On June 14, 2018 HLN submitted the following comments on the Centers for Medicare and Medicaid Services (CMS) 2019 Inpatient Prospective Payment System Notice of Proposed Rulemaking (NPRM) to Quality Payment Program based on our earlier comments:
HLN Consulting, LLC is pleased to submit the following comments on the recently-released CMS IPPS NPRM, CMS–1694–P. HLN is a leading public health informatics consulting company. With that in mind, we read documents like the NPRM through a public health lens, and confine our comments to that important context.
We are quite concerned by both the overall direction and the specific recommendations regarding public health objectives and measures in the NRPM. Regarding the changes to the proposed measures, CMS has not provided any explanation for why Syndromic Surveillance reporting was selected as the required measure. Other public health measures (e.g., Immunization reporting, Electronic Laboratory Reporting, Electronic Case Reporting) continue to require incentives for implementation. The effect of successive changes to the reporting requirements from Stage 1 to this NPRM for instance, has been to steadily de-emphasized immunization reporting. In addition, the language regarding exclusion for Syndromic Surveillance reporting is somewhat ambiguous: it states that if a EH/CAH claims exclusion for one or both of the public health measures that the points associated with this measure would be redistributed to the Provide Patients Electronic Access to their Health Information measure instead (emphasis added). It is not clear why exclusion for Syndromic Surveillance reporting should have any effect on the other required public health measure (If that’s what this in fact means). We recommend that the language be changed to require a program participant claiming exclusion for syndromic surveillance to engage another public health registry to meet the measure.
Rather than lower the requirements for public health reporting, we believe that CMS should at least leave the requirements at the same level as Stage 3 Meaningful Use (meaning, three public health measures), if not increase the requirements. We recommend that the objective be changed to require that a program participant be required to address as many as six measures: syndromic surveillance, immunization registries, ELR, ECR, a National Center for Health Statistics registry, and at least one clinical data registry or other public health registry, with the expectation that a clinical registry consists of data from multiple program participants, recognizing the programmatic theme of promoting interoperability. We also strongly suggest that CMS reconsider its stated intent to remove public health measures altogether for CY2022 as we still have much work to do to ensure pervasive interoperability of public health data.
There is also some concern that the fairly low threshold of points required to meet the requirements of the Program may have the adverse impact of further de-emphasizing public health reporting, whose proposed measures are being reduced in the NPRM (as noted above) as it becomes easier for an EH/CAH to reach 50 points with no public health reporting at all. We feel it is important that the program require participation in the public health objective rather than provide an arithmetic way to avoid them entirely.
Finally, the NPRM makes reference to TEFCA as a possible basis for future requirements and measures. As we said in our comments on the draft TEFCA document (https://www.hln.com/assets/pdf/HLN-TEFCA-Comments-Final.pdf), very few public health data exchange transactions are supported on the architecture described in TEFCA. Most public health reporting is done via unsolicited HL7 v2 messages (e.g., immunization data submission, electronic laboratory reporting), and in some cases via CDA document transmission (e.g., cancer reporting, electronic case reporting). Simply ignoring this represents a “missed opportunity” for the articulation of a consistent plan for these transactions. Queries to public health registries are usually executed with a known end‐point (i.e., the registry in the clinician’s jurisdiction), though with an increasingly mobile population and medical trading areas that cross jurisdictional lines there is certainly a need for query to public health registries beyond the provider’s home jurisdiction. Query to Immunization Information Systems (IIS) currently takes place using different standards than those described in the documents. The Common Agreement also pays little specific attention to the reality of inconsistent state, local and tribal patient consent and data sharing laws that are often an obstacle to cross‐jurisdiction interoperability. So, in summary, TEFCA as currently described in the draft document does not serve public health needs well at all, and we do not recommend its adoption until these deficiencies are addressed.
In addition, HLN assisted the following organizations in drafting their responses:
- American Immunization Registry Association (AIRA)
- American Medical Informatics Association (AMIA)
- Council of State and Territorial Epidemiologists (CSTE)
- Health and Information Management Systems Society (HIMSS)
- Meaningful Use (Promoting Interoperability) Public Health Reporting Requirements Task Force
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