January 14, 2013
Submitted electronically
Office of the National Coordinator for Health Information Technology
HIT Policy Committee
Department of Health and Human Services
Patriots Plaza II, 355 E Street, SW
Washington, D.C. 20201
RE: Request for Comment – Stage 3 Definition of Meaningful Use
Dear HIT Policy Committee:
The undersigned consumer organizations are members of the Consumer Partnership for e-Health
(CPeH). The CPeH is a coalition of more than 50 consumer, patient, and labor organizations
working at the national, state, and local levels to advance private and secure health information
technology (health IT) in ways that measurably improve the lives of individuals and their
families. The combined membership of CPeH represents more than 127 million Americans.
CPeH appreciates the opportunity to provide input on Stage 3 advancements in the definition of
meaningful use of health IT. In Stages 1 and 2, the Meaningful Use Electronic Health Record
(EHR) incentive program created foundational capabilities for delivering care differently and
supporting payment models that incentivize the kind of health care individuals need and deserve.
In Stage 3, we need to begin movement beyond the medical model to a more comprehensive,
person- and family-centered model for supporting health and wellness.1 Robust advancement of
Stage 3 Meaningful Use criteria that focus on improvement of outcomes is critical to ensure that
the outlay of public funds through this program results in a healthier population, better care,
and more affordable healthcare costs.
Below are the priorities we believe to be most critical to the achievement of this Triple Aim2.
1
For purposes of brevity, we refer throughout our comments to “patient’ and “care,” given that the Meaningful Use
incentive program is rooted in the medical model. It is important to note, however, that meeting the goals of the
Triple Aim will require a shift away from an exclusive medical model approach toward a more person- and familycentered approach that emphasizes wellness, prevention, and community-based supports, in addition to traditional
medical interventions. "Patients" and "care" imply a medical model with a focus on episodes of illness and
exclusive dependency on professionals. Any effort to improve patient and family engagement must include the use
of terminology that also resonates with the numerous consumer perspectives not adequately reflected by medical
model terminology. For example, the health care community may refer to “care planning,” while the independent
living movement would use the terminology “integrated person-centered planning.” People with disabilities
frequently refer to themselves as "consumers" or merely "persons." Choice of terminology is particularly important
for purposes of care planning and care coordination, when the worlds of independent living and health care provider
often intersect.
2
Berwick, D. M., Nolan, T. W., and Whittington, J., The Triple Aim: Care, Health, And Cost. Health Affairs, 27,
no.3 (2008):759-769
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Priority #1: Supporting Partnerships Among Patients, Their Family Caregivers, and Their
Care Team
Health IT is a tool that can be used to engage consumers as equal members of their health care
team by equipping them to work in partnership with professional care team members, make
better choices, and live healthier, more fulfilling lives. Consumers can be true partners only if
they have access to the information they need to be engaged in care. Stage 3 must advance
patient and family caregivers’ ability to both access and contribute to their own health
information – a critical component of electronic health information exchange.
Advance Directives - SGRP #112
We strongly support transitioning to core the criterion to record advance directive status for
Eligible Hospitals (EHs), and adding the criterion as a menu objective for Eligible Professionals
(EPs). Advance directives are a critical and well-accepted means of empowering patients to
identify the care they want, as well as the care they do not want in specific circumstances. CMS
data show that recording advance directive status has been among the most popular menu items
of Stage 1for EHs, underscoring the value of advancing this objective in Stage 3.
We urge HITPC to advance this objective more aggressively in Stage 3 by requiring that the
content of an advance directive be accessible through the EHR, in addition to a notation about
its existence. The specifics of an advance directive constitute essential patient preference
information that is necessary in order for providers to act according to their patients’ choices.
Patients and providers would benefit significantly from this information being available at the
point of care, and there are technological solutions available today that make this possible, such
as the MyDirectives website.3 Leveraging existing and future technical solutions for making
advance directive content available at the point of care is a meaningful way to incentivize greater
information exchange in Stage 3.
Information in advance directives should, in the future, inform Clinical Decision Support (CDS)
to ensure that individuals receive care according to preferences they have specified. A
significant first step that can and should be taken in Stage 3 is to make the content of an advance
directive available electronically. Availability of electronic advance directive content provides
essential information about an individual’s goals for their care, and therefore is also a
foundational step toward development of a comprehensive, shared care plan.
To maximize the potential of this criterion, we also suggest lowering the 65 year age limit to
all adult patients (18 years and older). Certification criteria should require that the capture of
this information is possible for any patient (regardless of age).
3
http://mydirectives.com/
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View/Download/Transmit - SGRP #204A
Giving patients the ability to view, download, and transmit (VDT) their own health information
was a monumental advancement for consumers in Stage 2 of Meaningful Use. We applaud the
advancement of this criterion toward real-time health data access and inclusive electronic health
information exchange by accelerating the time frame for making information available to 24
hours. We strongly support further advancing the threshold in Stage 3 for both the percentage
of patients provided electronic access to their health information, and the percentage of
patients who use V/D/T capability. To be truly transparent, we urge HITPC to require that
V/D/T criteria apply to entire medical records, such as visit notes. HITPC should build upon
experience from the Open Notes initiative,4 which provides patients electronic access to read
their doctors’ visit notes. In a quasi-experimental study, the vast majority of participants having
access to their notes reported an increased sense of control, greater understanding of their
medical issues, improved recall of their plans for care, and better preparation for future visits,5 all
of which are critical components of patient engagement and better health outcomes.
Participating providers experienced minimal impact on their workload. Furthermore, when
providers were offered the option to decline further participation at the end of the intervention,
none asked to stop.
Additionally, HITPC should be working with stakeholders to ensure that consumers can view,
download, or transmit their health information using diverse and accessible technology
platforms, including mobile technologies, and in the patient’s preferred language.
Consumers need a comprehensive and accurate view of their health and healthcare, and should
be able to direct their health information based on personal preferences. Depending on Stage 2
experience, we recommend exploring opportunities to leverage the automated Blue Button
function to direct a provider to transmit an individual’s health information to another location of
their choosing (e.g., from specialist to primary care portal or non-provider affiliated personal
health record). This approach would meet the intent of the V/D/T criterion while also limiting
provider burden and avoiding the unintended consequence of patients having to manage
information using multiple portals that do not connect to each other.
We are concerned that the availability to patients of some critical lab data may still be delayed.
We advise HITPC to shorten the time by which providers must make available lab results that
are unavailable at the time of the encounter to two business days.
4
http://www.myopennotes.org/
Delbanco, T., Walker, J., Bell, S. K., Darer, J. D., Elmore, J. G., Farag, N., Feldman, H. J., Mejilla, R., Ngo, L.,
Ralston, J. D., Ross, S. E., Trivedi, N., Vodicka, E., Leveille, S. G., Inviting Patients to Read Their Doctors' Notes:
A Quasi-experimental Study and a Look Ahead. Annals of Internal Medicine. 2012 Oct;157(7):461-470.
5
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Patient-Generated Health Information – SGRP #204B
We enthusiastically support the new Stage 3 criterion to offer patients and family caregivers the
ability to contribute information to their medical record that is specific and material to their care.
This is a pivotal opportunity to improve performance on high priority health conditions, address
unnecessary readmissions, and enhance patient and family engagement in care.
The information patients and their family caregivers provide about their abilities and support
needs for self-management complements clinical information generated by care teams to provide
a comprehensive, person-centered view of an individual’s health. As the healthcare system shifts
towards whole-person care, greater support for prevention, wellness, and independent living is
essential. Effective care planning and coordination require a comprehensive approach that is not
exclusively focused on interactions with the healthcare system. Use of both clinical and patient
generated data is a more effective approach for engaging patients and their families, ensuring
that care results in better outcomes, and decreasing costs associated with unnecessary
readmissions and difficulties with adherence.
While we appreciate establishing a modest threshold for new criteria, we urge HITPC to
increase the threshold for this criterion to at least 25 percent. This information – which is
often only available from the patient or a caregiver – is particularly valuable for care planning
and coordination, and is essential for meeting the goals of the Patient Centered Outcomes
Research Institute (PCORI), created by the ACA. A more meaningful threshold would help to
establish patients as valuable sources of health information, which is critical to the culture
change necessary for patient- and family-centered, high-quality care and to the development of
evidence with regard to person-centered outcomes.
The HITPC should specify a wide range of categories of high-value, patient-generated
information that have the most potential to significantly improve health, safety, and quality. The
kinds of information that consumers feel is of highest value for their providers to know from
their perspective include, but are not limited to:
o Goals for care
o Medication allergies and non-tolerated medications (i.e., those which in the past
have caused negative side effects for the individual), including over-the-counter
drugs and herbal supplements
o Caregiver (using DECAF6) and additional professional care team member
name(s), contact information, and role(s)
o Family history
o Functional limitations
6
DECAF is a standardized approach to defining the types and intensity of the roles family caregivers play to
facilitate improved communication. Each letter refers to a different type of contribution made by a family caregiver:
D= Direct Care Provision, E= Emotional Support, C= Care Coordination, A= Advocacy, and F= Financial
http://www.caretransitions.org/documents/Executing%20high%20quality%20-%20JHM.pdf
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o Supports and services necessary for independent living
o Patient values and preferences for care (e.g., advance directives, no blood
products, etc.)
o Patient experience
o Behavioral and mental health history
o Identification of problems or concerns from the patient’s perspective
o Psycho-social information, such as family support, caregiver limitations, financial
constraints, living situation, independent living skills, and activation level
o Data recorded by patient for monitoring of progress toward patient goals
o Risk factors indicated by structured surveys (such as health risk assessments)
Patients and family caregivers manage their health in the context of a multitude of priorities and
life circumstances. These priorities and circumstances have a direct bearing on their
effectiveness in home and self-care, and therefore constitute information that is material to their
care – whether or not they have a high-priority health condition. An equally important goal for
collecting patient generated health data is to engage patients and their family caregivers as
sources of information. For these reasons, this criterion should apply to all MU eligible
providers and all patients, and not be limited only to patients who have high-priority health
conditions.
As efforts to measure and improve health outcomes continue, it will be critical to link patientgenerated data to CDS technologies to generate alerts based on the non-clinical needs of patients,
including their preferences for care. To make progress toward this goal, we suggest increasing
the threshold to 25 percent and allowing providers to select one or more of the above areas
most pertinent to their patient population from which they will collect data directly from their
patients and/or their caregivers.
Finally, we note the importance of patient identity-proofing and information authentication in the
shift toward patient-generated information. The HITPC should prioritize dissemination of the
newly adopted best practices for identity proofing and authentication for private and secure use
of patient portals, developed by the Privacy and Security Tiger Team.
Record Amendments – SGRP #204D
As a coalition of consumers, we strongly support the new Stage 3 criterion to provide patients
with an ability to record an amendment to their health record online, as they are often the first to
identify errors in their own records. Increased access by individuals to their own health
information, as a result of Stage 2 criteria, will conceivably increase the number of errors
identified by patients, thereby underscoring the need for this capability. This criterion helps to
ensure the accuracy and reliability of data stored in an EHR, while simultaneously empowering
patients and their caregivers to be active partners in their health and healthcare. This new
criterion is also a stepping stone toward a more widespread and inclusive view of patients as
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important sources of information.
Clinical Summaries (Post Office Visit) – SGRP #205
Clinical summaries support the success of patients and families in home and self-care, and are
key components of any strategy to reduce avoidable hospitalizations and associated costs.
HITPC should build on lessons learned from Stage 1 and require in these care summaries
information that is meaningful and actionable to patients and their caregivers.
Feedback from patients, their families, and providers indicated that the format and content of
previous after-visit summaries were failing to provide meaningful and actionable information.
The summary is intended to summarize what transpired during the office visit, explain treatment
recommendations, and specify necessary follow-up care and next steps. To achieve this
purpose, we encourage HITPC to work with clinicians and patients to determine the most
helpful data elements to include, such as side effects, potential complications, and when to call
a doctor.
The way the clinical summary information is presented to the patient is equally important as the
kinds of information that are included. HITPC should consider ways to enhance the usability of
these documents. For instance, HITPC could advise ONC and CMS to develop guidance and
resources promoting plain language and a standardized format – similar to nutrition labels.
Graphic explanations are also extremely helpful to patient understanding, and should similarly be
promoted.
Secure Patient Messaging – SGRP #207
Secure messaging is a critical step toward advancing access, care coordination, and information
exchange between patients, caregivers, and providers by enabling more efficient responses to
questions and communication of basic information. Secure messaging is another important
source of patient-generated data, which is critical to a comprehensive view of individual health.
We supports the increased threshold in the Stage 3 RFC. Allowing secure messages sent and
received by a family or other caregiver approved by the patient to count towards the increased
threshold is advisable, and would reinforce their essential role as members of the care team.
We also urge the HITPC to add a criterion measuring timeliness of response from providers to
their patients who use secure messaging. We do not propose requiring a specific timeliness
standard, only the measurement and reporting of timeliness rates, as is current practice for
industry leaders such as Kaiser Permanente.
Communication Preferences – SGRP #208
As consumers, we fully support the inclusion of a separate criterion to record patient
communication preferences. This is vital to ensuring that patients receive information in a
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medium that is most accessible and meaningful to them, which promotes enhanced patient and
caregiver engagement and follow-up. EHRs should have the capability to differentiate
preferences for varying kinds of information. For example, individuals may want to receive lab
results by email, but prefer phone call or text message reminders regarding upcoming
appointments for follow-up care.
We urge HITPC to include the capability to record caregiver communication preferences in
certification criteria and to require collection of communication preferences for at least the
primary caregiver, where applicable. This is particularly important for EHs, given the
importance of safer, more effective care transitions and the role caregivers play in that process.
Identifying Available Clinical Trials – SGRP #209
We support requiring the capability for EHRs to identify relevant clinical trial opportunities for
individual patients as a way to introduce efficiencies for both providers and patients in terms of
identifying potential trials for patient participation. Facilitating communication between health
practitioners, the research community, and patients and their caregivers is critical to advancing
cures and treatments, and ensuring patient access to them.
Priority #2: Improving Coordination of Care
Consumers want better communication among and collaboration between providers, patients,
and their caregivers. Ensuring that the right information is available to the right person at the
right time will facilitate better outcomes that are more affordable for everyone.
Medication Reconciliation – SGRP #302
We strongly support the increase in the threshold for medication reconciliation to 50 percent in
Stage 3. We also enthusiastically support supplementing medication reconciliation for
transitions of care with reconciliation of medication allergies and problems, and encourage
advancement of the threshold in future stages. This criterion is essential for improving care
coordination and safety.
Patients and their caregivers are valuable sources of information and should be included in the
reconciliation process for specific information, especially information that is likely to change
between encounters with the health care system. There are numerous opportunities to leverage
the intent of the patient-generated health information criterion through advancement of the
reconciliation of information criterion. Opportunities to engage patients and caregivers in
information reconciliation include:
o Medications actually taken (including over-the-counter drugs and herbal
supplements)
o Caregiver name, contact information, and role
o Problems/complaints
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o
Advance directive status and content
o Additional care team members (primary care, specialists, ER, retail clinics, etc.)
Summary of Care Record – SGRP #303
This criterion is the primary vehicle for promoting robust, electronic exchange of health
information, and therefore the proposed threshold of 30 percent is far too low. CMS data shows
that, as of November 2012, 84 percent of all EHs were registered and 68 percent for paid for
successful meaningful use, while 63 percent of all EPs were registered and fully one out of three
were paid. Further, CMS expected December 2012 to be the biggest pay-out month to date, by
threefold.7 Given the rapidly increasing pace of EHR adoption and the time remaining between
now and the advent of Stage 3, it is more than reasonable to require more widespread
information exchange in Stage 3.
By the time Stage 3 is implemented, information exchange capabilities will be more widespread,
making a higher threshold more feasible than it may seem today. Furthermore, meaningful and
effective coordination of care requires electronic sharing of information across all providers, in
addition to those eligible for Meaningful Use incentives. In stage 3, providers earning taxpayerfunded incentives should be exchanging data regularly with non-MU eligible providers, such as
skilled nursing facilities (SNFs) and home health agencies (HHAs).
We strongly urge HITPC to increase the threshold of the percentage of summary of care records
that are provided electronically well beyond the 30 percent proposed. We suggest a criterion
that requires 80 percent of patients to have summary of care records shared, with no less than
65 percent transmitted electronically. By significantly increasing both thresholds, MU eligible
providers will be encouraged to begin exchanging data with SNFs and HHAs in their
communities that have the capability to receive electronic information. The Direct standard of
health information exchange8 is one method of achieving this goal, even in cases where a
receiving provider may not have a full EHR.
Electronic transmission of a summary of care record has been a practical starting place for
advancing meaningful information exchange that provides a static view of an individual’s
condition and needs at the time of a transition or referral. We strongly support advancing this
criterion in Stage 3 through the addition of a list of care team members, goals, instructions, and a
narrative summary of information critical for a safe, effective transfer of care. When recording
caregiver information, the DECAF classification system should be used.
7
Rob Anthony, HIT Policy Committee meeting, January 8, 2013
The Direct Project specifies a simple, secure, scalable, standards-based way for participants to send authenticated,
encrypted health information directly to known, trusted recipients over the Internet.
http://wiki.directproject.org/file/view/DirectProjectOverview.pdf
8
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We suggest that HITPC require the inclusion of both patient-defined and clinical goals as part
of the summary of care record. Requiring both kinds of goals will prompt discussion that
otherwise may not occur, and will be an important facilitator of shared decision-making. While
the summary of care record provides a discrete snapshot in time, the inclusion of health goals
that reflect both clinical objectives and individual aspirations will support the beginning of the
necessary shift from delivery of care in silos to better coordinated care, and will also recognize
patients and caregivers as central actors in the care planning and delivery process.
In addition to the categories of information required in the RFC, it is critical to begin providing
information about functional status and independent living services and supports at the point
of transition or referral. This information makes a significant difference in how prepared a
receiving provider is for meeting the needs of the individual being referred or transferred, and
therefore is essential to the quality and safety of care.
We support the certification criteria proposed in the RFC, which create the capacity for
additional steps toward a longitudinal, shared care plan by requiring certified EHRs to enable a
concise narrative section, automatically populate a referral form for specific purposes, and
include data elements related to consultation requests and transfers and care.
Care Plans – SGRP #304
We feel very strongly that HITPC should not wait for future stages of Meaningful Use to begin
advancing the capacity of EHRs and health information exchange to support a comprehensive,
interactive shared care plan platform. Care plans are necessary to provide a roadmap for
achieving the best possible outcomes, as defined by both clinical and individual patient goals.
Care plans also present a valuable opportunity to collect and synthesize patient-generated data
with clinical data across care settings. Ultimately, we are working toward care plans that are
interactive, real-time, and operational across settings, as opposed to static documents. While
achieving this vision is beyond the scope of Stage 3, there are important steps that can and
should be taken in Stage 3 to build the necessary foundation for interactive, flexible, accessible
care plans. In Stage 3, HITPC should advance the concept of the longitudinal, shared care
plan by requiring documentation of a cross-setting care team member list, comprehensive
patient goals (not setting specific), and psycho-social assessment information, such as
behavioral health needs, living situation, and community-based resources. When more than
one professional care team member is listed, a notation should be made regarding who serves as
the primary contact so that the patient and family member are never without a clear point of
contact. These pieces of information build upon the summary of care record, engage patients
and their caregivers in the planning of care (rather than exclusively at the point of decisionmaking about a medical intervention), and provide the necessary foundation for a more personfocused, comprehensive, integrated plan of care. They also incentivize electronic exchange of
information, since electronic exchange would significantly reduce provider burden in meeting
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this criterion. We suggest that the threshold for this Stage 3 criterion be 20 percent of all
patients.
Closing the Referral Loop – SGRP #305
We fully support the new criterion to close the referral loop and encourage threshold
advancement in future stages. We encourage the HITPC to consider making this information
available through the patient portal in order to include the patient and his or her family
caregiver(s) in the closing of the information loop with regard to referrals.
Notice of a Significant Healthcare Event – SGRP #308
We also strongly support the addition of a core criterion regarding significant event notification
for EHs, as it compliments SGRP #305 by “looping in” clinicians who are part of an individual’s
care team, but may not be aware of significant health events and interventions by other members
of the care team.
Priority #3: Increasing Health Equity
Improving health equity requires collection and use of data to identify differences and target
solutions that reduce disparities. In addition, the technology itself should be used to address the
root causes of disparities. Health IT should be used as a tool for both identifying and reducing
health disparities, so that outcomes for underserved populations are not just improved, but also
result in greater health equity.
Record Demographics – SGRP #104
We caution the HITPC that retiring this objective could have adverse effects on health
disparities, especially since there is no requirement in Stages 1 or 2 to actually use this data for
purposes of decreasing disparities. If the HITPC chooses to retire this criterion, it should
require the use of demographic data, and specifically disparity variables, in both functional
criteria and quality measurement. We respectfully remind the HITPC that the HHS Office of
Minority Health “National Stakeholder Strategy for Achieving Health Equity” identified the
availability of health data on all racial, ethnic, and underserved populations as a key strategy for
achieving health equity.9 In our view, this constitutes a mandate to ONC to ensure that such data
is accurately collected and made available in meaningful and useful ways through the use of
health IT.
Regardless of whether this objective is retired, we strongly urge HITPC to require the
stratification and reporting of patient lists and clinical quality measures, respectively, by
demographic data. This significant opportunity, which has not yet been leveraged, will reveal
specific disparities in care within a provider’s patient population, and support the creation of
strategies to reduce and eliminate them.
9
National Partnership for Action to End Health Disparities. National Stakeholder Strategy for Achieving Health
Equity. Rockville, MD: U.S. Department of Health & Human Services, Office of Minority Health, [April 2011].
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We urge HITPC to make the collection of sexual orientation/gender identity data mandatory,
rather than optional. Gathering such demographic information in EHRs is supported by other
Health and Human Services initiatives, such as Healthy People 202010 and Section 4302 of the
Affordable Care Act, as well as recent Institute of Medicine (IOM) reports11,12.
A 2012 IOM workshop explored the benefits of collecting sexual orientation and gender identity
data in EHR systems. A provider’s knowledge of a patient’s sexual orientation and gender
identity is essential to providing appropriate screening and care.13 Gathering sexual orientation
and gender identity data will also increase our understanding of lesbian, gay, bisexual, and
transgender (LGBT) health disparities and how to prevent and detect health conditions that
disproportionately affect LGBT people. Without this most basic data, there can be no progress
in ensuring that the LGBT community receives the quality of care that all people deserve.
Additionally, we strongly encourages HITPC to require the collection of disability status data.
This is an important point of alignment with the Affordable Care Act, which requires data
collection on race, ethnicity, sex, primary language and disability status. Determining disability
status is complex, and the definitions of disability vary even among federal programs. These
differences have significant implications for social services and resource eligibility, as well as
individuals’ ability to be independent at home and effective in their self-care.
We encourage the HITPC to consult with the Centers for Disease Control and Prevention (CDC),
National Center on Birth Defects and Developmental Disabilities (NCBDDD), and National
Center on Health Statistics (NCHS), Disability and Health Data Systems program for guidance
on how to most effectively incorporate disability status into Stage 3. We also encourage the
committee to consider the value of distinguishing medical disability status from equally
important patient-reported information about functional impairment. Accommodation or
assistance needs for functional impairments (e.g., American Sign Language interpretation,
Braille or large font, mechanical lifts or transfer assistance, among others) are critical facilitators
for quality care and patient engagement. To obtain data from patients regarding functional
impairments, we suggest that HITPC consider the use of American Community Survey (ACS)
questions,14 supplemented by additional questions to capture any relevant needs not otherwise
addressed.
10
United States Department of Health and Human Services, Healthy People 2020. (2011, June 29).
Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for
Better Understanding. Washington, DC: The National Academies Press, 2011.
12
Institute of Medicine. Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records Workshop Summary. (2012,December 20).
13
U.S. Department of Health and Human Services. Affordable Care Act to improve data collection, reduce health
disparities. News release. June 29, 2011. www.hhs.gov/news/press/2011pres/06/20110629a.html
14
http://www.census.gov/acs/www/Downloads/QbyQfact/disability.pdf
11
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Condition Reports and Patient Dashboards – SGRP #115
We fully support this measure and its advancement in future stages, and believe the measure can
be leveraged to strengthen disparities reduction efforts. Making these dashboards available to
patients and their caregivers will be critical for decision-making and care coordination,
especially during transitions of care.
Non-English Patient-Specific Education Materials – SGRP #206
We fully support utilizing data collected about a patients' preferred languages to provide access
to meaningful, useful education materials. We encourage greater clarity regarding the measure
denominator. Instead of “Provide 80% of patient-specific education materials in a at least one of
those languages,” the denominator should focus on percent of patients. The measure should
read: “80% of a provider’s patients preferring one of the top five non-English languages spoken
in the US receive educational materials in their own language.”
HITPC could also consider modifying the measure to include the top five non-English
languages spoken in the state where the EP/EH is located, in order to promote greater
relevance to the community in which an individual lives. We urge HITPC to encourage
providers to strive to offer materials in the language spoken by their patients, no matter what that
language is.
Priority #4: Enabling New Payment & Delivery Models
Health IT is an essential foundation for delivery system and payment reforms. New models of
care all require the ability not just to share data, but to integrate it across various sources
(including non-EHR) and across various types of data (i.e., clinical, claims, and patientgenerated data).15 Stage 3 Meaningful Use must advance progress in these areas to support care
delivery improvement and accountability for improved outcomes.
The Fundamental Mission of the EHR incentive Program Clinical Quality Measure (CQM)
Set – QMWG #01
We agree with the mission statement in the RFC, as long as “promoting the capabilities of
EHRs” includes promoting new capabilities not yet utilized in current EHR products. The kinds
of measures necessary to support new payment and delivery models are possible in an electronic
environment, but systems and infrastructure must be designed accordingly. We believe that it is
absolutely essential for quality measures used in the incentive program to stretch the capacity of
EHRs to support more meaningful quality measurement. Only then will we have quality metrics
that both reduce the burden of data collection and provide the kinds of data necessary to support
new payment and delivery models and achieve the three-part aim.
15
Commonwealth Fund report on Measuring progress toward accountable care
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High Priority Measures – QMWG #02
New payment and delivery models require new and different kinds of quality metrics that
leverage current and potential capabilities of EHRs. In many cases, such measures are not
currently available. There is work yet to be done to ensure that health IT increases the feasibility
of new, high-value measures. To that end, we urge the HITPC to ensure that technology
developers create and enable the functions and capabilities necessary for capturing information
required to populate measures of patient engagement, care coordination, functional status,
longitudinal (delta) measures, wellness and health promotion, and population-based measures
that can be used to improve health, reduce disparities, and decrease costs. The capabilities
required for these kinds of measures, which HITPC should prioritize in Stage 3 functional
criteria, include health information exchange, calculation of measures using multiple data
sources, and integration of patient-generated data.
Consumer-Reported Data – QMWG #07
New payment and delivery models all contain significant emphasis on engaging patients and
many include input from patients themselves in determining value of and accountability for
health care services. Patient experience surveys are among the most common vehicles for
obtaining this kind of input and they provide critical insights into quality care. Both Patient
Centered Medical Home (PCMH) Consumer Assessment of Healthcare Providers and Systems
(CAHPS) survey questions and H-CAHPS survey questions should become part of Meaningful
Use both in quality measures and functional capabilities.
In the future, consumer-reported data should also be incorporated into CQMs by including
certain consumer-reported data elements in the denominator of relevant measures. For example,
a measure that is intended to assess whether an individual received the appropriate treatment for
depression would incorporate information from clinical guidelines, as well as patient preference
data relative to how well that treatment option accommodates his or her personal preferences. In
this case, personal preferences might include not wanting to take a drug that contributes to
weight gain; a quality measure that incorporates consumer-reported data could reflect both
consistency of care with accepted guidelines (was this the most effective treatment according to
clinical evidence) and patient preferences (was this the best treatment for this patient, given his
desire not to gain weight).
Patient-Contributed/Directed Data and Shared Decision-Making – QMWG #08
The response to QMWG 07 above is one example of how patient-contributed data could be used
for shared decision-making. Building high-value elements of patient-contributed data into
clinical decision support would provide a structured way to use patient contributed data in shared
decision-making.
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High Priority Domains – QMWG #16
Prioritized attention should be given to filling measurement gaps in the areas already identified
by ONC in 2010. The measure domains of most importance to consumers include patientreported outcomes, care coordination, equity, patient-engagement, efficiency and prevention.
EHRs also need to be able to draw data for quality measurement from multiple data sources,
including registries and other population-based sources. Patient-contributed data must also be
used as a source, and some outcomes measures, especially those associated with prevention, will
require data from non-healthcare sources (e.g., missed school days).
Clinical Quality Measurement Pipeline: Meaningful Use & Innovation - QMWG #18 and
QMWG #19
Creating the capacity for better quality metrics through functional criteria in the Meaningful Use
incentive program is only part of what is necessary to support new models of care and payment.
The development of measures that leverage these capabilities must also be a priority. Therefore,
we strongly supports the inclusion of a voluntary innovation track for quality measurement in the
EHR Incentive Program. We also feel strongly that if HITPC suggests such an alternative, it
should also set specific parameters and criteria that will help ensure value from this novel
approach. HITPC would also need to work closely with the HIT Standards Committee to ensure
that certification criteria support the use of EHRs in conjunction with new measure authoring
tools being developed by the National Quality Forum (NQF).
The EHR Incentive program is a unique opportunity to address measurement gaps, since it is not
a quality measure performance or accountability program. CMS could promote rapid-cycle
measure development by encouraging eligible providers and others to create, test, and report on
measures that meet robust criteria in each of the six domains identified by the HITPC and its
Quality Measures (QM) work group. This sort of real-world testing is a critical part of the NQF
endorsement process. In addition, developing and testing new measures as a byproduct of
practice encourages the use of real-time, clinical data. Finally, an essential benefit of developing
measures as part of the MU process is that it would be done in the electronic environment in
which these new measures will be implemented, rather than re-tooling a measure designed for
the paper world. Creating such an option would result in shared learning and testing of new
measures that advance ability of EHRs to help measure outcomes.
For purposes of ensuring value, we would suggest that eligible measures be outcome focused, or
process measures that are submitted as part of a “suite” of measures having close proximity to a
desired outcome measure. We also feel strongly that eligible measures must addresses one or
more of the key gap areas identified by the QM workgroup in 2010, including patient-reported
outcomes, quality of shared decision-making, appropriate invasive testing, patient activation and
self-management, adverse drug events, health care acquired conditions, adverse events and suboptimal outcomes from chronic conditions. Highest priority should be placed on measures that
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address the six domains of the national quality strategy, particularly care coordination, patient
engagement, and efficient resource use.
Finally, HITPC should encourage those selecting this option to develop measures that use data
across multiple data sources (i.e., across settings of care, between patient and provider, with
registries, etc.) and that evaluate patient health/functional status over time, using data contributed
by the patient to the EHR.
HIT Policy Committee Questions



MU01 – We are very much in favor of ensuring that the EHR Incentive Program truly
incentivizes innovative use of technology to improve outcomes, without placing
unreasonable demands on providers who are making good faith efforts to transform the
care they provide. Our concern about any effort to reward providers with incentives for
meeting most, but not all, criteria is the lack of specificity about how such flexibility
would be implemented. Criteria that are most transformative, by their very nature, are
more difficult to achieve. Furthermore, these are the criteria which tend to be most
meaningful to consumers. As we have seen in the attestation data presented by CMS,
deferral rates are already high for the menu criteria that are most transformative. We
respectfully remind HITPC that there is already flexibility built into the criteria in the
form of menu criteria. Partial credit may be an option to consider for offering additional
flexibility during subsequent penalty phases, but must be carefully designed such that
patient and family engagement and care coordination criteria are not optional.
MU03 – While health IT, and EHRs in particular, have great promise to enhance patient
safety, there are risks associated with improper implementation and utilization of health
IT systems, and human interaction with technology. We applaud the recent release of the
Health IT Patient Safety Action and Surveillance Plan, and ONC’s efforts to ensure the
safety of health IT. Health IT safety risk assessments, or at least a formalized mechanism
for reporting safety issues (both with regard to the design of health IT products and the
human factors involved in the use of those products), is highly advisable.
MU05 – Building capacity for sending and receiving key categories of patient-generated
data is one concrete way to foster innovation in sharing information. We encourage
HITPC to build capacity for exchanging information from structured surveys focused on
critical gaps in information that is highly relevant to the care and management of an
individual. This would effectively leverage the “transmit” function and move providers
toward the exchange of essential contextual information.
Thank you once again for the opportunity to provide input into this transformative program. We
remain eager to work with the HITPC to ensure value for all stakeholders, and we are
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increasingly enthusiastic about the value consumers, specifically, will see as these criteria are
implemented by providers serving their communities.
Sincerely,
AARP
American Association on Health and Disability
American Hospice Foundation
Asian & Pacific Islander American Health Forum
Caregivers Action Network
Caring From a Distance
Center for American Progress
Center for Democracy & Technology
Center for Medical Consumers
Childbirth Connection
Colorado Consumer Health Initiative
Colorado Cross-Disability Coalition
Consumers Union of United States
Healthwise
National Consumers League
National Health IT Collaborative for the Underserved
National Health Law Program
National Partnership for Women & Families
National PACE Association
Summit Health Institute for Research and Education, Inc.
The Children’s Partnership
The Empowered Patient Coalition
Well Spouse Association
Lisa Fenichel, e-Health Consumer Advocate
Mark Gorman, Patient Advocate
Regina Holliday, Patient Advocate
Mary Anne Sterling, Family Caregiver Advocate
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Consumer Partnership for eHealth
Request for Comment – Stage 3 Definition of Meaningful Use
Summary of Recommendations
ID
Number
Criterion
Record Demographics
SGRP 104
Level of Support
 Retiring this
objective could
have adverse
effects on health
disparities
SGRP 112 Advance Directives
 Strongly support
transitioning to core
the criterion to
record advance
directive status for
EHs
 Strongly support
adding the criterion
as a menu objective
for EPs
SGRP 115 Condition Reports and
Patient Dashboards
 Fully support
SGRP
204A
 Support
accelerating the
time frame for
making information
available to 24
hours
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View/Download/Transmit
(V/D/T)
Recommendation
 If criterion is retired,
HITPC should require the
use of demographic data in
both functional criteria and
quality measurement (i.e.,
stratification and reporting
of patient lists and CQMs
by demographic data)
 Collection of sexual
orientation/gender identity
data should be mandatory
 Require collection of
disability status data
 Require the content of an
advance directive be
accessible through the EHR
 Lower 65 year age limit to
all adult patients (18 years
& older)
 Certification criteria should
require that the capture of
this information is possible
for any patient (regardless
of age)
 Encourage advancement in
future stages to strengthen
disparities reduction efforts
 Advance threshold for the
% of patients provided
electronic access and the %
of patients who use V/D/T
 Urge access to visit notes
 Shorten the time by which
providers must make
available lab results to 2
business days
 V/D/T using diverse and
accessible technology
platforms and in the
patient’s preferred language
 Support exploring
opportunities to leverage
the automated Blue Button
function to meet V/D/T
Consumer Partnership for eHealth
Request for Comment – Stage 3 Definition of Meaningful Use
Summary of Recommendations
criteria
SGRP
204B
SGRP
204D
Patient-Generated Health
Information
Record Amendments
SGRP 205 Clinical Summaries
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 Strongly support
giving patients the
ability to contribute
information to their
medical record
 Strongly support
new criterion to
provide patients
with an ability to
record an
amendment
 Support
clarification that
clinical summaries
should include
information that is
meaningful and
 Increase threshold criterion
to at least 25 percent
 Specify categories of highvalue patient information
that have greatest potential
to significantly improve
health, safety, and quality
o Goals for care
o Medication allergies and
non-tolerated medications
o Caregiver and additional
professional care team
member name(s), contact
information, and role(s)
o Family history
o Functional limitations
o Supports and services
necessary for independent
living
o Patient values and
preferences for care
o Patient experience
o Behavioral and mental
health history
o Identification of problems
or concerns from the
patient’s perspective
o Psycho-social information
o Data recorded by patient for
monitoring of progress
toward patient goals
o Risk factors indicated by
structured surveys
N/A
 Encourage HITPC to work
with clinicians and patients
to determine the most
helpful data elements to
include in clinical
summaries
Consumer Partnership for eHealth
Request for Comment – Stage 3 Definition of Meaningful Use
Summary of Recommendations
SGRP 205 Clinical Summaries
(cont’d)
(cont’d)
actionable to
patients
SGRP 206 Non-English PatientSpecific Education
Materials
 Fully support
utilizing patient
preference data to
provide access to
meaningful, useful
education materials
SGRP 207 Secure Patient Messaging
 Support
SGRP 208 Communication
Preferences
 Fully supports
inclusion of a
separate criterion to
record patient
communication
preferences
SGRP 209 Identifying Available
Clinical Trials
 Support
SGRP 302 Medication
Reconciliation
 Strongly support
the increase in the
threshold for
medication
reconciliation to 50
percent
 Enthusiastically
support
supplementing
medication
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 Consider developing
guidance and resources
promoting the use of plain
language, standardized
format, and graphic
explanations
 Clarify measure
denominator
 Modify the measure to
include the top 5 nonEnglish languages spoken
in the state where the
EP/EH is located
 Allow secure messages
sent and received by a
family or other patientapproved caregiver to
count towards the
increased threshold
 Add criterion measuring
timeliness of response
from providers to their
patients who use secure
messaging
 Certification criteria
should include capability
to record caregiver
communication
preferences
 Require collection of
communication
preferences for at least the
primary caregiver
N/A
 Encourage threshold
advancement for
reconciliation of
medication allergies and
problems in future stages
 Engage patients and
caregivers in information
reconciliation
o Medications actually taken
(including over-the-counter
Consumer Partnership for eHealth
Request for Comment – Stage 3 Definition of Meaningful Use
Summary of Recommendations
SGRP 302 Medication
(cont’d)
Reconciliation
(cont’d)
SGRP 303 Summary of Care Record
SGRP 304 Care Plans
reconciliation for
transitions of care
with reconciliation
of medication
allergies and
problems
 30% threshold
unacceptably low
for summary of
care records
provided
electronically
 Support addition of
a list of care team
members
 Support
certification criteria
which build
capacity for
longitudinal, shared
care plans
 HITPC should
more aggressively
advance the
capacity in Stage 3
of EHRs and HIE
to support a
comprehensive,
interactive shared
care plan platform
drugs and herbal
supplements)
o Caregiver name, contact
information, and role
o Problems/complaints
o Advance directive status
and content
o Additional care team
members (primary care,
specialists, ER, retail
clinics, etc.)
 Significantly increase
threshold to 80% of patients
to have summary of care
records shared, with no
less than 65% transmitted
electronically
 Require the inclusion of
both patient-defined and
clinical goals
 Require functional status
and independent living
services and supports at
the point of transition or
referral
 Advance concept of the
longitudinal, shared care
plan by requiring
documentation of:
o Cross-setting care team
member list
o Comprehensive patient
goals
o Psycho social assessment
information
 Suggest threshold of 20
SGRP 305 Closing the Referral Loop
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 Fully support new
criterion
percent of all patients
 Encourage threshold
advancement in future
stages
 Encourage making
information available to
patients and family
members through the
patient portal
Consumer Partnership for eHealth
Request for Comment – Stage 3 Definition of Meaningful Use
Summary of Recommendations
N/A
SGRP 308 Notice of a Significant
 Strongly support
Healthcare Event
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