Medicare and Medicaid Programs; Electronic Health Record Incentive Program Stage 3 and Modifications to Meaningful Use in 2015 Through 2017

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1 November 12, 2015 Andy Slavitt Acting Administrator Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Medicare and Medicaid Programs; Electronic Health Record Incentive Program Stage 3 and Modifications to Meaningful Use in 2015 Through 2017 Dear Mr. Slavitt: The American Society of Cataract and Refractive Surgery (ASCRS) is a medical specialty society representing nearly 9,000 ophthalmologists in the United States and abroad who share a particular interest in cataract and refractive surgical care. We appreciate the opportunity to provide comment on Stage 3 Meaningful Use. Overall, ASCRS urges CMS to delay the implementation of Stage 3 Meaningful Use. As the program is currently designed, our members continue to struggle with successfully attesting to Meaningful Use, even with the recently released Stage 2 Modifications Rule. Therefore, with the unachievable requirements put forth in the CMS final rule for Stage 3, it will be nearly impossible for most of our members to participate and ultimately succeed in the Meaningful Use program. CMS should not mandate that providers move to the Stage 3 Meaningful Use program until a significant majority of providers are successfully attesting to Stage 2. With the upcoming implementation of the Merit-Based Incentive Payment System (MIPS), which includes meaningful use as one of its components, it is critical that CMS make changes to the Meaningful Use program that ensure it is achievable for all physicians. Specifically, ASCRS asks CMS to work with specialty societies to reduce the thresholds required in Stage 3 to more reasonable levels; eliminate measures that are outside the providers control, and develop measures relevant to specialty providers and the patients they treat. ASCRS believes that the majority of the current Meaningful Use objectives and measures are designed for primary care providers, and have very little, if any, relevance to specialty care, and in particular, ophthalmology.

2 Finally, ASCRS believes providers should receive credit for partial Meaningful Use attestation success; asks CMS to require EHR vendors to resolve current interoperability issues, and urges flexibility for providers who must file hardship exemptions. Delay the Implementation of Stage 3 Meaningful Use ASCRS urges CMS to delay the implementation of Stage 3 Meaningful Use. CMS should not mandate that providers advance to Stage 3 Meaningful Use until a significant majority of providers are successfully attesting to Stage 2. Stage 3 Meaningful Use as finalized by CMS, will prohibit the majority of our members from successfully meeting Stage 3 Meaningful Use and, therefore, being able to successfully participate in the MIPS program due to the increased measure thresholds and the measures based on factors outside a provider s control. It is essential that prior to the implementation of MIPS, CMS make changes to the program that will ensure Meaningful Use is achievable and meaningful for all physicians, including specialists, such as ophthalmologists. Reduce Thresholds CMS should reduce the thresholds required in Stage 3 to more reasonable and achievable levels. Only 12 percent of providers were able to successfully attest to the Stage 2 measures prior to the Stage 2 Modifications Rule. CMS addressed many of the Meaningful Use issues in the Stage 2 Modifications Rule, however, CMS has increased the thresholds even further for the final Stage 3 requirements. It is counterintuitive to offer the Stage 2 Modifications Rule flexibility for providers who could not meet Stage 2 Meaningful Use, and then expect physicians to be able to meet even higher thresholds in Stage 3 going forward. For example, one measure for Stage 3 Meaningful Use requires more than 10 percent of all patients to either view, download or transmit their health information, or access their information through an API, or a combination of the two. Our members treat an older Medicare patient population that is not typically interested in or able to engage with their health information online. Therefore, this threshold would be impossible for many of our members to meet. ASCRS, along with other groups from the medical community, brought providers issues with the thresholds to CMS attention during Stage 2, and CMS lowered the thresholds for this measure in the Stage 2 Modifications rule. It is illogical for CMS to revert back to an increased threshold for this measure in Stage 3 and will make it significantly more difficult, if not impossible, for our providers to meet Meaningful Use. Other measure thresholds also increased in Stage 3 Meaningful Use including electronic prescribing; using computerized provider order entry to enter medication, laboratory and diagnostic imaging orders, and using the EHR to send secure electronic messages to patients. Many of our members have had trouble meeting the required thresholds in Stage 2 Meaningful Use, and an increase in these requirements will make meeting Meaningful Use Stage 3 very difficult. Eliminate Measures That Hold Providers Responsible for Factors Outside Their Control Many measures included in Stage 3 Meaningful Use are outside of the providers control and require the action of patients or other providers.

3 For example, one measure included in Stage 3 Meaningful Use requires that for more than 50 percent of transitions of care and referrals, the eligible professional creates a summary of care and electronically exchanges the summary of care record. While CMS has clarified with ASCRS that providers can meet this measure for Stage 2 by sending an , many EHR systems are only able to meet this measure by exchanging information with other providers who have an EHR system that will accept a Consolidated-Clinical Document Architecture (C- CDA) formatted document. This is problematic as many of our providers are located in areas where the doctors they refer patients to and receive patients from do not have an EHR. Therefore, our providers are often penalized for the decision of surrounding providers not to adopt EHR systems. As discussed above, another measure for Stage 3 Meaningful Use requires more than 10 percent of all patients to either view, download or transmit their health information, or access their information through an API, or a combination of the two. As previously mentioned, our members treat an older Medicare patient population that typically choose not to engage with their health information online. Consequently, our members will be penalized for actions of patients over which they have no control. Overall, providers who are attempting to attest to Meaningful Use should not be penalized for actions they cannot control. CMS should ensure that each measure required for Meaningful Use is one that providers are able to attest to without relying on the actions of other individuals (patients or referring providers). CMS created a hardship exemption for Stage 2 Meaningful Use for providers who are unable to meet this measure due to the inaction of receiving providers. ASCRS urges CMS to extend this hardship exemption to Stage 3 Meaningful Use as well. Develop Meaningful and Achievable Measures for Specialty Providers The majority of Stage 3 Meaningful Use measures are focused on primary care providers and the conditions they treat and are not applicable to specialty physicians. ASCRS believes Stage 3 should consist of meaningful measures for specialists that are within their control. As we have consistently stated, many of the current measures are designed for primary care physicians and are not easily attainable by specialty providers. For example, measures such as computerized provider order entry for laboratory or radiology reports, and medication reconciliation are not typically relevant to ophthalmology. We often hear from our members that these measures are time-consuming, while also not related to the care they are providing. The measures are not meaningful to our member s patients or the services they provide to patients. Forcing providers to attest to Meaningful Use measures that are not relevant to their practice is inefficient. ASCRS reiterates that providers should only be required to report Meaningful Use measures that are relevant to their specialty. In addition, under Stage 3 Meaningful Use, providers must meet two of the following measures- immunization registry reporting, syndromic surveillance reporting, electronic case reporting, public health registry reporting and clinical data registry reporting in order to satisfy the public health objective. This is another example of a measure designed for primary care providers that is not relevant to specialists. While it is true that some of our members are currently reporting to a clinical data registry, the other four measures are not applicable to ophthalmologists. Therefore, the requirement that providers report on two of these measures is impossible for ophthalmologists to meet. In 2015, there are exclusions for this objective for providers that were not previously

4 planning to report the public health measure as one of their menu measures or if the measure is not applicable to a provider. The exclusions must also be included in Stage 3 Meaningful Use. In addition, the requirement to meet two of these five measures is impossible for ophthalmologists, because the clinical data registry measure is the only one that applies to their specialty. As they did for Stage , CMS should also create a broad exclusion from this objective for ophthalmologists and other specialists to whom these measures do not apply. Stage 3 Meaningful Use would be greatly improved if specialties and subspecialties were able to develop their own measures. ASCRS urges CMS to work with medical specialty organizations to focus on providing meaningful measures for specialty providers and ensuring that all required measures are within a provider s control. Partial Credit for Meaningful Use Attestation As we have stated in previous comments, ASCRS believes providers should be able to receive partial credit for Meaningful Use attestation. ASCRS feels strongly that if providers are attesting for Meaningful Use and meet a certain percentage of the measures, there should be an option for them to get credit for the percentage of Meaningful Use requirements they were able to successfully complete. We have heard from many of our members that they are dropping out of Meaningful Use reporting because they have difficulty with the patient engagement measures. It is discouraging to these providers for the program to be an all-or-nothing system, and providing a sliding scale for Meaningful Use, or allowing providers to successfully attest if they are able to meet 75 percent of the measures, may encourage fewer providers to drop out of the program. Interoperability ASCRS believes there are significant interoperability issues in the current Meaningful Use program. EHR vendors are not sharing data with each other and are also not sharing data with registries. There are also welldocumented issues with problems between vendors for measures, such as sharing summaries of care. CMS should focus on increasing the functional interoperability between vendors and among vendors and registries to ensure Meaningful Use is a program that actually has the potential to improve healthcare, and not another unnecessary regulatory burden on providers. Hardship Exemptions There should be significant flexibility in the type of hardship exemptions that are offered for Stage 3 Meaningful Use. Many of our members face, and will continue to face, unique situations that may not fall into an established hardship exemption category, but cause the provider to be unable to meet Meaningful Use. For example, one of our providers filed a lawsuit against his EHR vendor during the 2015 Meaningful Use reporting period and the vendor would not let him attest using their software while the lawsuit was ongoing. Situations such as this one should be addressed on a case-by-case basis. Many of our members are unable to successfully attest to Meaningful Use through no fault of their own. A significant number of our members have had EHR vendors that have delayed updates, provided inaccurate information, and had faulty software that have caused practices to be unable to successfully report Meaningful Use. We expect these issues to continue moving forward with Stage 3 Meaningful Use given the changes to

5 measures and thresholds that vendors must incorporate. ASCRS believes providers should not be penalized for the inability of their EHR software to complete Meaningful Use for a given year, and Stage 3 Meaningful Use hardship exemptions should provide as much flexibility as possible. ***** Overall, ASCRS strongly encourages CMS to delay Stage 3 Meaningful Use. As Stage 3 Meaningful Use is designed currently, the majority of our members will be unable to successfully participate due to the increased thresholds for objectives, such as patient engagement. We reiterate, the issues with Stage 3 Meaningful Use must be addressed prior to the inclusion of the program in MIPS. In addition, ASCRS believes providers should receive credit for partial Meaningful Use attestation success; asks CMS to require EHR vendors to resolve current interoperability issues, and urges flexibility for providers who must file hardship exemptions. Thank you for providing our organization with the opportunity to present our comments on Stage 3 Meaningful Use. Should you have any questions regarding our comments, please do not hesitate to contact Ashley McGlone, Manager of Regulatory Affairs, at or Sincerely, Robert Cionni, MD President, ASCRS

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