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MGMA Letter

MGMA Letter

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02/24/2010

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 November 12
,
2009David Blumenthal
,
M
.
D
.,
M
.
P
.
P
 
National Coordinator for Health Information Te
c
hnologyU
.
S
.
Department of Health and Human
S
ervi
c
e
s
 Offi
c
e of the National Coordinator for Health Information Te
c
hnology200 Independen
c
e Avenue
,
 
S
W
S
uite 729DWa
s
hington
,
DC 20201Dear Dr
.
Blumenthal:A
s
the nation
'
s
prin
c
ipal voi
c
e for medi
c
al group pra
c
ti
c
e with 22
,
500 member
s
 managing and leading 13
,
700 organization
s
,
in whi
c
h almo
s
t 275
,
000 phy
s
i
c
ian
s
 pra
c
ti
c
e
,
the Medi
c
al Group Management A
ss
o
c
iation (MGMA) i
s
very
s
upportive ofphy
s
i
c
ian pra
c
ti
c
e adoption of health information te
c
hnology (HIT)
.
However weare very
c
on
c
erned about the implementation pro
c
e
ss
for the Medi
c
are andMedi
c
aid ele
c
troni
c
health re
c
ord (EHR) in
c
entive program
s
 
c
urrently underdevelopment
.
We believe that an inappropriate definition of meaningful u
s
e andineffi
c
ient admini
s
tration of the program will lead to failed implementation of theAmeri
c
an Re
c
overy and Reinve
s
tment A
c
t of 2009 (ARRA) and re
s
ult in the needle
ss
 
s
quandering of re
s
our
c
e
s
and
s
ignifi
c
ant di
s
ruption to the nation
c
are
s
y
s
tem
.
 It i
s
 
c
lear that the key goal
s
of the
s
e health IT inve
s
tment
s
are to improve health
c
are quality
,
 
c
ontrol growth in
c
o
s
t
s
,
enhan
c
e the effi
c
ien
c
y of health
c
areadmini
s
tration
,
 
s
timulate innovation
,
and en
s
ure the priva
c
y and
s
e
c
urity ofpatient information
.
At the
s
ame time that the definition
s
upport
s
the
s
e goal
s
,
 meaningful u
s
e
s
hould al
s
o be verifiable without
c
reating an undue burden on
c
lini
c
ian
s
and phy
s
i
c
ian pra
c
ti
c
e
s
.
Thi
s
i
s
e
s
pe
c
ially
c
riti
c
al in the fir
s
t year
s
ofimplementation
.
We offer the following re
c
ommendation
s
to a
ss
i
s
t in thedevelopment of the meaningful u
s
e definition and the
c
reation of animplementation pro
c
e
ss
that will meet the need
s
of a very
c
omplex and diver
s
ehealth
c
are
s
y
s
tem
.
 
Recommendation
s
 Focu
s
criteria on value and achievability
  
 
Meaningful u
s
e mea
s
ure
s
 
s
hould have a highly predi
c
tive and demon
s
trable value for improving thenation
s
health and effi
c
ien
c
y
.
The meaningful u
s
e
c
riteria mu
s
t
s
et atraje
c
tory of mea
s
urable target
s
toward tho
s
e obje
c
tive
s
.
In thi
s
effort
,
goal
s
 for health improvement
s
hould go hand-in-hand with the ability forphy
s
i
c
ian
s
to integrate the
s
e mea
s
ure
s
into their workflow with minimaldi
s
ruption or
c
o
s
t
.
 Avoid reliance on third party compliance -
S
everal of the draft meaningfulu
s
e
c
riteria require
,
for example
,
the reporting of per
c
entage
s
of patient
s
 undergoing
s
pe
c
ifi
c
te
s
t
s
.
We
s
trongly en
c
ourage you not to impo
s
earbitrary
thre
s
hold
s
that phy
s
i
c
ian
s
would have to meet for the reporting
 
2
of the
s
e type
s
of mea
s
ure
s
.
In the
c
a
s
e of patient
s
re
c
eiving te
s
t
s
,
forexample
,
phy
s
i
c
ian
s
 
c
learly
c
annot for
c
e patient
s
to undergo te
s
t
s
whi
c
h (i)may be phy
s
i
c
ally un
c
omfortable for the patient
,
(ii) one that the patientobje
c
t
s
to
,
or (iii) one for whi
c
h the patient
s
health plan
c
over
s
only part ofthe
c
o
s
t
,
or none of the
c
o
s
t
.
 
S
election of criteria already in wide
s
pread u
s
e
  
 
It i
s
 
c
riti
c
al to avoidimpo
s
ing
c
riteria that do not have wide
s
pread experien
c
e in the
s
mall andrural
c
lini
c
al
s
etting
s
.
To en
s
ure that meaningful u
s
e
c
an be
s
u
cc
e
ss
fullyadopted in a wide range of pra
c
ti
c
e
s
etting
s
,
in
c
luding
s
mall phy
s
i
c
ian andrural pra
c
ti
c
e
s
,
we
s
trongly en
c
ourage you to adopt the approa
c
h takenthrough the government
s
ele
c
troni
c
pre
s
c
ribing rulemaking pro
c
e
ss
.
A
s
 
s
etout in the Medi
c
are Pre
s
c
ription Drug
,
Improvement
,
and ModernizationA
c
t of 2003
,
the HH
S
 
S
e
c
retary i
s
only to adopt
s
tandard
s
that have wideindu
s
try u
s
age and to
c
ondu
c
t pilot
s
to determine the appli
c
ability of anyadditional
s
tandard
s
.
We believe a
s
imilar approa
c
h for determiningappropriate meaningful u
s
e
c
riteria
s
hould be adopted
.
 
S
election of appropriate admini
s
trative criteria
  
The admini
s
trativetran
s
a
c
tion
s
 
c
urrently outlined in the meaningful u
s
e matrix that phy
s
i
c
ian
s
 would have to report do not take into a
cc
ount the reality of
c
urrent pra
c
ti
c
eworkflow or the ineffi
c
ien
c
y of the
c
urrent
s
tandard
s
them
s
elve
s
.
 
o
 
In the
c
a
s
e of the ele
c
troni
c
 
c
laim
s
tandard mandated under theHealth In
s
uran
c
e Portability and A
cc
ountability A
c
t of 1996 (HIPAA)
,
 the AN
S
I X12N 4010A1 837
,
the majority of
s
mall and medium-
s
izedpra
c
ti
c
e
s
 
c
urrently utilize a
c
learinghou
s
e or billing
s
ervi
c
e to
s
ubmit
c
laim
s
to health plan
s
for payment
.
In many
c
a
s
e
s
the
s
e
c
laim
s
 originate a
s
paper CM
S
1500 form
s
or other
,
non-HIPAA
c
ompliantformat
s
.
In addition
,
the
c
urrent
c
omplian
c
e date for the late
s
titeration of the HIPAA 837
s
tandard (5010) i
s
not until
J
an
.
1
,
2012
,
 well after the 2011
s
tart date for the EHR in
c
entive program
.
 
o
 
The
c
urrent patient in
s
uran
c
e eligibility verifi
c
ation
s
tandard (AN
S
IX12N 4010A1 270/271) i
s
not widely u
s
ed by provider
s
be
c
au
s
e ofthe la
c
k of
s
tandardization among health plan
s
.
While thi
s
 
s
tandardization i
ss
ue ha
s
been addre
ss
ed
s
omewhat by the Coun
c
ilfor Affordable Quality Health
c
are Committee on Operating Rule
s
forEle
c
troni
c
Tran
s
a
c
tion
s
(CAQH CORE)
,
the CORE operating rule
s
 remain voluntary for health plan
s
and to date not widely u
s
ed in theindu
s
try
.
A
s
with the 837
,
the
c
omplian
c
e date for the 5010 ver
s
ionof the 270/271 tran
s
a
c
tion
s
 
s
tandard
s
i
s
not until
J
an
.
1
,
2012
.
 
In
s
titute a pilot
 
  
On
c
e the final rule i
s
publi
s
hed
,
and well before to the2011 program
s
tart date
,
we believe that the government
s
hould
c
ondu
c
t apilot with a
s
mall number of vendor
s
and in a variety of phy
s
i
c
ian pra
c
ti
c
e
s
etting
s
to en
s
ure that the pro
c
e
ss
of demon
s
trating meaningful u
s
e i
s
 a
c
hievable and pra
c
ti
c
al
.
Thi
s
pilot
c
ould a
ss
i
s
t in determining potentialroadblo
c
k
s
to program
s
u
cc
e
ss
and identify
s
olution
s
to tho
s
e roadblo
c
k
s
.
 
Program logi
s
tical
s
upport -
To avoid phy
s
i
c
ian
s
en
c
ountering problem
s
 during the meaningful u
s
e reporting pro
c
e
ss
,
we believe that thegovernment
s
hould:
 
3
o
 
En
s
ure timely re
s
pon
s
e
s
from CM
S
to phy
s
i
c
ian
s
on
c
e data are
s
ubmitted in
s
upport of their meaningful u
s
e reporting requirement
s
.
 
o
 
The government mu
s
t be ready to a
cc
ept meaningful u
s
e data in late2010 in order for phy
s
i
c
ian
s
to
s
end te
s
t data
,
re
c
eive feedba
c
k froman appropriate government agen
c
y and
s
till have
s
uffi
c
ient time totake the appropriate a
c
tion to modify their
s
y
s
tem
s
hould theyen
c
ounter
 
data
c
ontent or reporting problem
s
.
 
Flexibility in achieving meaningful u
s
e -
Rather than develop the programwith a
s
impli
s
ti
c
 
pa
ss
 /fail
 
s
tru
c
ture
,
we re
c
ommend that phy
s
i
c
ian
s
begiven a
report
on their meaningful u
s
e a
c
hievement and
s
uffi
c
ient time tore
s
tru
c
ture/modify their
s
y
s
tem
s
and
s
ubmit
c
orre
c
ted data to a
c
hieve fullmeaningful u
s
e during a parti
c
ular reporting period
.
 
Demon
s
tration of meaningful u
s
e --
Creating a pro
c
e
ss
that i
s
effe
c
tive yet
s
imple for phy
s
i
c
ian pra
c
ti
c
e
s
to demon
s
trate meaningful u
s
e will be a
c
riti
c
al
c
omponent of a
s
u
cc
e
ss
ful in
c
entive program
.
We re
c
ommend thatatte
s
tation and/or
s
urvey in
s
trument
s
 
s
erve a
s
the primary method
s
ofdemon
s
tration
.
Thi
s
would be e
s
pe
c
ially important for the initial pha
s
e
s
ofthe program and
c
ould be verified through an audit pro
c
e
ss
.
Thedevelopment of a
c
ompli
c
ated and time-
c
on
s
uming pro
c
e
ss
for pra
c
ti
c
e
s
toprove that they meet the in
c
entive qualifi
c
ation
s
will re
s
ult in fewerorganization
s
tran
s
itioning to EHR
s
.
 
S
implified phy
s
ician atte
s
tation
  
 
The pro
c
e
ss
for phy
s
i
c
ian
s
todemon
s
trate that they have a
c
hieved meaningful u
s
e
s
hould be
s
imple andflexible enough
s
o that phy
s
i
c
ian
s
in all type
s
and
s
ize
s
of pra
c
ti
c
e
c
an atte
s
tthi
s
to the government
.
We
s
trongly en
c
ourage that
s
elf-atte
s
tation be theprimary atte
s
tation approa
c
h adopted
.
In addition
,
mu
c
h like phy
s
i
c
ian u
s
eof the data regi
s
trie
s
for PQRI reporting
,
third party atte
s
tation
s
hould al
s
obe
c
on
s
idered
.
 
Clo
s
ely monitor the EHR marketplace
  
 
S
e
c
tion 3007 (a) of the ARRAlegi
s
lation require
s
that the
National Coordinator
s
hall
s
upport thedevelopment and routine updating of qualified ele
c
troni
c
health re
c
ordte
c
hnology (a
s
defined in
s
e
c
tion 3000)
c
on
s
i
s
tent with
s
ub
s
e
c
tion
s
(b) and(
c
) and make available
s
u
c
h qualified ele
c
troni
c
health re
c
ord te
c
hnologyunle
ss
the
S
e
c
retary determine
s
through an a
ss
e
ss
ment that the need
s
anddemand
s
of provider
s
are being
s
ub
s
tantially and adequately met throughthe marketpla
c
e
.
We en
c
ourage the
c
lo
s
e monitoring of the EHRmarketpla
c
e to en
s
ure that appropriate and
c
o
s
t-effi
c
ient produ
c
t
s
are beingoffered to phy
s
i
c
ian pra
c
ti
c
e
s
,
e
s
pe
c
ially
s
mall pra
c
ti
c
e
s
with limitedfinan
c
ial re
s
our
c
e
s
.
We al
s
o en
c
ourage the early re
c
ognition of marketpla
c
efailure
s
and
s
ub
s
equent deployment of an appropriate low-
c
o
s
t alternativeEHR
s
oftware produ
c
t and
s
upporting
s
tru
c
ture
.
 
S
implify the reporting
 
proce
ss
-- Quality reporting i
s
a
c
entral element ofmeaningful u
s
e
.
Allowing pra
c
ti
c
e
s
of varying
s
ophi
s
ti
c
ation the ability toreport the quality data utilizing variou
s
methodologie
s
(ie
,
 
c
laim
s
-ba
s
ed
,
 data regi
s
trie
s
,
and
s
ummary
c
lini
c
al data tran
s
mitted dire
c
tly via the EHR)would en
s
ure that a
s
broad a group of pra
c
ti
c
e
s
a
s
po
ss
ible would have theability to move forward with adoption of HIT
,
 
s
u
cc
e
ss
fully report qualitymea
s
ure
s
and qualify for the in
c
entive
s
.
 
In addition
,
it i
s
 
c
riti
c
al that thi
s
 

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