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Electronic Health Record Incentive Program, March 2010

March 15, 2010

Ms. Charlene Frizzera
Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-0033-P
Comments submitted electronically to http://www.regulations.gov

Re: Electronic Health Record Incentive Program

Dear Ms. Frizzera:

On behalf of the American Association for Geriatric Psychiatry (AAGP), I welcome the opportunity to submit comments regarding the proposed rule published on January 13, 2010 specifying the criteria that eligible professionals (EPs) and eligible hospitals must meet to qualify for Medicare and Medicaid incentives as meaningful users of certified electronic health record (EHR) technology. The AAGP is a professional membership organization dedicated to promoting the mental health and well-being of older people and improving the care of those with late-life mental disorders. Our membership consists of more than 2,000 geriatric psychiatrists as well as other health care professionals who focus on the mental health problems faced by senior citizens.

Meaningful Use Criteria

AAGP fully appreciates the desire of the Centers for Medicare & Medicaid Services (CMS) to spur rapid progress in the adoption and meaningful use of EHR technology. However, we believe that the proposed rule is overly ambitious and carries the risk that EPs, including geriatric psychiatrists, will decide there is no feasible way for them to become meaningful users of certified EHR technology and hence no opportunity for them to benefit from the Medicare and Medicaid financial incentives authorized by Congress as part of the American Recovery and Reinvestment Act (ARRA). Worse yet, EPs may be discouraged from taking the initial steps needed to avoid incurring Medicare financial penalties (beginning in 2015) for EPs who do not become meaningful EHR users. Thus, we strongly urge CMS to re-examine its list of meaningful use criteria and their associated Stage 1 measures and develop a final policy that is more balanced and attainable. As part of this re-examination, we also recommend that CMS provide more flexibility to EPs (for example, by allowing them to meet some but not necessarily all meaningful use criteria in the first few years of the incentive program). In other words, even if CMS decides to reduce the number of meaningful use criteria for EPs from the current 25 to some smaller number, the agency should still allow EPs to choose a minimum number of the remaining criteria rather than preserving the current “all or nothing” policy.

In terms of the proposed meaningful use criteria themselves, AAGP believes that the following would be especially difficult to achieve in the near term:

* Computerized provider order entry (CPOE);
* E-prescribing;
* Recording vital signs;
* Incorporating clinical lab test results;
* Reporting ambulatory quality measures through attestation;
* Sending reminders to patients; and
* Performing medication reconciliation.

For example, there are many questions regarding the intended numerator and denominator for CPOE and whether orders might be entered by non-physician staff (in order to limit disruptions to work flow). The e-prescribing criterion would be problematic in communities where pharmacies have limited ability to receive e-prescriptions or where patients prefer to receive hard-copy prescriptions. The proposed vital signs that would need to be recorded (height, weight, and blood pressure, with body mass index calculations for all patients and growth chart plotting for children) are not particularly relevant to some EPs. Lab test results are not always received from laboratories as structured data or electronically, even in physician practices using available EHRs, and requiring manual entry of lab test result data seems rather anachronistic in a program intended to foster electronic communication. Sending reminders to 50 percent of all patients that are 50 and over would appear to make more sense in a primary care practice than in other cases. Further, medication reconciliation is not an automated EHR process and the medication reconciliation criterion raises a number of definitional and operational issues. We discuss below our concerns regarding the near-term reporting of quality measures.

AAGP also believes that the following three proposed criteria should be dropped because the functionalities in question are typically performed through practice management systems and should not be transformed into criteria for meaningful use of certified EHR technology:

* Recording patient demographic information;
* Checking insurance eligibility electronically; and
* Submitting claims electronically.

Finally, AAGP recommends that the measures for other proposed meaningful use criteria be adjusted to take into account the current limitations of EHR technology and the significant impact the measures are likely to have on physician practice productivity. In particular, we urge CMS not to adopt measures that would require EPs to perform complex manual calculations in order to generate required numerators and denominators. In addition, we would urge CMS to significantly reduce or even eliminate the percentage thresholds associated with these measures (for example, 80 percent of all unique patients seen by the EP) since we consider the proposed thresholds to be overly ambitious even in the case of meaningful use criteria that appear relatively achievable in the near term. Lastly, we recommend dropping the 48- and 96-hour deadlines for providing patients with electronic copies of, or electronic access to, certain health information since the time limits are impractical for practices not open 24-7 and ignore the many circumstances under which information should first be provided to a patient during a face-to-face encounter. We also seriously question the value of providing clinical summaries of each office visit (through a personal health record, patient portal on the web site, secure email, electronic media such as CD or USB fob, or printed copy), whether requested by the patient or not. The fact that CMS is proposing to “limit” this requirement to 80 percent of all visits during Stage 1 is far from comforting.

Clinical Quality Measures

AAGP strongly opposes the proposed attestation methodology relating to clinical quality measures. Until CMS is prepared to accept performance data from EHRs and until other necessary work can be successfully completed (including developing e-specifications for measures and allowing for public comment on such specifications), we believe that CMS should defer any requirement to submit quality data.

AAGP also opposes the three proposed core measures (inquiry regarding tobacco use, blood pressure measurement, and drugs to be avoided in the elderly). We join the HIT Policy Committee in urging CMS to drop these measures. In general, we believe it would be extremely difficult if not impossible for CMS to identify any single set of measures that would be appropriate for all EPs to report, even in future Stages of the program. Such a “one size fits all” approach is likely to be problematic and disruptive to patient care. Expecting EPs to report measures not relevant to the patients they see or the clinical problems they manage will do nothing to advance the effective and efficient use of EHR technology.

CMS has also identified separate Measure Groups for a number of physician specialties, including psychiatry, while noting that it would expect any final Measure Group for a specialty to include no more than 3 to 5 measures. For psychiatry, the proposed rule identifies the following 6 measures, the first 3 of which are currently used under the Physician Quality Reporting Initiative (PQRI):

* Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD;
* MDD: Diagnostic Evaluation;
* MDD: Suicide Risk Assessment;
* Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement;
* New Episode of Depression: (a) Optimal Practitioner Contacts for Medication Management, (b) Effective Acute Phase Treatment, (c) Effective Continuation Phase Treatment; and
* Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use.

Given our support for deferring quality reporting until it can be accomplished electronically, we believe that there is no immediate need to settle on which measures would apply to psychiatrists or other EPs. Instead, we believe that CMS should work with stakeholders to develop necessary e-specifications for a manageable number of measures and then seek further public comment on those measures and e-specifications. Further, we believe that each EP should be accorded some flexibility in choosing those measures that are most appropriate for his or her practice rather than being limited to some rigid measure set. Finally, we believe it will be critically important for CMS to assure itself that available EHR technology will permit EPs to efficiently generate and electronically transmit whatever quality data the agency expects EPs to submit. In sum, we believe it would be a serious mistake to forge ahead in requiring the manipulation or submission of clinical quality data before CMS and EPs are actually ready to accomplish this accurately and efficiently.

Other Matters

AAGP supports CMS’ proposed 90-day reporting period for the first year under the EHR incentive program. In fact, we would urge CMS to adopt the same policy for any EP’s first year of meaningful EHR use. This would allow EPs to begin meaningful use as late as October 1 in their first year (even if that first year occurs after 2011) and still qualify for incentive payments for that year. We believe the expanded application of the 90-day reporting period would do much to encourage EPs to adopt and meaningfully use EHR technology.

Although CMS has laid out a tentative plan regarding Stages 2 and 3, AAGP believes that it would be premature to provide any input regarding these later stages except to recommend that CMS’ tentative plan be re-examined as information becomes available regarding the number of EPs able to achieve Stage 1 criteria and the evolving nature of EHR technology. In general, we believe that CMS and the Office of the National Coordinator for Health Information Technology significantly underestimate the challenges facing EPs with respect to the acquisition and implementation of certified EHR technology, let alone its meaningful use. Of course, even CMS estimates that 47 to 79 percent of EPs could face Medicare penalties in 2015 for failure to satisfy EHR meaningful use criteria, an estimate we find truly disturbing, especially since AAGP’s membership specializes in the care of older, typically Medicare-eligible individuals.

I hope the preceding input is helpful. If you have any questions regarding our comments or need more information, please contact Marjorie Vanderbilt at 301-654-7850 or by e-mail at: mvanderbilt@aagponline.org.

Sincerely,

Christine M. deVries
Chief Executive Officer

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