Senate Committee on Health, Education Senate Committee on Health, Education

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1 August 3, 2015 The Honorable Lamar Alexander The Honorable Patty Murray Chairman Ranking Member Senate Committee on Health, Education Senate Committee on Health, Education Labor and Pensions Labor and Pensions 428 Dirksen Senate Building 428 Dirksen Senate Building Washington, DC Washington, DC Dear Chairman Alexander and Ranking Member Murray: The American Academy of Dermatology Association (AADA), which represents more than 13,500 dermatologists nationwide, welcomes the opportunity to provide feedback on implementation of the Electronic Health Records (EHR) Incentive Program. The AADA is committed to excellence in the medical and surgical treatment of skin disease; advocating high standards in clinical practice, education, and research in dermatology and dermatopathology; and supporting and enhancing patient care to reduce the burden of disease. The AADA supports the development of interoperable health information technology (HIT) standards. The goal of adoption and use of EHR systems is to improve the safety and enhance the quality of patient care. Portable and secure EHRs will enable dermatologists and patients to access point of care information as well as provide for better coordination of patient care through sharing of information with other physicians and providers. The AADA supports incentives that promote the voluntary adoption of affordable and reliable HIT solutions and believes that an incentive based approach to adoption, particularly once interoperability standards are available and implemented, is preferable to the current penalty-based approach. In addition, the AADA supports efforts to provide relief and exemption from HIT penalties facing solo and small dermatology practices. The AADA views the following as key priorities that should be addressed related to EHR implementation: Interoperability The AADA supports the development of interoperability standards. Physicians often run into information blocking or the practice of interfering with the availability, exchange, and use of electronic health information which impedes coordination of patient care and penalizes physicians trying to meet Meaningful Use requirements. Currently, one measure available under Meaningful Use (MU) requires a summary of care record be exchanged amongst providers regardless of the physician s respective EHR vendor. Most physicians cannot meet this measure because there is currently no network available for EHRs to exchange health information. Additionally, HIPAA requires that this exchange be performed under encrypted technology which does not include most exchanges. Additionally, there are currently no universal electronic standards for EHR

2 vendors. While Health Level Seven (HL7) standards are used across the industry, each vendor has its own HL7 format which is not recognized from vendor to vendor. If a universal standard was adopted, it would promote more electronic exchange of information amongst different vendors. Interoperability standards will also improve clinical data registries ability to securely exchange health information with providers. These standards would help reduce the number of practical and functional barriers that currently make it difficult for clinical data registries to access health information for the purpose of tracking clinical outcomes and improving quality of care. It is critical that the creation of interoperability standards prevent vendors of health information technology from passing the costs of enhanced interoperability on to physicians and other health care providers. Many dermatologists have small or solo practices and are not in the position to absorb these additional costs. Laboratory Interface Pathology is a large component of the day-to-day operation of any dermatology office. Dermatologists utilize laboratories, both within their practice and outside of their practice, to diagnose and treat many different diseases, including skin cancer, eczema, infections, psoriasis, immunologic diseases, and many genetic disorders. Currently, EHR vendors offer very limited integration or no integration with a laboratory. This leaves dermatologists in the position of paying for their own integration with their preferred laboratory if the EHR vendor is not connected to it. The AADA supports the creation of a data exchange standard that allows any laboratory to exchange information with any EHR vendor so dermatologists and other physicians can readily access the data and ensure that patients are receiving accurate, reliable, and timely diagnosis. Data Ownership Currently there is no data ownership language regarding electronic health information. The Health Insurance Portability and Accountability Act (HIPAA) dictates that a patient owns their health information; however when that health information is contained in an EHR housed on the internet, the vendor in effect owns the data and can allow anyone to have access to it with or without the patient s or physician s permission. Additionally, if a physician decides to change EHR vendors, the vendor can hold the data hostage and refuse to allow the physician to access the data. The AADA strongly supports the adoption of common data ownership language that prevents vendors from allowing outside providers or hospitals from freely accessing their data. Simplify Documentation Required for MU Dermatologists are spending an increasing amount of time documenting patient information to meet MU requirements which is resulting in decreased time to converse and examine patients. For example, one measure requires physicians

3 to inquire if their patients smoke and if so, the amount which must be documented in the EHR system by a staff member for every patient. This adds up to an immense amount of time collecting and documenting information which is often irrelevant to the dermatologist-patient relationship. There should be simplification of the required documentation to meet MU to allow more time for physicians to focus on providing high quality patient care. Sharing of Application Program Interfaces (APIs) In order to meet MU requirements, physicians must have patient portals installed in their EHR which typically results in the physician incurring an additional fee. The Stage 3 MU proposed rule allows a change whereby APIs may be enabled by a provider to provide the patient with access to their health information through a third-party application with more flexibility than often found in many current patient portals. From the provider perspective, using this option would mean the provider would not be required to separately purchase or implement a patient portal, nor would they need to implement or purchase a separate mechanism to provide the secure download and transmit functions for their patients because the API would provide the patient the ability to download or transmit their health information to a third party. Thus, if an EHR vendor creates their own API, it should be mandated that the API be shared for free with physicians for purposes of patients accessing their health information regardless of EHR vendor used. Modification of Patient Engagement Objectives The AADA continues to have concerns regarding objectives that rely on patients actions. While physicians can educate and encourage their patients to engage in certain behaviors, it is the patients themselves who control their own actions. The AADA supports the removal of the five percent threshold for the patient action to view, download, or transmit health information measure, and its replacement with a requirement that at least one patient must view, download, or transmit health information to a third party. This new proposed measure would still accomplish the goal of ensuring that Certified EHR Technology (CEHRT) is fully operational, but would not penalize a physician for his or her patients actions (or lack of actions). Hardship Exceptions The AADA strongly supports the creation of a hardship exception, particularly for physicians in solo practice and providers who are beyond retirement age as defined by the Social Security Administration. The unique nature of dermatology practice, in which a majority of time is spent examining patients' skin, has resulted in difficulty integrating EHRs into our practices. Many dermatology offices have had to reduce the number of patients they can see in a day by more than 30% at a time when demand for physician care is reaching an all-time high. In the AADA s annual survey of its members, we found that 65% of respondents

4 close to retirement age found pressures to implement EHR to be a significant factor in their decision to retire. For these physicians in particular, the program requirements are simply too costly and time-consuming to implement given the providers brief period in which they would need to meet the EHR program requirements. Additionally, solo practices often lack the infrastructure, resources and staff required to purchase and implement an EHR into their office. While current data demonstrate widespread dissatisfaction with current EHRs, even among large practices and academic centers, at a minimum providing these physicians with the option of a hardship exception allows them to continue caring for patients without jeopardizing access to care for their community or the viability of their practice. In addition, we encourage the Committee to continue closely monitoring the impact of EHRs and consider exploring additional hardship exceptions or other avenues that recognize those who have found the systems unworkable and detrimental to patient care. The AADA appreciates your leadership and attention to this issue and encourages the Committee to work with CMS to address areas where the EHR Incentive Program could be further improved to meet the needs of both physicians and their patients. If you have any questions or if we can provide any additional information, please contact Katie Jones, the Academy s Assistant Director, Political and Congressional Affairs, at or at (202) Sincerely, Mark Lebwohl, MD, FAAD President, American Academy of Dermatology Association

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