AVAC Answers Questions Regarding Assessing Interoperability for MACRA

AVAC offered comments in response to the Office of the National Coordinator for Health Information Technology (ONC) request for information on interoperability. The ONC metrics for measuring and certifying interoperable health information presents a critical opportunity to improve and clarify standards for interoperability between certified electronic health records and Immunization Information Systems (IIS). AVAC strongly believes that interoperability between immunization providers and state and local IIS is well within our reach and has the potential to facilitate greater utilization of ACIP recommended adult immunizations.

To Whom It May Concern:

AVAC appreciates the opportunity to offer comments in response to the Office of the National Coordinator for Health Information Technology (ONC); Medicare Access and CHIP Reauthorization Act of 2015; Request for Information Regarding Assessing Interoperability for MACRA. As a stakeholder interested in the goal of interoperability, we are grateful to ONC for its work in this area.

AVAC consists of over 45 organizational leaders in health and public health that are committed to tackling the range of barriers to adult immunization and to raising awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions that will strengthen and enhance access to adult immunization across the health care system. Our mission is informed by a growing body of scientific and empirical evidence in support of the benefits immunizations provide by improving health, protecting lives against a variety of debilitating and potentially deadly conditions and saving costs to the healthcare system and to society as a whole.

AVAC priorities and objectives are driven by a consensus process with the goal of enabling the range of stakeholders to have a voice in the effort to improve access and utilization of adult immunizations. One of our key coalition priorities is to improve reporting of adult vaccination data to state and jurisdictional immunization information systems (IIS) and to encourage greater integration and interoperability of health information technology to enhance the exchange adult immunization data. We believe these efforts will result in more complete and timely information regarding an adult’s vaccination status that will improve patient care and health outcomes.

Near universal access to immunizations for children has been one of the greatest public health accomplishments of the 20th century. However, despite Advisory Committee for Immunization Practices (ACIP) recommendations, vaccines have been consistently underutilized in the adult population and lag far behind the Healthy People 2020 goals for the most commonly recommended vaccines (influenza, pneumococcal, Tdap, HepB, herpes zoster, HPV). The Adult Vaccine Access Coalition (AVAC) is working to raise awareness, improve access, and increase utilization of vaccines among adults. Every year, more than 50,000 adults die from vaccine preventable diseases and thousands more suffer serious health problems that cause them to miss work and leave them unable to care for those who depend on them.

IIS systems, also known as registries, are confidential, population-based, computerized systems that have the power to provide timely information to providers at the point of care about recommended vaccines for the adult population and foster their ability to receive and send information about a patient’s immunization status. At the population level, an IIS can also provide aggregate data on immunizations for use in surveillance and program operations, and guide essential public health activities and decision making.

Despite widespread availability of state and jurisdictional IIS’ and their frequent use by pediatric providers, only 32 percent of adults 18 and over have immunization records in an IIS.1 While thirty-six IIS programs have the authority to transmit or allow access to immunization data across state borders, only eleven are currently exchanging information directly with another IIS using batch files or bidirectional real-time exchange.2 Advancements in technology create multiple opportunities for greater access and utilization of immunizations among adults. To be a truly useful tool, immunization registries must receive and contain data that is timely, accurate, and complete.

The ONC metrics for measuring and certifying interoperable health information presents a critical opportunity to improve and clarify standards for interoperability between certified electronic health records and IIS’. AVAC strongly believes that interoperability between immunization providers and state and local IIS is well within our reach and has the potential to facilitate greater utilization of ACIP recommended adult immunizations.

Scope of Measurement: Defining Interoperability and Population

Our goal of improving access to and utilization of ACIP-recommended adult vaccines aligns closely with ONC’s efforts to assess the extent to which ‘meaningful EHR users’ are electronically sending, receiving, finding and integrating information that has been received within an EHR. A number of public and private stakeholders, including ONC, are engaged in complementary efforts to break down technological and geographical barriers to more timely and complete reporting of immunization encounters into state and jurisdictional IIS’, as well as enhance immunization provider access to real-time data on a patient’s immunization status to inform education and support clinical decision making.

Question: Should the focus of measurement be limited to ‘‘meaningful EHR users,’’ as defined in this section and their exchange partners? Alternatively, should the populations and measures be consistent with how ONC plans to measure interoperability for the assessing progress related to the Interoperability Roadmap?

AVAC supports building on the work and accomplishments of the CMS Medicare and Medicaid EHR incentive program in terms of encouraging greater reporting and bidirectional exchange between “meaningful EHR users” and their exchange partners, which would be other immunizers (eg. pharmacy and employer-sponsored health clinics) and state and jurisdictional IIS’. It is however, important to work towards broader alignment with ONC plans to measure interoperability in accordance with the standards for progress included in the Roadmap. Immunization opportunities can occur in a wide variety of health care settings, including Medicare beneficiaries who might be receiving home health care or residing in a long-term care facility as well as individuals who receive immunization services from public health clinics. For the chronically ill elderly and disabled, being up to date on recommended immunizations can be critical to overall health and wellbeing. Reporting of immunization encounters and access to up-to-date immunization records is particularly important in these settings to avoid missed opportunities to immunize and ensure that a patient is not receiving redundant vaccines as well.

Question: How should eligible professionals under the Merit-Based Incentive Payment System (MIPS) and eligible professionals who participate in the alternative payment models (APMs) be addressed?

Please refer to attachment #1, the AVAC comment letter in response to CMS-3321-NC Request for Information (RFI) regarding implementation of the Merit-based Incentive Payment System, Promotion of Alternative Payment Models and Incentive Payments for Participation in Eligible Alternative Payment Models.

Question: ONC seeks to measure various aspects of interoperability. Do these aspects of interoperability adequately address both the exchange and use components of section 106(b)(1) of the MACRA?

The RFI indicates that ONC seeks to measure the electronic sending, receiving and finding, integrating of information received into a patient’s medical record and subsequent use of the information received from outside sources as well as the use of information received for clinical decision-making. Achieving bidirectional exchange of immunization information across the range of community immunizers and IIS’ consistently across providers, health care settings and states would go a long way toward improving adult immunization rates. It would enable providers to communicate and share immunization information via the IIS as well as enable providers to have access to accurate and complete immunization records in order to provide patient education and help inform clinical decision-making. In order for that to happen, however, IIS’, EHRs and providers need to continue working to standardize the transmission of bidirectional information consistently.

Measures Based Upon National Survey Data

The RFI indicates that ONC is considering measures based on national survey data for hospitals and office-based physicians that would track the proportion of healthcare providers who are sending, receiving and finding, integrating key health information; use information received electronically from outside providers and sources for clinical decision-making; and who electronically perform reconciliation of clinical information. AVAC views all of these measures to be very important in the context of adult immunization and urge ONC to make immunization a foundational element of the measure development process.

Question: Do the survey-based measures described, which focus on measurement from a health care provider perspective adequately address the two components of interoperability as described in section 106(b)(1) of MACRA?

Both the AHA Health IT Supplement Survey and the National Electronic Health Record Survey of office-based physicians referenced in the RFI include a question on whether or not a computerized system is available to submit electronic data to immunization registries/information systems. In addition, the AHA Health IT Supplement survey includes questions regarding technical capability to send and receive patient health information with outside providers and sources. We believe these questions can provide important information regarding barriers to bidirectional exchange.

Question: Could office-based physicians serve as adequate proxies for eligible professionals who are “meaningful EHR users” under the Medicare and Medicaid EHR Incentive Programs?

We would urge ONC to explore other survey opportunities that would more directly capture the participation of “meaningful EHR users” across the broader health care workforce in terms of providers and health care settings. We also would encourage ONC to engage other outside providers and public health stakeholders, including pharmacy organizations as well as entities involved in the development, implementation and management or IIS’ in order to development measurement tools that will capture a complete picture of progress around IIS/EHR interoperability.

Question: Do national surveys provide the necessary information to determine why electronic health information may not be widely exchanged? Are there other recommended methods that ONC could use to obtain this information?

AVAC consists of a wide range of organizations representing providers, public health, minority health organizations, patient groups, vaccine innovators and immunization registry organizations. As such, we would encourage ONC to also engage directly with individual organizations since many conduct regular surveys of their membership to solicit feedback on concerns and challenges in their respective fields. Specifically, the Pharmacy Quality Alliance (PQA) is working to develop measures focused on administered vaccines and IIS reporting that could be beneficial to ONC. Many of our member organizations also have knowledge and understanding of barriers preventing the wide exchange of electronic health information.

CMS Medicare and Medicaid EHR Incentive Programs Measures

The RFI notes that ONC is considering using the proportion of transitions or care or referrals as a measure to evaluate the exchange and use aspects of interoperability under the following circumstances: where a record was created using certified EHR technology and exchanged/transmitted electronically; where a new provider receives, requests or queries a summary of care document to incorporate into the patient’s record; where a medication reconciliation is performed; and where a new provider receives a transition or referral and performs a clinical information reconciliation for medications, medication allergies and problem lists.

Question: Given the limitations described, do these potential measures adequately address the “exchange” component of interoperability?

As the RFI indicates, while proposed system would capture individual eligible professionals, hospitals and CAH’s under Medicare, it would not be able to do the same for Medicaid providers. Additionally, it would ensure a summary of care was sent but does not have the ability to assess whether a summary of care was electronically received. AVAC would note that the summary of care documents used to meet the meaningful use objective must include immunizations among the information provided. While the summary of care helps to provide a least part of a patient’s immunization record, it may not present the entire picture. We would encourage ONC to consider including the exchange of immunization record data to and from IIS’ systems among the possible measures of interoperability.

Question: Do the reconciliation-related measures serve as adequate proxies to assess the subsequent use of exchanged information? What alternative national-level measures should ONC consider for assessing this specific aspect of interoperability?

As noted earlier, AVAC would encourage ONC to consider including the exchange of immunization record data from IIS’ among the measures of interoperability. While a summary of care from a provider might contain some of a patient’s immunization history, directly querying and receiving information from an IIS’ would potentially reveal additional immunizations a patient may have received in health care settings outside of a provider’s office.

Question: Can state Medicaid agencies share health care provider level data with CMS similar to how Medicare currently collects and reports on these data in order to report on progress toward widespread health information exchange and use? If not, what are the barriers to doing so? What are some alternatives?

Medicaid is a federal-state partnership and as such Medicaid agencies run independently from one another. Given this variability, it would seem that getting standardized health care provider level data similar to what Medicare currently collects and reports would be a significant challenge. It could take many years to get the appropriate systems in place to allow for such reporting by Medicaid providers.

Identifying Other Data Sources to Measure Interoperability

Question: Should ONC select measures from a single data source for consistency, or should ONC leverage a variety of data sources? If the latter, would a combination of measures from CMS EHR Incentive Programs and national survey data of hospitals and physicians be appropriate?

From the standpoint of immunization, the CMS EHR Incentive Programs and national survey data of hospitals and physicians provide a solid foundation of measurement for immunization upon which ONC can build as time goes on. These two data sources have long prioritized immunization reporting and their processes are ones with which eligible providers are comfortable.

Question: If ONC seeks to limit the number of measures selected, which are the highest priority measures to include?

AVAC would strongly encourage ONC to maintain reporting of immunization record data and the bidirectional exchange of this information among the foundational measures included for interoperability. The Medicare and Medicaid EHR Incentive and the ONC Meaningful Use program has made bidirectional exchange between provider EHR systems and IIS’ a top priority. This emphasis has been essential to driving public-private collaborations to achieve consensus on standards3 as well as inspiring local technology solutions to discreet barriers to interoperability. This also supports NVAC’s Adult Immunization Standards that call for any provider of adult immunizations to assess immunization status, recommend appropriate vaccinations, administer the vaccine or refer the patient to a provide who will, and to document the administered vaccines. A strong emphasis on the immunization neighborhood built around collaboration, coordination and communication are the pillars supporting the measures in this area.

AVAC is concerned that potentially removing this measure as a priority would send the wrong signal to providers about the importance of adult immunization and result in reductions in coverage rates among this population. As a nation, we presently lag behind Healthy People 2020 targets for adult immunizations and simply cannot afford to lose ground.

Question: How should ONC define ‘‘widespread’’ in quantifiable terms across these measures? Would this be a simple majority, over 50%, or should the threshold be set higher across these measures to be considered ‘‘widespread’’?

AVAC would encourage ONC to define “widespread” in a manner that is realistic and achievable in the beginning and seek to modify the term as interoperability takes hold across a wide arrange of providers and health care settings. AVAC urges ONC to consider incentives and benchmarks that will gradually encourage the range of meaningful EHR users or other documentation system (like pharmacies) who are immunization providers in the community to input adult immunization records into state and jurisdictional IIS’.

Thank you for this opportunity to offer our perspective on this series of questions being considered by ONC. Please contact the AVAC Coalition Manager at (202) 540-1070 or info@adultvaccinesnow.org if you wish to further discuss our responses or would like to learn more information about AVAC and our work.


American Association of Occupational Health Nurses
American College of Preventive Medicine
American Pharmacists Association
Asian Pacific Islander American Health Forum
Gerontological Society of America
Hepatitis B Foundation
National Association of County and City Health Officials
National Council of Asian Pacific Islander Physicians
Trust for Americas Health