CPeH Comments: Meaningful Use Stage 3 NPRM

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1 PROGRAMMATIC CHANGES: SUPPORT full-year reporting (vs. 90 day reporting periods) to make benefits of online access available to patients and families 365 days a year, and also to transform clinical practices and workflows in support of patient and family engagement. o If CMS moves to a 90 day reporting period, it should consider the impact on measures and related exclusions (i.e., for summary of care and care coordination/engagement measures). SUPPORT attestation to thresholds of all measures (100%, all-or-nothing attestation to demonstrate meaningful use) DISAGREE: with proposed delay until 2018 (for those providers who choose to wait until 2018); patients and families have waited long enough to receive the benefits of electronic health information collection, exchange, and use SUPPORT efforts to align quality measurement and requirements across CMS quality measurement and reporting programs, and where feasible, greater alignment of quality measurement across private and public payer initiatives to reduce the burden on providers. MISSING: Parallel CMS/policy requirements to ensure that certification requirements that will help to identify and reduce health disparities are being used by providers (for example, filtering Clinical Quality measure results by disparities variable(s)). MISSING: Progress in making electronic health information available in non-english languages MISSING: Progress in person-centered health and care plans OBJECTIVES: Objective 1: Protect Personal Health Information SAME AS STAGE 2 EP, EH (Core): Conduct or review a security risk analysis (including addressing the encryption/security of data) and implement security updates as necessary and correct identified security deficiencies. Specifies when to conduct a security risk analysis: Once per reporting year When updates are installed Whether a hospital would issue refills upon discharge for medications the patient was taking when they arrived at the hospital and, if so, whether distinguishing those refill prescriptions from new or altered prescriptions is unnecessarily burdensome for the hospital. Should over-the-counter (OTC) medicines be included in this objective for Stage 3? SUPPORT: continued attention paid to protecting the privacy and security of consumers e-health information. Acknowledge confusion amongst both providers and consumers surrounding existing privacy laws demonstrated in NPWF survey. SUPPORT: adding administrative safeguards (e.g. risk analysis, training) and physical safeguards (e.g. access controls) is consistent with previous P&S Tiger Team recommendations. Objective 2: Electronic Prescribing (erx) EP: More than 80 percent of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT. 50% in Stage 2 EH: More than 25 percent of hospital discharge medication orders for permissible prescriptions (for new and changed prescriptions) are queried for a drug formulary and transmitted electronically using CEHRT. Whether to continue to allow, but not require, providers to limit the measure of this objective to those patients whose records are maintained using CEHRT. Circumstances where an eligible hospital or CAH which focuses on a particular patient population or specialty may have an EHR reporting period where the calculation results in a zero denominator No CPeH comments planned

2 10% in Stage 2 Permissible prescriptions include those for controlled substances in states where it is legal. Objective 3: Clinical Decision Support (CDS) SAME AS STAGE 2 EP, EH: Both need to be met Measure 1: Implement 5 CDS interventions related to four or more CQMs at a relevant point in patient care for the entire EHR reporting period. Absent four CQMs related to an EP, eligible hospital, or CAH's scope of practice or patient population, the CDS interventions must be related to high-priority health conditions 1. Doesn t require the provider to report a change in performance, but recommends each provider set internal goals. Measure 2: Functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period. Objective 4: Computerized Provider Order Entry (CPOE) for one of the measures, how often such circumstances might occur, and whether an exclusion would be appropriate. (NEW) MISSING: Clinical decision support measure design and certification specifications should include all stakeholders, (patients, families, non-mu eligible providers etc). CDS as designed accommodates a machine and provider interface and leaves out the patient. CDS that includes the patient is most often called shared decision making (SDM). CDS should include the patient s values and goals of care in order for the provider to make the most informed decision. SDM includes electronic tools that gather patient values, leanings and preferences that promotes discussion between the provider and the patient. Must meet all 3 Measure 1: More than 80 percent of medication orders are recorded using CPOE; 60% in Stage 2 Measure 2: More than 60 percent of laboratory orders are recorded using CPOE 30% in Stage 2 No CPeH comments planned Measure 3: More than 60 percent of diagnostic imaging orders are recorded using CPOE. 30% in Stage 2 (radiology orders) 1 Recommended intervention areas: preventative care; chronic condition management; heart disease & hypertension; appropriateness of diagnostic orders and procedures; advanced medication-related decision support (including pharmacogenetic/pharmacogenomic test result support).

3 Objective 5: Patient Electronic Access to Health Information Need to satisfy both measures Measure 1 (Access): For more than 80 percent of all unique patients: (50% in Stage 2 o The patient (or patient-authorized representative) is provided access to view online, download, and transmit their health information within 24 hours of its availability to the provider; or 4 days (EP), 36 hours (EH) in Stage 2 o The patient (or patient-authorized representative) is provided access to an ONC-certified API that can be used by third-party applications or devices to provide patients (or patient-authorized representatives) access to their health information, within 24 hours of its availability to the provider. Measure 2 Patient-Specific Education Materials (PSEM): More than 35 percent of unique patients seen by the EP or discharged from EH are provided electronic access to clinically relevant PSEM identified by CEHRT. 10 in Stage 2 VDT: If using an API, does it provide the same level of access and use as VDT does? o Whatever method is chosen must only support and enhance the current level of access and use Should providers be required to use APIs? If so, should providers also be required to offer access through VDT? Support proposed alternative A (offer and use both VDT & APIs) to preserve existing electronic access and functionalities enabled through patient portals while APIs are tested. Measure 2 (PSEM): What are the challenges in measuring patient access through apps? What are solutions to these challenges? Our understanding is that the API should be able to measure downloads in the same way as the current VDT/portal. What are the pros and cons of measuring a minimum number of patients who access their information through apps? Are there alternatives to measure access? Measure 1 (Access): Highlight role of electronic access; cite recent NPWF survey Thank CMS for explicit inclusion / recognition of patient authorized representatives (i.e., caregivers) in measure SUPPORT: increasing both the percentage of unique patients that are offered access, as well as accelerating to 24 hours the timeframe that information is made available to the patient/representative SUPPORT: In general support move towards API, but have several outstanding concerns (privacy and security of 3 rd party apps; awareness and education; availability of existing portal functionalities such as secure messaging, reminders, refill requests) o Privacy & Security Guidance: Encourage CMS/ONC to work with FTC/OCR to develop and publish guidance for use, educational materials for app developers, providers, and patients to communicate / understand privacy policies. o Testing & Education: Thorough testing & education re: APIs necessary for providers and patients/reps (REVISED) CLARIFY: ONC certified APIs will be published, publicly available; and that no barriers are placed on consumers for use of APIs MISSING: No progress has been made in providing access to health information in non-english languages. MISSING: Online access to visit (provider progress) notes Measure 2 (PSEM): SUPPORT: Continuation of measure and increased threshold. Materials should be written in plain language, accessible, culturally appropriate SUPPORT: We appreciate that CMS still encourages providers to provide paper-based information in honor of patient preferences, but realize that electronic attestation is required to demonstrate the meaningful use of EHRs. MISSING: Still no policy requirement to provide education materials in non-english languages. (NEW) MISSING: make PSEM available to patients and caregivers via online access (i.e., VDT)

4 Objective 6: Coordination of Care through Patient Engagement Need to meet 2/3 measures; but attest to all 3 Measure 1 (Patients using access): During the EHR Measure 2 (Secure Messaging): reporting period, more than 25 percent of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department actively engage with the electronic health record made accessible by the provider. An EP, eligible hospital or CAH being included (e.g. CC d).? o may meet the measure by either: o 25% view, download, or transmit to a third party their health information; or o 25% access through the use of an ONC-certified API responses that can be used by third-party applications or devices. o 5% in Stage 2 (PROPOSED MODIFICATION TO 1 PATIENT) Measure 2 (Secure Messaging): For more than 35 percent of all unique patients, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient's authorized representatives), or in response to a secure message sent by the patient (or the patient's authorized representative). 5% in Stage 2 (UNDER MODIFICATION TO TURNING FUNCTION ON) CMS is proposing to count situations where providers communicate with other care team members and the patient is engaged in the message and has the ability to be an active participant in the conversation. Measure 3 (PGHD): Patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for more than 15 percent of all unique patients. New to Stage 3 CMS defines a non-clinical setting as any provider that isn t eligible for Meaningful Use (EP, EH, CAH). Examples: nutritionists, physical therapists, occupational therapists, psychologists, & home health care providers How should CMS define patient-centered communication? To meet the requirement, do patients need to actively participate (i.e. respond), view the message, or just If measure finalized as proposed, patient-centered communication should require views (not simply ccs) and track both views and Should it only be the provider initiating the message who can count it towards the threshold for this measure, or any provider that contributes to the conversation? Measure 3 (PGHD): Should the measure be divided into two measures: o 1.) data generated by the patient o 2.) all other data from non-clinical settings o See CPeH Option B Should the PGHD measure apply to EHs, or just EPs? If only EPs, should EHs attest to 1 of the 2 remaining measures or both? Should the measure only be out of the number of patients with whom the provider has multiple encounters? How could this information be captured, standardized, and incorporated into an EHR: Should it be automated? Does it require provider verification? Does the provenance of the data need to been recorded (and for all types of data)? o Support retaining the external data source s provenance as part of the incorporation process. Overarching Comments: Both care coordination and patient/family engagement are critical to high-quality health care systems. However, collapsing coordination and engagement measures may undermine or dilute efforts to engage patients and families. As written, providers could meet objective by sending secure messages and receiving information from a non-clinical setting (neither require direct patient engagement/action) Encourage CMS to separate care coordination and engagement measures (see details below, Option B). If measures are finalized as proposed, providers should be required to meet all three measures (not 2 out of 3) Measure 1 (Patients using access): SUPPORT: Important to not only offer but to require/document use of online access to change practices and culture. SUPPORT: Pleased to see the increased threshold from Stage 2 for patients using access, and encourage CMS to maintain its commitment to online access requirements as a core component of meaningfully using certified health IT. Measure 2 (Secure Messaging): SUPPORT: including authorized representatives as those who can receive secure messages to meet measure. CLARIFY: Communication between providers (even if the patient is copied on the message) while valuable is not truly patient engagement. Measure 3 (PGHD): SUPPORT: Inclusion of PGHD as measure; patients are a source of valuable information that can inform and enhance care. CLARIFY: Inclusion of data from non-clinical settings is valuable, but is not / should to be distinguished from true patient-generated data. (NEW) CLARIFY: PGHD should be part of measures for any histories gathered in other measures. Drug history for drug/drug checkers, demographics, SOGI information, etc. Any measure where the data source is the patient.

5 Objective 7: Health Information Exchange Must meet 2/3 measures; attest to all Measure 1 (send Summary of Care): For more than 50 percent of transitions of care and referrals, the EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care: (1) creates a summary of care record using CEHRT; and (2) electronically exchanges the summary of care record. Must send Common Clinical Data Set (as defined in voluntary 2015 CEHRT NPRM) encourage providers to send a list of items that he or she believes to be pertinent and relevant to the patient's care, rather than a list of all problems Now all of SoC (50%) sent electronically; Stage 2 10% of the 50% SoC Alternate Options (proposed by CPeH): CPeH Option A: Providers are required to meet all 3 measures as proposed CPeH Option B (All 3 measures required): Measure 1: 10% of patients view, download or transmit health information or use ONC certified API (threshold lowered to 10%) Measure 2: 35% of unique patients, a secure message is sent to patient or in response to secure message sent by patient. Measure 3: For 10% of unique patients, provider-requested patient -generated health data is incorporated into EHR (only data generated/contributed by patient (or authorized rep) counts; threshold lowered to 10%; non-clinical data from a non-mu eligible provider moved to HIE Objective, #7) Measure 1 (Send Summary of Care): SUPPORT: Increased exchange threshold from Stage 2, requirement that SoC must be sent electronically (without specifying standard for electronic exchange). SUPPORT: Appreciate use of Common Clinical Data Set; contains critical information like granular race & ethnicity data (see further discussion in CEHRT comments). (REVISED) DISAGREE: We don t support including transitions/referrals to providers on the same EHR sharing a common data source. These so-called selfies do not add to patient care relevant information is already available in the EHR and in most cases is accessed that way by providers in the same system. Allowing selfies for providers using a common EHR is not in the spirit of care coordination, and should not count towards the measure threshold. NOTE: If CMS elects Option B for Objective 6 (and the change to the PGHD measure), HIE Measure 1 would be amended to: Must electronically exchange summary of care/common Clinical data set OR receive clinical information from a non-mu eligible provider NEW: Clarify SOC requires the documentation of the UDIs of implanted devices at the time of the procedure. Measure 2 (receive SoC): For more than 40 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the Measure 2 (incorporate SoC): SUPPORT: Appreciate the addition of the incorporation measure as a pivotal moment in the MU program; requiring

6 patient, the EP, eligible hospital or CAH incorporates into the patient's EHR an electronic summary of care document from a source other than the provider's EHR system. New to Stage 3 the receipt of electronic health info helps to close the referral loop and achieve real-time coordination of care. ACKNOWLEDGE: Lack of experience incorporating SoC record and other info into EHR (measure new to Stage 3). Measure 3 (Reconciliation): For more than 80 percent of Measure 3 (Reconciliation): transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP, eligible hospital, or CAH performs a clinical information reconciliation (meds, med allergy, problem list). Is it necessary to conduct different types of reconciliation of data for different patients? For example, it is possible that the data for certain patients should always be reviewed for medication allergy measure does not dictate what subset of information must be included in reconciliation. reconciliation, when it may not be as relevant to other patient populations? Information included in the process is determined by the provider's clinical judgment of what is most relevant to patient care. Should the measure instead allow providers to choose 2 of 3 information reconciliation data sets (medication, 50% in Stage 2 (only medication) medication-allergy, and problem list) relevant to their specialty or patient population? ACKNOWLEDGE: Flexibility may be necessary to accommodate differences in providers and practice settings Objective 8: Public Health & Clinical Data Registry Reporting EPs must meet 3/5 measures; EHs 4/6 Criteria met through active engagement, which Immunization registry can be accomplished in one of three ways: o bidirectional data exchange between the 1.) Completed registration to submit data if provider's certified EHR technology and the awaiting response from PHA/CDR immunization registry is required 2.) Testing and validation Syndromic surveillance Electronically submitting production data Case reporting o new Public health registry Clinical data registry Electronic reportable laboratory results* (EH only) Measure 3 (Reconciliation): SUPPORT: Broader reconciliation and higher thresholds than included in Stage 2 now includes medication allergy and problem list (in addition to medication). Reconciliation is valuable opportunity to engage patients and caregivers in their health and care No CPeH comment planned

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