Andrew Slavitt
Acting Administrator
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
Hubert H. Humphrey Building, Room 445–G
200 Independence Avenue, SW
Washington, DC 20201
Karen B. DeSalvo, MD, MPH
Acting Assistant Secretary for Health
National Coordinator for Health Information Technology
U.S. Department of Health and Human Services
Office of the National Coordinator for Health Information Technology
Hubert H. Humphrey Building, Suite 729D
200 Independence Avenue, SW
Washington, DC 20201
Dear Mr. Slavitt and Dr. DeSalvo:
On behalf of the 25,000 physician, resident and medical student members of the Massachusetts Medical Society I am writing to provide our comments on Stage III Meaningful Use as it relates to the Medicare Access and Child Health Reauthorization Act. It is our understanding that the AMA is
submitting extensive and detailed comments on specific aspects of the Meaningful Use Stage III, including a proposed revision of the program which we strongly urge the Department to consider going forward. Our comments will highlight several of the overarching problems with the meaningful use program as currently constructed
and its impact on practicing physicians and our patients.
To put our comments into context I would like to underscore that Massachusetts physicians were early adopters of Electronic Health Records. The MMS has been committed to helping our members understand and implement successfully EHRs for well over a decade. We were one of the founding
members of the MA EHealth Collaborative (MAeHC) and continue to support this important project which helps physicians choose and implement EHRs in their offices. We understand well the promise of this technology.
Over 80% of MA physicians currently use EHRs, with a significant percentage having used them for nearly 10 years. Despite this fact, only 20% of these same physicians have been able to meet Meaningful Use Stage II including some of our most tech-savvy and
enthusiastic providers. These numbers are both telling and compelling. Although a significant percentage of our physicians successfully use an EMR, and have for years, they cannot successfully attest to the MU regulations. We believe the inherent problems with the
design of the meaningful use program must be acknowledged and corrected before going forward. The problems and frustration with the MU program are so great, that many physicians in our membership would strongly urge the Department to completely abandon the current approach which focuses on the number of tests completed
as opposed to clinical relevance or usefulness. It is also difficult to conceive how final Meaningful Use regulations could be issued at this time without having the overall framework of the MIPS program in place. The goal of the new MIPS is to consolidate the various and disparate
reporting requirements into one program. The MMS was one of the many national medical and state organizations which supported MACRA. We believe the development of the MIPS system gives CMS the opportunity to significantly refocus the MU program so that it is
meaningful to patient care and an important tool for physician practices – a goal I believe we all share.
Lack of Interoperability
One of the greatest barriers to improved patient care through the use of Electronic Health Records is the lack of interoperability among EHRs. A resolution was passed at our most recent House of Delegates on this point (relevant excerpts below). That the MMS support:
- Enhanced efforts to accelerate development and adoption of universal, enforceable electronic health record standards for all vendors before the implementation of penalties associated with the Merit-Based Payment System or any other end-user penalties
- A clear statement of MMS policy that there should be no end-user penalties associated with the Meaningful Use program
- The recommendation for significant financial penalties against vendors who do not provide, and health care organizations that do not allow, for full interoperability features with their products.
Many physicians are truly outraged by the onus placed on them to make electronic health records successful, as defined by their meaningful use achievement, while health systems and vendors are not held accountable for any of the actions on their parts which hinder interoperability. Physicians
are also frustrated by the fact that, in short, the entire premise of the electronic healthcare record - to improve the quality of their patients care by accessing data readily, expediting communications between clinicians and providing important data for disease management – is completely unachievable
without interoperability. The fact that physicians are being penalized for their failure to comply with detailed MU II regulations, while vendors and health systems are not held accountable for their failure to promote interoperability is unfair.
We have heard countless stories from primary care physicians who are required to purchase and maintain more than one EHR because they have admitting privileges at more than one hospital. Many of our physicians have lost productivity, put aside useful patient health initiatives for lack of time and resources, and
spent tens of thousands of dollars per practicioner annually on information technology fees in attempts to meet Meaningful Use requirements – for the most part, unsuccessfully. Nor is the seemingly rapid acceptance of the EPIC system a solution to this problem as
each health system develops an EPIC based EHR that by design cannot interface with another health system’s EPIC-based EHRs. The impact on the practicing physician and their patients is significant, in terms of wasted time, excessive demand on financial and other
resources and other inefficiencies which do little to improve patient care.
Interoperability and workflow challenges take many forms within the daily clinical practice beyond simply preventing the sharing of clinical information along the chain of care. Meaningful Use features are often tacked on to older EHR products requiring redundant
documentation screens, multiple clicks and wasted time; a myriad of quality reporting systems which don’t share data force clinicians and staff to re-enter by hand data into multiple systems; confusing, proprietary interfaces distract from quality of patient-physician communication. All of these create inefficiencies in care at
a time when the medical profession needs better quality for more patients.
The MMS strongly supports enhanced efforts to accelerate development and adoption of universal, enforceable electronic health record standards for all vendors before the implementation of penalties associated with the Merit-Based Payment System or any other end-user penalties. We also
feel strongly that if incentives are left in place for those who do manage to meet MU stages 2 or 3, that any and all penalties for lack of successful attainment of MU stage 2 or 3 should be eliminated. Additionally, we support the AMA recommendation that CMS develop a uniform understanding of clinical terms
across groups of clinicians to ensure a consistent meaning when data is captured, exchanged and reused. Interoperability is not merely two computers exchanging data, but the ability for the information to be exchanged and presented to a physician in a
meaningful context for patient care. Unfortunately the current MU regulations focus on the quantity of the information that is exchanged versus the relevance of the information to a specific patient’s care.
Flexibility
We encourage CMS to recognize that this is a time of significant transition with the changes in MACRA and the new payment methodologies. Vendors will need time to develop and test new software to comply with the new MIPS requirements, which are as of yet undefined.
Physicians, implementing new EHRs and moving to new payment methodologies will need time to transition. There is no value to making physicians try to meet MU Stage 3 now, when within two years at most, they will need to adopt a new program based on the MACRA requirements for MIPS and APMs.
Quality Measurements
As stated earlier, we believe CMS has an opportunity to significantly revise its approach to meaningful use to move away from process based tasks to measures meaningful to patient care. This will be particularly important as the Agency seeks to align clinical
quality requirements with the MIPS system into one quality reporting system. It is truly imperative, and a fundamental premise of the MIPS program, that all the current and varied reporting programs be united into one single system. We understand the AMA will
be submitting extensive comments in this area. At a minimum, we believe the quality measurements must be scientifically valid, verified and meaningful to patient care. This is a significantly different approach from that currently used in the MU process.
Patient Privacy and Security
The MMS is a staunch defender of patient privacy and the need for strong security measures to protect data and the exchange of data against data breaches. We support the agency’s concern in this regard. As EHRs become more interoperable, our ability to protect
identifiable information will become even more pressing.
Clearly there are a number of issues which CMS will need to address both with the development of the MIPS and APMS system as well as how MU and the other reporting programs are melded into one coordinated meaningful system. The MMS signed onto the AMA’s earlier comments detailing the problems with
Meaningful Use Stage 3 proposed rules. We look forward to working with the agency throughout this process.
Sincerely,
Dennis M. Dimitri, M.D.
President
Massachusetts Medical Society
