Response to Comment document

CMS-10250 Response to Public Comments

The following is a summary of the comments received and the responses.

1) Comment:  A commenter asserted that the burden estimate associated with the Emergency Care Access & Timeliness electronic clinical quality measure (eCQM), and eCQMs in general, includes only the burden associated with the submission of data and does not include the cost or effort associated with other activities such as: education to providers and staff on the impact of the measure on their workflow; modifications to documentation as appropriate; evaluation of measure report details against electronic health record (EHR) documentation, especially on fallouts and exclusions to identify opportunities for improved discrete documentation; time needed for review of Office of the National Coordinator for Health Information Technology (ONC) Project Tracking for ongoing issues identified with the eCQM measures; development of trending and benchmark reports for awareness of reported outcomes prior to submission of data; reprocessing of data when errors have been identified and corrected; and meetings with vendors and IT, quality, leadership, and other staff to assure an understanding of what is reported on Medicare.gov/Care Compare, its impact on public reporting, star reporting, and use by other reporting agencies.

Response to comment:  Because we assume the collection of data for eCQMs is already being collected in each Hospital Outpatient Department’s (HOPD’s) EHR system as part of the HOPD’s patient workflow, the burden estimates provided in this final rule with comment period include only the time associated with submission of data to CMS. However, as noted in the Regulatory Impact Analysis in section XXV.C.3.b. of this final rule with comment period , we agree with the commenter that there are additional recurring and non-recurring activities associated with the adoption of new eCQM measures.

Comment: A commenter stated their opinion that the burden estimate associated with the Excessive Radiation eCQM includes only the burden associated with the submission of data and does not include the cost or effort associated with other activities such as: contracted physicist time for scanner reconfiguration and validation; health information system, radiology information system, and EHR modifications to create separate low-, routine-, and high-dose orderable exams; radiologist and technologist labor for workflow redesign and training; IT integration across picture archiving and communication systems, dose monitoring systems, and reporting vendors; and scanner manufacturer support to ensure redesigned protocols remain consistent with each scanner’s technology and capability. The commenter further noted that first-year costs associated with these activities range between $20,000 and $50,000 with additional annual expenses incurred thereafter.

Response to comment: Reporting on this measure will continue to be voluntary, and as such HOPDs can determine their readiness to implement any changes necessary if they elect to report on this measure. Because we assume the collection of data for eCQMs is already being collected in each HOPD’s EHR system as part of the HOPD’s patient workflow, the burden estimates provided in this final rule with comment period include only the time associated with submission of data to CMS. However, as noted in the Regulatory Impact Analysis in section XXV.C.3.b. of this final rule with comment period, we agree with the commenter that there are additional recurring and non-recurring activities associated with adoption of new eCQM measures.