May 20, 2019
Seema Verma, Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
P.O. Box 8016
Baltimore, MD 21244-8016
Attention: CMS-9115-P
Dear Administrator Verma:
Thank you for the opportunity to comment on the proposed rule for improving interoperability and patient access. The National Committee for Quality Assurance (NCQA) overall strongly supports this proposed rule to promote electronic data exchange for improving health care quality.
These proposals, along with the aligned Office of the National Coordinator for Health IT (ONC) interoperability, information blocking and health IT certification proposals, will bring the promise of health IT much closer to its full potential. The proposals also support the NCQA and CMS shared goal of automatically extracting quality measurement data from EHRs, registries, health information exchanges (HIE) and other electronic health information (EHI) sources. Automatically extracting quality measurement data from electronic sources can reduce reporting burden, improve the accuracy of results and support measures that are more meaningful than traditional reporting based on claims data.
We do, however, have some suggested refinements to what is proposed:
- A 10-year time frame rather than 5-year timeframe for forwarding patient data to other entities will better support look-back periods for important clinical quality measures.
- The proposed uniform interoperability standards are important, but do not yet include critical fields—for example, on social determinants of health and care coordination—and thus will require regulatory updates as quickly as feasible, as improvements continue.
- Publicly reporting entities that negatively attest to not engaging in data blocking may help, but we urge you to also establish an easy way for stakeholders to report suspected inappropriate data blocking, for investigation and potential penalties.
- Requiring providers to report contact information changes to the National Plan and Provider Enumeration System within a set period, such as 30 days, will better support health plan provider directory accuracy.
- An additional provision to require more-robust systems validation and testing for producing measures will help improve data sharing and better support accurate measurement.
Detailed comments on these and other issues in the proposed rule are below.
Time Frame for Forwarding Patient Data: We support requiring payers to forward data to another plan or entity upon request by former enrollees. Sharing such information can greatly enhance efforts to coordinate care, avoid waste, and measure and improve quality. However, the proposed 5-year time frame does not support clinical quality measures with look-back periods of up to 10 years. These include Medicare Advantage Star Ratings pay-for-performance system HEDIS®[1] measures such as Colorectal Cancer Screening, as well as vaccination measures such as Pneumococcal Vaccination Status for Older Adults. We therefore urge you to extend the time frame to 10 years.
Interoperability Data Standards: We support adopting ONC EHI content and vocabulary standards and the application programming interface (API) technical standards. These standards enjoy broad international support, will help make EHI readily available and are moving in the right direction. However, the Fast Healthcare Interoperability Resources (FHIR) and US Core Data for Interoperability (USCDI) are works in progress and will need substantial improvement to fulfill their promise. For example, these standards do not yet include fields for data on social determinants of health, risk adjustment and stratification, care plan goal progress, care coordination, care transitions and opioid use. In addition, not all systems are ready to use these standards.
We appreciate that there is a need to balance progress toward comprehensiveness with the ability of different stakeholders to adapt to these standards. We therefore urge you to incorporate any and all updates as quickly as feasible, if your final rule adopts these broadly supported standards.
Data Blocking: We strongly support proposals to prevent inappropriate blocking of data sharing with other payers and providers and to publicly report entities who negatively attest that they do not inappropriately block data. However, we urge you to strengthen this provision further by also establishing an easy way for stakeholders to report suspected inappropriate data blocking for investigation and potential penalties.
Trusted HIE Networks: We support requiring health plans to participate in health information networks that are part of the Trusted Exchange Framework and Common Agreement (TEFCA), maintain an open API and participate in testing of new interoperability standard use cases. This will greatly enhance our ability to automatically extract data for quality measurement from HIEs and other EHI sources.
However, as we noted in comments to ONC last year, we have serious concerns about centralizing authority and operation of TEFCA into a single Recognized Coordinating Entity (RCE). We support the idea that the RCE, as a third-party, independent evaluator, would evaluate the operational and organizational aspects of health information networks. However, we have concerns that the RCE would also function as the tester and technical standard conformance authorizing body.
We recommend building a multi-stakeholder advisory council to guide the RCE to function as a convener, collaborator, and consensus-builder working transparently with appropriate stake-holders to identify issues and solutions.
Provider Directory Data: We support the proposal to improve the accuracy of health plan provider directories by publicly reporting clinicians who do not submit their digital contact information to the National Plan and Provider Enumeration System. We urge you to strengthen this further by requiring clinicians to update their reports within a set period, such as 30 days, from a change in information, and to reaffirm the information’s accuracy at least annually.
Patient Event Notifications: We strongly support requiring hospitals to send automated patient admission, discharge and transfer notifications, immediately before or at the time of these events, to other facilities and providers that have established care relationships with patients. Lack of timely information about patient events is a key contributor to gaps in care coordination and needed follow-up.
Downloads on Shared Patient Populations: It is feasible and critically important for providers to request a download on a shared patient population via APIs, which HIPAA rules regarding data exchange for treatment, payment and operations allow. The Da Vinci project referenced in the proposed rule (NCQA is a founding member) is diligently working to develop a constructive approach and practical solutions for payers and providers to meet data-exchange requirements in a standardized, secure fashion. The ability to titrate the amount of data shared is critical. Sharing entire patient histories can be useful for plans and larger provider systems, but it is also important to allow specific data requests as needed, rather than broad “data dumps” that could overwhelm smaller practices. We also greatly appreciate CMS participating in Da Vinci and encouraging payers to align with it. We look forward to working with you and all other stakeholders to continue advancing this cutting-edge work.
Validation and Testing of Systems Producing Measures: Finally, we urge that the final rule include provisions requiring more robust validation and annual testing of systems producing performance measures. This proposed rule and its ONC companion greatly enhance our ability to automatically extract measurement data from EHI sources to reduce burden, improve accuracy and measure what matters. However, the wide variations in the accuracy and reliability of quality measure results, which determine value-based payments, could undermine confidence in such payments.
ONC has approved NCQA’s e-measure testing methodology, which is much more robust than ONC’s Project Cypress methodology. We are asking ONC to transfer e-measure certification testing to NCQA in our comments on their proposed rule. We could further promote better accuracy and validity of measure results if CMS required annual testing of measurement reporting systems, as is the case for Medicare Advantage Stars HEDIS measures.
Thank you again for the opportunity to comment on the draft. If you have any questions, please contact Paul Cotton, NCQA Director of Federal Affairs, at (202) 955-5162 or at cotton@ncqa.org.
Sincerely,
Margaret E. O’Kane
President
[1]HEDIS®, the Healthcare Data and Information Set, is a registered trademark of NCQA.