are not FQHCs have reported difficulty meeting the 30% Medicaid patient volume required by section 1903(t)(2)(A)(i). This is because NMHCS serve our most vulnerable patients, including high percentages of uninsured. Although we understand that ONC must implement the language of the ARRA, we believe that limiting the availability of the Incentive Program frustrates Congress s intent to modernize our health system through wide adoption of EHR and to provide quality healthcare to our country s most vulnerable populations. By adopting three stages for implementation, ONC created a significant opportunity for input from health providers regarding how to make meaningful use attestation improve care. We encourage ONC to reconsider limits to EP qualification even as the Incentive Program enters its third stage and find new ways to make qualification even easier. Because Medicaid Expansion will not be occurring in every state, it will continue to be difficult for many safety-net providers to qualify providers to qualify Excluding eligible providers from the Incentive Program on the basis of an uninsured patient population impedes the goals of the program. We believe that ONC recognizes the importance of allowing EPs serving low-income populations to qualify for the Incentive Program. Stage 2 expanded the methods of patient volume calculation available to states. We commend ONC for clarifying that a Medicaid encounter includes a service provided to a patient enrolled in Medicaid even when Medicaid does not pay for the service, co-payment, etcetera 8 and note that the statutory language specifies that the methodology established by the Secretary for patient volume shall include 7 42 U.S.C.A. 1903(t)(1)(B) (2012) C.F.R (e) (2012). 4

5 individuals enrolled in a Medicaid managed care plan. 9 Similarly, we support ONC s decision to add the year prior to attestation as one of the timeframes in which an EP can identify a continuous 90-day period. 10 The Stage 2 improvements favor the inclusion of more providers in the Incentive Program and wider adoption of meaningful use standards for EHR, and in so doing, honor Congress s intent in establishing the program. However, we suggest that ONC can further advance these goals by including individuals eligible for Medicaid even when not enrolled. Medical assistance is intended to benefit low-income individuals and considering services provided to such individuals extends the benefits of the Incentive Program to the most vulnerable populations. As states debate whether to expand Medicaid, clinics will continue to serve largely uninsured populations. Clinics providing this safety-net function deserve encouragement and support as they modernize their services and improve patient care. ONC gives states the power to choose which method of patient volume calculation to employ in the State Medicaid HIT Plans. Although we appreciate the need for state specific Medicaid determinations, we are concerned that some states will not adopt the more lenient interpretation of the Incentive Program that the federal government has reflected in its Stage 2 changes. Thus, we encourage ONC to explicitly articulate its goals to increase EP participation in the program and access to quality care for low-income populations to encourage states to implement the most flexible and encompassing Medicaid patient calculation methods. Finally, we encourage ONC to continue its conversations with state Medicaid offices and health groups to explore the issues faced by EPs attempting to use EHR meaningfully in areas with large numbers of uninsured populations. We appreciate the opportunity to comment. If you have any questions I can be reached at (215) or tine@nncc.us. Very truly yours, Tine Hansen-Turton, MGA, JD, FAAN, FCPP Chief Executive Officer National Nursing Centers Consortium 9 42 U.S.C.A. 1903(t)(2) (2012) C.F.R (c), (d), (g) (2012). 5