June 10, 2015 Andy Slavitt Acting Administrator

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June 10, 2015 Andy Slavitt Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-3311-P Submitted electronically at: http://www.regulations.gov Re: Medicare and Medicaid Programs; Electronic Health Record Incentive Program – Modifications to Meaningful Use in 2015 through 2017 Proposed Rule Dear Mr. Slavitt: On behalf of CHRISTUS Health, we appreciate the opportunity to comment on the Modifications to Meaningful Use for 2015 through 2017 proposed rule published by the Centers for Medicare & Medicaid Services (CMS) in the April 15, 2015, Federal Register. CHRISTUS Health is an international, faith-based, not-for-profit health system comprised of nearly 350 services and facilities, including more than 50 hospitals, primarily located in Texas, Louisiana, and New Mexico. CHRISTUS Health appreciates that CMS has responded to the requests from Eligible Hospitals (EHs), Critical Access Hospitals (CAHs), and Eligible Providers (EPs) by issuing a streamlined proposal with reduced redundancy in reporting. The adjustment to the Calendar Year for all provider types allows additional support for interoperability alignment and encourages further the continuity of care across the health care spectrum. CHRISTUS Health continues to be concerned about the patient engagement objectives and the impact of patient choice on caregiver reimbursement, however. While we fully support that patient engagement has a positive impact on outcomes and long-term health care, we suggest the adoption of objectives that would measure provider action versus patient action. For example, the reduction of Measure 2 of the Patient Electronic Access from >5% to one patient is positive in that it creates the ability to measure the availability of the functionality, if that is what is to be validated. Consideration of a measure that supports patient education about the available functionality could be a more positive step in helping direct provider action. In regard to the electronic prescribing objective, CHRISTUS Health appreciates the option of exclusion for CMS Certification Numbers (CCNs) who were not planning to use it as one of the Menu Objectives. Our work continues on this initiative, and movement is being made on the functionality; however, there remain many scenarios which are challenging for EHs and CAHs to create final workflows and processes around. The extra time to safely finish this implementation is critical to patient safety and satisfaction, as well as provider confidence. OUR MISSION “To Extend the Healing Ministry of Jesus Christ” CHRISTUS Health 919 Hidden Ridge Irving TX 75038 Tel 469.282.2000 www.christushealth.org

Finally, CHRISTUS Health is concerned about the mid- year reporting changes to the Public Health Reporting Measures. We have been continually working and perfecting the reporting for the three original measures. A change to bi-directional immunization functionality is one example of a change that will create additional hours of focus and is discouraged as a part of the final rule. This functionality is important and should be considered in the future; however, the impact would be detrimental to moving forward at a consistent and steady pace. The additional three reporting options are appreciated for their increased impact on health care across the population spectrum, as well as the tracking and studying of disease around the world. Initial technical requirements should be limited to encourage engagement with increased specifications in the coming stage(s) of Meaningful Use. CHRISTUS Health supports the agency’s vision for Meaningful Use and the ability for providers to share information across the health care continuum. It is imperative, however, that it is done in a way that preserves patient safety and allows the adoption of new technology at a speed that health care providers can accommodate effectively. Comments on the ten specific objectives being proposed are included below. Objective/Measure Computerized Provider Order Entry 1. More than 60 percent of medication orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry. 2. More than 30 percent of laboratory orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded

Comments We support this challenging objective in the interest of increasing patient safety.

OUR MISSION “To Extend the Healing Ministry of Jesus Christ” CHRISTUS Health 919 Hidden Ridge Irving TX 75038 Tel 469.282.2000 www.christushealth.org

Objective/Measure using computerized provider order entry. 3. More than 30 percent of radiology orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry. Clinical Decision Support 1. Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four clinical quality measures related to an EP, eligible hospital or CAH's scope of practice or patient population, the clinical decision support interventions must be related to highpriority health conditions. It is suggested that one of the five clinical decision support interventions be related to improving healthcare efficiency. 2. The EP, eligible hospital, or CAH has enabled and implemented the functionality for drug-

Comments

We support the continuance of this objective.

OUR MISSION “To Extend the Healing Ministry of Jesus Christ” CHRISTUS Health 919 Hidden Ridge Irving TX 75038 Tel 469.282.2000 www.christushealth.org

Objective/Measure drug and drug allergy interaction checks for the entire EHR reporting period. Exclusion: For the second measure, any EP who writes fewer than 100 medication orders during the EHR reporting period. Patient Electronic Access (VDT) 1. More than 50 percent of all patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH have their information available online within 36 hours of discharge. 2. At least 1 patient who is discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH (or his or her authorized representative) views, downloads, or transmits to a third party his or her information during the EHR reporting period. Protect Electronic Health Information 1. Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security

Comments

We agree that increased patient engagement contributes to better patient outcomes. We also agree that the functionality to allow patients to view, download, and/or transmit their data should be available to them within a reasonable timeframe, and 36 hours after discharge is reasonable. We appreciate CMS’ move to decrease the burden of reporting patient engagement by EHs and CAHs by decreasing the threshold from >5% to one patient. This does seem to reflect providers’ concerns and indicate that patient action or inaction is not the sole responsibility of the EH or CAH. The decrease is concerning, however, based on our understanding that the Stage 3 proposed rule is intended to reverse the reduction and increase the threshold significantly. It would seem more advantageous to find a way to encourage EHs and CAHs to educate patients regarding the availability of their records and measure that EH and CAH action, rather than the patient action.

We agree that security is of the utmost importance. Clarification on whether the timing of the Security Risk Analysis is during the Reporting Period versus the Reporting Year would be helpful.

OUR MISSION “To Extend the Healing Ministry of Jesus Christ” CHRISTUS Health 919 Hidden Ridge Irving TX 75038 Tel 469.282.2000 www.christushealth.org

Objective/Measure (to include encryption) of ePHI data stored in Certified EHR Technology in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the EP, eligible hospital, or CAHs risk management process. Patient Specific Education 1. More than 10 percent of all unique patients admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) are provided patient specific education resources identified by Certified EHR Technology. Medication Reconciliation 1. The EP, eligible hospital or CAH performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23).

Comments

CHRISTUS Health supports patient specific education and encourages CMS to consider an additional measure related to this objective that would provide a threshold for patient engagement education. For example: The EH or CAH will provide, view, download, and transmit functionality education to patients prior to discharge. The threshold could match the >50% availability of the VDT Measure 1.

We support the continued inclusion of this important process.

OUR MISSION “To Extend the Healing Ministry of Jesus Christ” CHRISTUS Health 919 Hidden Ridge Irving TX 75038 Tel 469.282.2000 www.christushealth.org

Objective/Measure Summary of Care 1. The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care (1) uses CEHRT to create a summary of care record; and (2) electronically transmits such summary to a receiving provider for more than 10 percent of transitions of care and referrals. Electronic Prescribing 1. More than 10 percent of hospital discharge medication orders for permissible prescriptions (for new, changed and refilled prescriptions) are queried for a drug formulary and transmitted electronically using Certified EHR Technology.

Comments CHRISTUS Health supports this important functionality necessary to ensure the continuity of care for our patients. We also recognize that the technology to allow easy exchange of valuable data is still “young” and needs continued work before ultimate value is achieved.

Public Health Reporting 1. Immunizations The EP, eligible hospital, or CAH is in active

We support public health reporting. However, changes to the interface requirements between CEHRT editions potentially create diversion for the CEHRT vendors who are developing the software for the next release. Considering the time of publication of this proposed rule and

We agree that electronic prescribing is important, and we are continuing to work to effectively implement the functionality. Some related challenges include post-discharge process and difficulty in following-up with providers and patients in the event of a prescription transmission failure. Often when a transmission failure occurs, both the patient and the provider have already left the facility, which makes it difficult to alert the provider and patient so that alternative prescription methods can be utilized. Some patients prefer written prescriptions, especially when a portion of their discharge prescriptions cannot be transmitted (such as narcotics). Many prefer to have all prescriptions in one format, so if one cannot be sent electronically, they will request that all be written. Other patients do not trust electronic transmission of prescriptions based on unfamiliarity or previous problematic experiences. Finally, there are patients who use pharmacies that do not accept electronic prescribing at this time. For patients who are discharged late in the evening, they may wish to utilize a nearby pharmacy for more critical prescriptions, while wishing to take the remainder of their prescriptions to a local pharmacy. In addition, patients who are traveling may desire to return to their home pharmacy to obtain their medications.

OUR MISSION “To Extend the Healing Ministry of Jesus Christ” CHRISTUS Health 919 Hidden Ridge Irving TX 75038 Tel 469.282.2000 www.christushealth.org

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Objective/Measure engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS). Syndromic Surveillance The EP, eligible hospital/, or CAH is in active engagement with a public health agency to submit syndromic surveillance data from a nonurgent care ambulatory setting for EPs, or an emergency or urgent care department for eligible hospitals and CAHs (POS 23) Case Reporting The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit case reporting of reportable conditions. Public Health Registry The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit data to public health registries. Clinical Data Registry The EP, eligible hospital, or CAH is in active engagement to submit data to a clinical data

Comments the end of the reporting year, vendors would be hard-pressed to develop and implement the required functionality while remaining on the needed timeline for the 2014 CEHRT software release. We support continuing with current requirements for the Public Health interfaces, and we do not support bi-directional immunization interfaces at this time. We support the three Active Engagement Options for successful attestation for Public Health Reporting.

OUR MISSION “To Extend the Healing Ministry of Jesus Christ” CHRISTUS Health 919 Hidden Ridge Irving TX 75038 Tel 469.282.2000 www.christushealth.org

Objective/Measure registry. 6. Reportable Laboratory Results The eligible hospital or CAH is in active engagement with a public health agency to submit electronic reportable laboratory results.

Comments

Again, thank you for your consideration of our recommendations and for this opportunity to be a partner in shaping the future of health care. Sincerely,

John Gillean EVP Chief Clinical Officer

George Conklin SVP and Chief Information Officer

OUR MISSION “To Extend the Healing Ministry of Jesus Christ” CHRISTUS Health 919 Hidden Ridge Irving TX 75038 Tel 469.282.2000 www.christushealth.org