Federal Register / Vol. 78, No. 45 / Thursday, March 7, 2013 / Notices 14793 

1Hsiao CJ, Hing E. Use and characteristics of 

electronic health record systems among office-based 

Continued 

pursuant to section 19 of the Shipping 

Act of 1984 (46 U.S.C. 40101) effective 

on the date shown. 

License No.: 017269N. 

Name: Fastmark Corporation. 

Address: 7206 NW 84th Avenue, 

Medley, FL 33166. 

Date Reissued: January 22, 2013. 

Vern W. Hill, 

Director, Bureau of Certification and 

Licensing. 

[FR Doc. 2013–05314 Filed 3–6–13; 8:45 am] 

BILLING CODE 6730–01–P 

FEDERAL MARITIME COMMISSION 

Ocean Transportation Intermediary 

License Rescission of Order of 

Revocation 

The Commission gives notice that it 

has rescinded its Order revoking the 

following license pursuant to section 

40901 of the Shipping Act of 1984 (46 

U.S.C. 40101). 

License No.: 008504N. 

Name: Hyun Dae Trucking Co., Inc. 

Address: 3022 S. Western Avenue, 

Los Angeles, CA 90018. 

Order Published: January 25, 2013 

(Volume 78, No. 17, Pg. 5440). 

Vern W. Hill, 

Director, Bureau of Certification and 

Licensing. 

[FR Doc. 2013–05315 Filed 3–6–13; 8:45 am] 

BILLING CODE 6730–01–P 

FEDERAL MARITIME COMMISSION 

Ocean Transportation Intermediary 

License Revocations 

The Commission gives notice that the 

following Ocean Transportation 

Intermediary license has been revoked 

pursuant to section 19 of the Shipping 

Act of 1984 (46 U.S.C. 40101) effective 

on the date shown. 

License No.: 021062F. 

Name: International Trade 

Compliance Group, LLC. 

Address: 101 North Riverside Drive, 

Suite 203, Pompano Beach, FL 33062. 

Date Revoked: February 20, 2013. 

Reason: Voluntary Surrender of 

License. 

Vern W. Hill, 

Director, Bureau of Certification and 

Licensing. 

[FR Doc. 2013–05311 Filed 3–6–13; 8:45 am] 

BILLING CODE 6730–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Office of the Secretary 

Centers for Medicare & Medicaid 

Services 

[CMS–0038–NC] 

Advancing Interoperability and Health 

Information Exchange 

AGENCY: Office of the National 

Coordinator for Health Information 

Technology (ONC) and Centers for 

Medicare & Medicaid Services (CMS), 

Department of Health and Human 

Services (HHS). 

ACTION: Notice with comment; Request 

for Information. 

SUMMARY: HHS seeks input on a series 

of potential policy and programmatic 

changes to accelerate electronic health 

information exchange across providers, 

as well as new ideas that would be both 

effective and feasible to implement. To 

further accelerate and advance 

interoperability and health information 

exchange beyond what is currently 

being done through ONC programs and 

the EHR Incentive Program, HHS is 

considering a number of policy levers 

using existing authorities and programs. 

DATES: To be assured consideration, 

written or electronic comments must be 

received at one of the addresses 

provided below, no later than 5 p.m. on 

April 22, 2013. 

ADDRESSES: You may submit comments 

identified by any of the following 

methods below (please do not submit 

duplicate comments). Because of staff 

and resource limitations, we cannot 

accept comments by facsimile (FAX) 

transmission. 

• Federal eRulemaking Portal: Follow 

the instructions for submitting 

comments. Attachments should be in 

Microsoft Word or Excel, Adobe PDF; 

however, we prefer Microsoft Word. 

http://www.regulations.gov. 

• Regular, Express, or Overnight Mail: 

Department of Health and Human 

Services, Office of the National 

Coordinator for Health Information 

Technology, Attention: Interoperability 

RFI, Hubert H. Humphrey Building, 

Suite 729D, 200 Independence Ave. 

SW., Washington, DC 20201. Please 

submit one original and two copies. 

• Hand Delivery or Courier: Office of 

the National Coordinator for Health 

Information Technology, Attention: 

Interoperability RFI, Hubert H. 

Humphrey Building, Suite 729D, 200 

Independence Ave. SW., Washington, 

DC 20201. Please submit one original 

and two copies. (Because access to the 

interior of the Hubert H. Humphrey 

Building is not readily available to 

persons without federal government 

identification, commenters are 

encouraged to leave their comments in 

the mail drop slots located in the main 

lobby of the building.) 

Inspection of Public Comments: All 

comments received before the close of 

the comment period will be available for 

public inspection, including any 

personally identifiable or confidential 

business information that is included in 

a comment. Please do not include 

anything in your comment submission 

that you do not wish to share with the 

general public. Such information 

includes, but is not limited to: A 

person’s social security number; date of 

birth; driver’s license number; state 

identification number or foreign country 

equivalent; passport number; financial 

account number; credit or debit card 

number; any personal health 

information; or any business 

information that could be considered to 

be proprietary. We will post all 

comments received before the close of 

the comment period at http:// 

www.regulations.gov. 

Docket: For access to the docket to 

read background documents or 

comments received, go to http:// 

www.regulations.gov or the Department 

of Health and Human Services, Office of 

the National Coordinator for Health 

Information Technology, Hubert H. 

Humphrey Building, Suite 729D, 200 

Independence Ave. SW., Washington, 

DC 20201 (call ahead to the contact 

listed below to arrange for inspection). 

FOR FURTHER INFORMATION CONTACT: 

• Kelly Cronin, Health Care Reform 

Coordinator; or 

• Steven Posnack, Director, Federal 

Policy Division 

Office of the National Coordinator for 

Health Information Technology, 202– 

690–7151. 

SUPPLEMENTARY INFORMATION: 

I. Background 

Since enactment of the Health 

Information Technology for Clinical and 

Economic Health Act as part of the 

American Recovery and Reinvestment 

Act, adoption and use of electronic 

health records in the United States has 

dramatically increased. Adoption of 

EHRs that met the criteria for a basic 

EHR system by office-based physicians 

grew by over 80% between 2009 and 

2012, from 22% in 2009 to 40% in 

2012.1 2 Among non-federal acute care 


emcdonald on DSK67QTVN1PROD with NOTICES
14794 Federal Register / Vol. 78, No. 45 / Thursday, March 7, 2013 / Notices 

physician practices: United States, 2001–2012. 

NCHS data brief, no 111. Hyattsville, MD: National 

Center for Health Statistics. 2012. 

2A basic EHR system for office-based practices 

includes the following functionalities: Patient 

history and demographics, patient problem lists, 

physician clinical notes, comprehensive list of 

patients’ medications and allergies, computerized 

orders for prescriptions, and ability to view 

laboratory and imaging results electronically. Note 

that functionalities associated with basic EHR differ 

from functionalities required for meaningful use. 

3ONC analysis of data from the 2011 American 

Hospital Association Survey Information 

Technology Supplement. Data brief forthcoming. 

4A basic EHR system for hospitals includes the 

following functionalities: Patient history and 

demographics, patient problem lists, physician 

clinical notes, nursing assessments, comprehensive 

list of patients’ medications and allergies, discharge 

summaries, computerized orders for prescriptions, 

and the ability to view diagnostic test results, 

laboratory reports and radiology reports 

electronically. Note that functionalities associated 

with basic EHR differ from functionalities required 

for meaningful use. 

5 King J, Patel V, Furukawa MF. Physician 

Adoption of Electronic Health Record Technology 

to Meet Meaningful Use Objectives: 2009–2012. 

ONC Data Brief, no. 7. Washington, DC: Office of 

the National Coordinator for Health Information 

Technology. December 2012. 

6ONC analysis of data from the 2011 American 

Hospital Association Survey Information 

Technology Supplement. Data brief forthcoming. 

7ONC analysis of data from the 2011 American 

Hospital Association Survey Information 

Technology Supplement. 

8ONC analysis of data from the 2011 National 

Ambulatory Medical Care Survey Electronic Health 

Record Supplement. 

9Wolf L, Harvell J, Jha A. Hospitals Ineligible For 

Federal Meaningful-Use Incentives Have Dismally 

Low Rates Of Adoption Of Electronic Health 

Records http://content.healthaffairs.org/content/31/ 

3/505.full. 

10Wolf L, Harvell J, Jha A. Hospitals Ineligible 

For Federal Meaningful-Use Incentives Have 

Dismally Low Rates Of Adoption Of Electronic 

Health Records http://content.healthaffairs.org/ 

content/31/3/505.full. 

hospitals, adoption of at least a basic 

EHR system has increased by over 260% 

since 2009, from 12% to 44%.3 4 Since 

2009, there has been strong and steady 

growth in adoption of EHR technology 

to meet Meaningful Use objectives to 

improve quality, safety and efficiency. 

Adoption of many of the computerized 

functionalities associated with 

Meaningful Use has substantially 

increased among both office-based 

physicians as well as hospitals.5 6 For 

example, physician adoption of five 

core Meaningful Use functionalities— 

ranging from e-prescribing to clinical 

decision support—has grown by at least 

66% since HITECH in 2009. 

As part of stage 2 rulemaking HHS has 

taken major steps to expand the 

functionality and utility of EHRs to 

providers and patients. We seek to build 

on that work by engaging other policy 

areas within HHS jurisdiction to 

promote routine sharing of information 

among health care providers across 

settings of care to support care 

coordination and delivery system 

reform. We also recognize that economic 

and regulatory barriers may impair the 

development of a patient centered, 

information rich, high performance 

health care system where a persons’ 

health information follows them 

wherever they access health care 

services. 

The Medicare and Medicaid 

Electronic Health Record (EHR) 

Incentive Programs and Office of the 

National Coordinator (ONC) for Health 

IT (HIT) Certification Program are 

increasing standards based health 

information exchange (HIE) across 

health care providers and settings of 

care to support greater coordination of 

health care services. However, this 

alone will not be enough to achieve the 

widespread interoperability and 

electronic exchange of information 

necessary for delivery reform where 

information will routinely follow the 

patient regardless of where they receive 

care. With fee-for-service 

reimbursement and other business 

motivations often being the stronger 

influencer of provider behavior, both 

providers and their vendors do not yet 

have a business imperative to share 

person level health information across 

providers and settings of care. 

For example, in 2011, 4 in 10 

hospitals electronically sent laboratory 

and radiology data to providers outside 

their organization; however, only 1⁄4 of 

hospitals could exchange medication 

lists and clinical summaries with 

outside providers.7 In addition in 2011, 

only 31 percent of physicians are 

exchanging clinical summaries with 

other providers.8 There is even more 

limited HIE involving post-acute and 

institutional long-term care providers as 

well as behavioral health and lab 

providers who may not eligible for 

incentive payments under the EHR 

incentive program. Only 6 percent of 

long-term acute care hospitals, 4 percent 

of rehabilitation hospitals, and 2 percent 

of psychiatric hospitals have a basic 

electronic health record system.9 Close 

to 1⁄3 of all Medicare beneficiaries 

discharged from acute care hospitals are 

discharged to post-acute care settings 

such as rehabilitation hospitals but 

there is little capacity in the system 

today to support HIE across these 

settings.10 Similarly consumers and 

patients are not actively engaged in 

accessing and using their personal 

health information and requesting that 

their providers do the same. Based upon 

the 2012 ONC Privacy & Security 

Survey, 19 percent of consumers 

reported that they were given online 

access to a part of their medical record 

by a health care provider within the last 

12 months. 

ONC has been advancing standards 

based HIE through a variety of programs 

and initiatives including the Standards 

and Interoperability Framework, the 

State HIE Cooperative Agreement 

Program, the Direct Project, the 

Nationwide Health Information Network 

Exchange and the HIT Certification 

Program. Other HHS policies also 

encourage HIE through the adoption of 

interoperable Electronic Health Record 

(EHR) technology. For example we 

recognize that the EHR exception to the 

federal Physician Self-Referral law and 

EHR safe harbor to the federal AntiKickback Statute which protect the 

donation of certain software and related 

training and services when various 

requirements are met, have created a 

pathway for arrangements that promote 

EHR implementation and use. To 

further accelerate and advance 

interoperability and health information 

exchange beyond what is currently 

being done through ONC programs and 

the EHR Incentive Program, HHS is 

considering a number of policy levers 

using existing authorities and programs. 

The overarching goal is to develop and 

implement a set of policies that would 

encourage providers to routinely 

exchange health information through 

interoperable systems in support of care 

coordination across health care settings. 

This goal potentially could be achieved 

through a combination of incentives, 

payment adjustments, and requirements 

that collectively result in a more 

coordinated, value-driven health care 

system over the next 1 to 3 years and 

beyond. The Patient Protection and 

Affordable Care Act (Pub. L. 111–148), 

as amended by the Health Care and 

Education Reconciliation Act of 2010 

(Pub. L. 111–152) (collectively referred 

to as the Affordable Care Act) has 

created new opportunities to align 

current and new policies in a way that 

provides a compelling business and 

patient care case to providers to change 

culture and share clinical data with all 

providers across the health care 

spectrum as a part of their routine 

delivery of care and services. The 

Affordable Care Act initiatives 

including the Medicare Shared Savings 

Program, hospital readmission payment 

adjustments, Medicaid health homes, 

and new models being tested by the 

Center for Medicare and Medicaid 

Innovation are creating a stronger 

business case for many providers to 

exchange health information. 

HHS recognizes the need to use 

evidence and data on provider behavior 

to inform ongoing policy development 


emcdonald on DSK67QTVN1PROD with NOTICES
Federal Register / Vol. 78, No. 45 / Thursday, March 7, 2013 / Notices 14795 

11McGlynn, E.A., S.M. Asch, J. Adams, J. Keesey, 

J. Hicks, A. DeCristofaro, and E.A. Kerr, ‘‘The 

Quality of Health Care Delivered to Adults in the 

United States.’’ New England Journal of Medicine 

2003 348: 2635–45. See also, Rosenbaum, R., ‘‘Data 

Governance and Stewardship: Designing Data 

Stewardship Entities and Advancing Data Access,’’ 

Health Services Research 2010 45:5, Part II. 

that will result in a connected, personcentric health care system where health 

information is routinely shared across 

providers and settings of care to 

encourage the consistent provision of 

high-quality care, promote efficient use 

of health care resources, and ensure that 

health outcomes are good and care is 

affordable. As HHS, the provider, and 

the health IT vendor communities gain 

more experience with new delivery 

models, meaningful use of health IT, 

and HIE, these insights along with upto-date market data on provider 

behavior will inform the evolution of 

policies and programs that accelerate 

HIE and contribute to better quality 

care. 

This request for information (RFI) lays 

out some of the potential options to 

accelerate the existing progress and 

enhance a market environment that will 

accelerate HIE across providers thereby 

improving the likelihood of successful 

delivery and payment reform. HHS is 

seeking input on the options addressed 

below, as well as other options that 

stakeholders believe would be effective 

and feasible. 

A. Vision 

We are on the dawn of a new era of 

health care delivery—a transformed 

system that is person-centered and 

value-based. Existing CMS programs 

and demonstrations, as well as new 

programs and initiatives authorized by 

the Affordable Care Act, focus on 

improved care coordination and new 

service delivery and payment models 

that encourage and facilitate greater 

coordination of care and improved 

quality, including accountable care 

organizations (ACOs), bundled 

payments, health and medical homes, 

and reductions in hospital readmission. 

Critical to the success of these programs 

and the ultimate goal of a transformed 

health care system is the real-time 

electronic exchange of health 

information. Experts agree that greater 

access to person level health 

information is integral to improving the 

quality, efficiency, and safety of health 

care delivery.11

The lack of widespread electronic HIE 

is a significant barrier to achieving truly 

coordinated, person-centered health 

care. The Medicare and Medicaid EHR 

Incentive Programs and other valuebased payment programs are significant 

drivers of use of interoperable health 

information technology and the 

exchange of health information. We 

introduced many concepts of 

interoperability in Stage 2 and expect 

that the Medicare and Medicaid EHR 

Incentive Programs criteria for Stage 3 of 

meaningful use will include 

requirements for advanced 

interoperability. As other value-based 

payment programs evolve, they might 

include a greater emphasis on HIE as 

either a requirement for participation, 

receipt of incentive payments, or 

avoidance of payment adjustments. 

However, gaps and challenges still 

remain to wide-spread use of 

interoperable systems and HIE across 

providers, settings of care, consumers 

and patients, and payers. CMS and ONC 

will continue to collaborate on the EHR 

Incentive Program and HIT Certification 

Program to ensure they support delivery 

and payment reform. In addition, HHS 

intends to rely on all applicable and 

appropriate statutory authorities, 

regulations, policies, and programs to 

accelerate rapid adoption of health 

information exchange across the care 

continuum in support of delivery and 

payment reform. This combination of 

diverse policies and programs will 

ensure health information follows a 

person regardless of where they access 

health care services. HHS envisions an 

information rich, person-centered, high 

performance health care system where 

every health care provider has access to 

longitudinal data on patients they treat 

to make evidence-based decisions, 

coordinate care and improve health 

outcomes. As the Affordable Care Act 

continues to be implemented, HHS will 

develop and evolve policies and 

programs to achieve this vision. 

B. Policies and Questions 

CMS and ONC are jointly issuing this 

RFI to seek input on policies and 

programs that would further drive HIE 

to support more person-centered, 

coordinated, value-driven care. In 

section II of this RFI, HHS discusses 

policies and programs that may further 

encourage HIE. They are organized by 

various gaps and challenges that the 

policies and programs are intended to 

address (for example, low rates of 

adoption and HIE among post-acute and 

long-term care providers). HHS is 

soliciting comments on these policy and 

programmatic options, as well as 

comments on other policy and 

programmatic options HHS could 

consider. In addition, the RFI includes 

several questions in section III on which 

HHS would like stakeholder input. 

II. Policies and Programs Under 

Consideration by CMS and ONC 

A. Low Rates of EHR Adoption and 

Health Information Exchange Among 

Post-Acute and Long-Term Care 

Providers 

There are a variety of options HHS 

might pursue to encourage HIE among 

post-acute and long-term care providers. 

Some of these options are described 

below. 

• CMS has existing authority to allow 

states flexibility to implement 

innovative delivery and payment 

models for Medicare and Medicaid 

beneficiaries which could accelerate 

HIE as a part of improving care 

coordination across acute, post-acute 

and long-term care providers, reducing 

avoidable readmissions and improving 

health outcomes. For example, under 

section 1945 of the Social Security Act 

(the Act), added by section 2703 of the 

Affordable Care Act, states can establish 

Medicaid health homes for certain 

beneficiaries by amending their state 

plans to include the new benefit. Use of 

HIT is required to the extent ‘‘feasible 

and appropriate’’ to link services. 

• Section 1115 of the Act gives the 

HHS Secretary authority to approve 

experimental, pilot, or demonstration 

projects that promote the objectives of 

Medicaid and Childrens Health 

Insurance Program (CHIP). These 

demonstrations give states additional 

flexibility to design and improve their 

programs, demonstrate and evaluate 

policy approaches such as providing 

services not typically covered by 

Medicaid or using innovative service 

delivery systems that improve care, 

increase efficiency, and reduce costs. 

Some states use this authority to 

advance and support their ability to 

incentivize health outcomes 

improvement and rely less on 

traditional forms of payment that 

reward high volume of discrete services. 

Furthermore, some of these models 

build on the concepts in the Medicare 

Shared Savings Program and encourage 

disparate providers to create formal 

arrangements establishing responsibility 

for managing all Medicaid services and 

total cost of care for an assigned 

population, including behavioral health 

and long-term care. HIE could be an 

important component of programs like 

these or other programs that rely on care 

coordination across settings of care. 

Special terms and conditions (STCs) for 

these demonstration projects can require 

the use of HIE in delivery system and 

payment reform efforts, to coordinate 

and manage services, and monitor 

quality of care. For example, in Oregon’s 

recent section 1115(a) demonstration 


emcdonald on DSK67QTVN1PROD with NOTICES
14796 Federal Register / Vol. 78, No. 45 / Thursday, March 7, 2013 / Notices 

[1]http://medicaid.gov/Medicaid-CHIP-ProgramInformation/By-Topics/Waivers/1115/downloads/ 

or/or-health-plan2-ca.pdf pgs 121–122. 

project (Oregon Health Plan),[1] HIE is 

fundamental to the delivery system and 

payment changes being demonstrated. 

For this reason, the STCs required 

coordination between the demonstration 

project, Oregon’s HIE Operational Plan, 

and the State Medicaid HIT Plan to 

ensure that these systems support the 

overall quality improvement and 

decreased expenditures that are critical 

to the state’s demonstration. 

• Section 1915(c) of the Act permits 

states to provide an array of home and 

community based services (HCBS), 

including long term supports and 

services, to individuals who would 

otherwise require the level of care 

provided in certain institutions. Section 

1915(i) of the Act permits states to 

provide these services to certain eligible 

individuals without considering 

whether such individuals would 

otherwise require an institutional level 

of care. Section 1915(k) permits states to 

provide home and community-based 

attendant services to certain eligible 

individuals that may include skills 

training for daily life activities and 

back-up systems to ensure continuity of 

care and provides an increase in the 

federal financial participation rate for 

these services. Under these authorities, 

states can offer an array of specified 

home and community based services as 

well as other services requested by the 

state and approved by the Secretary that 

serve the purposes of the benefit. These 

services are important adjuncts to the 

care people receive from other areas of 

the health care system. Encouraging the 

appropriate exchange of health and 

other information across all providers 

involved in caring for these individuals 

is necessary to support effective care 

coordination and cost-effective care 

delivery. Furthermore, tracking their use 

of the health care system through health 

information technology will be critically 

important to development of new 

models of care delivery. Exchange of 

health information as beneficiaries 

transition to home or between providers 

(including acute, specialty, and primary 

care) could significantly improve 

continuity and the quality of their 

health care and result in reduced 

expenditures when care is continually 

managed in community settings. 

• In addition, CMS issued a State 

Medicaid Director (SMD) letter 

regarding a cost allocation policy for 

developing and sustaining HIE 

infrastructure as a part of the 

administration of the Medicaid EHR 

Incentive Program. Certain state 

expenditures related to the development 

and sustaining of HIE may be eligible for 

90 percent Federal financial 

participation (FFP) under this program, 

however, CMS approval of funding for 

HIE infrastructure costs requires 

assurances that other payers and 

providers will bear an appropriate share 

of the costs, risks and governance. States 

could propose to implement HIE 

infrastructure enhancements that enable 

the creation and exchange of health 

information across settings of care, 

including post-acute and long-term care 

providers with the Medicaid program. 

CMS’ Conditions of Participation or 

Coverage are designed to ensure that 

providers and suppliers maintain health 

care quality and safety. CMS and State 

staff oversee compliance with Medicare 

health and safety standards in hospitals, 

laboratories, nursing homes, home 

health agencies, hospices, rural health 

clinics, ambulatory surgical centers, 

organ transplant centers, and End Stage 

Renal Disease facilities. CMS has a role 

in advancing clinical standards in 

keeping with advancements in health IT 

capacity and the implementation of 

delivery and payment reforms in the 

Affordable Care Act that increasingly 

rely on coordination of care across 

institutional and non-institutional 

settings of care. CMS could require new 

clinical standards in the form of 

conditions of participation or 

requirements to ensure timely, 

electronic exchange of health 

information to support patient 

admissions, discharge, and transfers as 

well as care planning to ensure care 

continuity as patients receive care 

across inpatient, post-acute and longterm care providers. 

B. Low Rates of HIE Across Settings of 

Care and Providers 

There are several potential ways in 

which HHS might accelerate HIE across 

providers including ambulatory care, 

post-acute and long-term care, 

behavioral health, and lab providers. 

Four examples of options are briefly 

summarized below. 

• HHS can collaborate in the 

development of new e-specified 

measures of care coordination that 

encourage electronic sharing of 

summary records following transitions 

in care. This could be incorporated into 

and aligned across multiple programs 

including the EHR Incentive Program, 

and other CMS quality reporting 

programs. 

• The Medicare Shared Savings 

Program establishes requirements for 

participating ACOs. CMS might 

consider new ways to require or 

encourage Medicare ACOs to exchange 

health information as a part of 

coordination of care across aligned 

providers or patient engagement 

strategies. Currently, meaningful use of 

EHRs is treated as a measure of quality, 

which is used to determine ACO 

eligibility for the shared savings and/or 

shared losses. 

• Under the Affordable Care Act, 

CMS has the authority to test innovative 

payment and service delivery models 

that have the potential to reduce 

Medicare, Medicaid, or CHIP 

expenditures while maintaining or 

improving the quality of care for 

beneficiaries. Several new models are 

underway that encourage the use of HIE 

in support of care coordination such as 

the Bundled Payments for Care 

Improvement Initiative, Comprehensive 

Primary Care Initiative, the Pioneer 

ACO model and the State Innovation 

Model Initiative. For future and new 

models, CMS could request applicants 

to explain how they are using 

interoperable technology to advance HIE 

strategies in support of care 

coordination and quality improvement. 

Their HIE capacity could be factored 

into model participation decisions, as 

well as requirements over the model 

testing period, similar to meaningful use 

requirements under the Pioneer ACO 

model. 

• Under the Affordable Care Act 

authority, CMS is testing models to 

better align the financing of Medicare 

and Medicaid and integrate care 

delivery for people who are enrolled in 

both Medicare and Medicaid, also 

known as dual eligibles. Under the 

Capitated Financial Alignment model, 

CMS will contract with states and 

health plans, and the health plans will 

receive a prospective, blended payment 

to provide comprehensive, coordinated 

care. CMS could address requirements, 

expectations, and/or the role of HIE in 

these new arrangements, which have the 

potential to use HIE to deliver a higher 

degree of coordinated care for this 

fragile and costly population whose 

members often see numerous types of 

providers and require a high degree of 

care. 

C. Low Rates of Consumer and Patient 

Engagement 

CMS wants to encourage beneficiary 

engagement in their care through 

improved beneficiary access to their 

personal health information and better 

electronic communication between 

beneficiaries and their health care team. 

There are several ways CMS could 

encourage beneficiary access to their 

information through the use of new 

measures or patient-reported care 

experiences, new technology tools, and 


emcdonald on DSK67QTVN1PROD with NOTICES
Federal Register / Vol. 78, No. 45 / Thursday, March 7, 2013 / Notices 14797 

new financial models. These options are 

described below. 

• The Medicare Advantage Program 

could encourage improved beneficiary 

access to their personal health 

information by incorporating new 

measures in the Consumer Assessment 

of Healthcare Providers and Systems 

(CAHPS®) survey. The Medicare 

CAHPS® surveys are a set of surveys 

sponsored by CMS that collect 

consumer evaluations of health care 

experiences that are not currently 

assessed by other means. Questions 

could be expanded to include topics 

such as the extent to which patients 

believe they are able to participate 

collaboratively in decisions about their 

health, and the extent to which 

information technology supports their 

ability to share and communicate with 

providers and other members of their 

health care team, and manage their care 

between various providers. 

• CMS could promote the use of Blue 

Button. The Blue Button provides easy 

electronic access to personal health 

information for consumers. To 

strengthen its success, ONC released 

guidelines for data holders and 

application developers that support the 

growth of an ecosystem of tools to help 

consumers manage their health. The 

Blue Button Plus guidelines include 

specifications for a structured data 

format (consistent with Meaningful Use 

Stage 2), and enable updates of the 

information contained in individual 

consumer’s health records to be sent 

automatically to the applications of 

their choice. Tools built on Blue Button 

Plus specifications could be made 

available to all CMS beneficiaries, and 

widely promoted by healthcare 

providers and via avenues such as the 

Medicare Handbook, Medicare.gov, and 

Medicare Advantage plans. 

• As stated previously, under the 

Affordable Care Act, CMS has the 

authority to test innovative payment 

and service delivery models that have 

the potential to reduce program 

expenditures while maintaining or 

improving the quality of care for 

beneficiaries. In future and new models, 

CMS could encourage applicants to 

experiment with providing incentives 

for consumers to more actively 

participate in their health and health 

care—including through shareddecision making—supported by the 

collection, use, and sharing of electronic 

health information. 

• Modifications to Clinical Laboratory 

Improvement Amendments of 1988 

regulations and the Health Insurance 

Portability and Accountability Act of 

1996 (HIPAA) Privacy Rule could 

enable patients’ direct access to their lab 

results from laboratories. CMS and the 

HHS Office for Civil Rights (OCR) 

received public comments on this 

potential modification through a notice 

for proposed rulemaking (76 FR 56712). 

III. Questions for Public Comment 

CMS and ONC are soliciting public 

comments on the following questions: 

1. What changes in payment policy 

would have the most impact on the 

electronic exchange of health 

information, particularly among those 

organizations that are market 

competitors? 

2. Which of the following programs 

are having the greatest impact on 

encouraging electronic health 

information exchange: Hospital 

readmission payment adjustments, 

value-based purchasing, bundled 

payments, ACOs, Medicare Advantage, 

Medicare and Medicaid EHR Incentive 

Programs (Meaningful Use), or medical/ 

health homes? Are there any aspects of 

the design or implementation of these 

programs that are limiting their 

potential impact on encouraging care 

coordination and quality improvement 

across settings of care and among 

organizations that are market 

competitors? 

3. To what extent do current CMS 

payment policies encourage or impede 

electronic information exchange across 

health care provider organizations, 

particularly those that may be market 

competitors? Furthermore, what CMS 

and ONC programs and policies would 

specifically address the cultural and 

economic disincentives for HIE that 

result in ‘‘data lock-in’’ or restricting 

consumer and provider choice in 

services and providers? Are there 

specific ways in which providers and 

vendors could be encouraged to send, 

receive, and integrate health 

information from other treating 

providers outside of their practice or 

system? 

4. What CMS and ONC policies and 

programs would most impact post acute, 

long term care providers (institutional 

and HCBS) and behavioral health 

providers’ (for example, mental health 

and substance use disorders) exchange 

of health information, including 

electronic HIE, with other treating 

providers? How should these programs 

and policies be developed and/or 

implemented to maximize the impact on 

care coordination and quality 

improvement? 

5. How could CMS and states use 

existing authorities to better support 

electronic and interoperable HIE among 

Medicare and Medicaid providers, 

including post acute, long-term care, 

and behavioral health providers? 

6. How can CMS leverage regulatory 

requirements for acceptable quality in 

the operation of health care entities, 

such as conditions of participation for 

hospitals or requirements for SNFs, NFs, 

and home health to support and 

accelerate electronic, interoperable 

health information exchange? How 

could requirements for acceptable 

quality that involve health information 

exchange be phased in overtime? How 

might compliance with any such 

regulatory requirements be best assessed 

and enforced, especially since 

specialized HIT knowledge may be 

required to make such assessments? 

7. How could the EHR Incentives 

Program advance provider directories 

that would support exchange of health 

information between Eligible 

Professionals participating in the 

program. For example, could the 

attestation process capture provider 

identifiers that could be accessed to 

enable exchange among participating 

EPs? 

8. How can the new authorities under 

the Affordable Care Act for CMS test, 

evaluate, and scale innovative payment 

and service delivery models best 

accelerate standards- based electronic 

HIE across treating providers? 

9. What CMS and ONC policies and 

programs would most impact patient 

access and use of their electronic health 

information in the management of their 

care and health? How should CMS and 

ONC develop, refine and/or implement 

policies and program to maximize 

beneficiary access to their health 

information and engagement in their 

care? 

What specific HHS policy changes 

would significantly increase standards 

based electronic exchange of laboratory 

results? 

Dated: February 22, 2013. 

Marilyn Tavenner, 

Acting Administrator, Centers for Medicare 

& Medicaid Services. 

Dated: February 27, 2013. 

Farzad Mostashari, 

National Coordinator. 

[FR Doc. 2013–05266 Filed 3–6–13; 8:45 am] 

BILLING CODE 4150–45–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Office of the Secretary 

Findings of Research Misconduct 

AGENCY: Office of the Secretary, HHS. 

ACTION: Notice. 

SUMMARY: Notice is hereby given that 

the Office of Research Integrity (ORI) 


emcdonald on DSK67QTVN1PROD with NOTICES