June 20, 2023
Micky Tripathi, PhD, MPP
National Coordinator for Health Information Technology
Office of the National Coordinator for Health Information Technology
U.S. Department of Health and Human Services
330 C Street SW
Washington, DC 20201
Attention: 0955-AA03
Dear Dr. Tripathi,
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the Office of the National Coordinator for Health Information Technology Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing Proposed Rule (HTI-1).
NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation and measurement programs. We are a national leader in quality oversight and a pioneer in quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate the challenges associated with moving to an equitable health care system. Our mission to improve the quality of health for all Americans, with a focus on health equity and support for meaningful value-based payment models, propels our daily work.
NCQA is pleased to provide the following comments on the proposals and considerations outlined in HTI-1.
Raising the baseline version of USCDI from Version 1 to Version 3
NCQA applauds ONC’s proposal to accelerate USCDI adoption through USCDI v3. This step will help ensure that certified vendors can identify and respond to the inequities plaguing American health care. USCDI v3 is important for spurring the industry to capture and respond to health equity data (beyond USCDI v1, which includes only race/ethnicity data). By requiring USCDI v3, both sexual orientation and gender identity data will be elements of social determinants of health and standardized to drive quality improvement activities that aim rectify health inequities.
We appreciate that ONC is supporting the public-private partnership efforts of the HL7 Gender Harmony Project and the Gravity Project. Both initiatives have driven meaningful consensus that will help produce more equitable outcomes. NCQA will leverage both in our efforts to advance health equity measurement through digital health data.
NCQA agrees with CMS about the benefits of these proposed updates, particularly to certification criterion §170.315(g)(10), Design and Performance—Standardized API for patient and population services. “CMS has identified an intent to leverage APIs for population services to modernize quality measurement and quality reporting under value-based payment programs[1]. In 2016, a report found that quality measurement reporting bears an estimated $15.4 billion cost on clinicians for chart abstraction, data validation, and measure reporting.[2]” In a more recent report,[3] a health system published the cost of reporting quality measures and found that claims and chart-abstracted measures result in a cost of over $30,000 per measure, while electronic measure reporting costs less than $2,000 per measure.
This is why we have intensified our commitment to investing in full transition to digital quality measures. In 2022, pioneering health care organizations and vendors joined the Pilot Program for NCQA’s Digital Content Services to help advance digitized quality measurement initiatives and to maximize flexibility and transparency in HEDIS® performance measurement. The Digital Content Services product will be available to the public this year.
In May, NCQA announced the upcoming publication of requirements and open-source software for interpreting and executing Clinical Quality Language (CQL), so any organization or software developer can use HEDIS Digital Content Services. This action makes it easy for developers to understand digital requirements and test capabilities for working with NCQA’s digital measure content. It is part of NCQA’s larger goal of building better health care, better choices and better health by convening and aligning stakeholders around digital quality requirements and testing. We look forward to bringing more innovations to market to support our aligned goals for digital quality measurement.
Insight Conditions for EHR Reporting
NCQA is encouraged to see ONC “Insight Conditions” efforts to provide interoperability transparency and reporting for EMR vendors. The nine outlined measures are a solid first step toward introducing operational measures that will provide the true landscape of the adoption, use and mechanics of interoperability reform outlined in the 21st Century Cures Act.
RFI Definition of Encounters: We thank ONC for recognizing the valuable role NCQA and HEDIS play in identifying clinical encounters and outcomes across American health care. We agree with the HITAC and the Urban Institute, and we recommend that ONC align EMR reporting requirements with NCQA’s HEDIS outpatient value set and SNOMED CT inpatient encounter codes.
NCQA updates HEDIS and associated value sets annually. We encourage ONC to align reporting requirements with other national measure reporting timelines, to the extent possible.
Proposed Requirements for Decision Support Interventions and Predictive Models (Algorithmic Transparency)
We support renaming the “Clinical Decision Support” certification criterion to “Decision Support Interventions,” and we support its recategorization as part of the care coordination criteria in
§ 170.315(b). We are particularly encouraged by ONC’s proposal to build transparency and trust into the decision support tools available to practitioners through certified technology. We emphatically agree that transparency is key to understanding the potential impact of artificial intelligence on American health care, and we support the proposal to ensure clear identification of source attributes and data relevant to health equity (race/ethnicity, sexual orientation/gender identity, SDOH) when used.
NCQA updated our national Health Plan Accreditation program in 2022 to ensure that managed care organizations assess their segmentation and/or stratification algorithms for the presence of racial bias. The proposed requirements for certified technology in HTI-1 will help health plans and delivery systems understand the effects—both positive and negative—of algorithms deployed in the delivery of care. We believe ONC, the FDA, CMS and the Office of Civil Rights all play a role in ensuring equitable use of AI in the evolution of care delivery, and we encourage a governmentwide approach to aligning transparency and oversight requirements for stakeholders impacted by rapid innovation.
Thank you for the opportunity to comment. We remain committed to working with the ONC to build a more equitable, sustainable and responsible American health care system. We welcome a discussion on our experience and recommendations to continue to strengthen the OMB’s proposals for updating race and ethnicity categories. If you have any questions, please contact Eric Musser, Assistant Vice President of Federal Affairs, at (202) 955-3590 or at musser@ncqa.org.
Sincerely,
Margaret E. O’Kane
President
[1] CMS Digital Quality Roadmap, March 2022: https://ecqi.healthit.gov/sites/default/files/CMSdQMStrategicRoadmap_032822.pdf.
[2] Health Aff (Millwood). March 2016. U.S. Physician Practices Spend More Than $15.4 Billion Annually To Report Quality Measures. https://pubmed.ncbi.nlm.nih.gov/26953292/.
[3] Saraswathula, A., Merck, S. J., Bai, G., et al. (2023). The Volume and Cost of Quality Metric Reporting. JAMA. 329(21):1840–1847. doi:10.1001/jama.2023.7271