Navigating Cancer’s Official Comments on Stage 3 Meaningful Use Proposed Rule

To:      Centers for Medicare & Medicaid Services
Date:    May 28, 2015
Re.:     Comments on the Centers for Medicare Medicaid Services (CMS) Proposed Rule: Electronic Health Record Incentive Program Stage 3.

Navigating Cancer, Inc. appreciates this opportunity to comment on the Centers for Medicare Medicaid Services (CMS) Proposed Rule, Electronic Health Record Incentive Program Stage 3.

Navigating Cancer is a HITECH-certified, modular EHR vendor that provides oncology patient portals and care management solutions for cancer clinics throughout the United States. Currently, our patient portal gives over a million cancer and hematology patients, and over a thousand healthcare professionals, the ability to securely access and exchange health information online. For patients, Navigating Cancer provides a single, comprehensive hub that operates with any electronic health record system, enabling them to stay seamlessly informed and engaged in their own care across multiple clinics, caregivers and geographies. For providers, Navigating Cancer offers a scalable solution for care management and engagement and an agile means of satisfying current requirements for Meaningful Use, Commission on Cancer and new payment reform models.

It is from this experience, and our unique focus on the needs and challenges of cancer survivors and oncology healthcare providers, that we offer the following comments:

We strongly support the availability of ONC-certified Application Programming Interfaces (APIs).

Within a short timespan, an individual diagnosed with cancer will interact with multiple care providers. Cancer patients may be seen by their primary care doctor, surgeon, radiation oncologist, medical oncologist and potentially others. We frequently hear from patients who are frustrated by the need to use multiple patient portals or online systems to access their disparate health information – sometimes even within the same health system. While even healthy individuals are challenged to remember multiple logins and product interfaces, cancer patients newly diagnosed and/or in the midst of intensive therapies and subsequent side effects can find it especially difficult to recall and navigate multiple systems of varying designs. The availability of secure, ONC-certified APIs at low cost (or no cost) that are provided by EHR vendors, and thereby provided to healthcare providers to provide patients, will provide patient’s the ability to readily integrate and consolidate their own health information across care providers into applications of their choosing. In this fashion, patients will gain comprehensive access to their own health records, as well as the ability to direct sharing of that unified record with other providers as needed. This clearly benefits patients, and will lead to better-informed providers and better care coordination overall.

To ensure that APIs optimize patient engagement, we believe that additional specifications are necessary.

While we understand that definition of the API should be left to the EHR vendor, we recommend that the following broad requirements be part of ONC API certification:

    1. For maximum flexibility and ease of use, the delivery mechanism of the API should be a RESTful web service.
    2. The API must implement clear error handling.
    3. The API must come with a clear outline of the interface itself – inputs, output and errors.
    4. The API must come with sample code and applications that demonstrate a successful use of the API calls.
    5. The API should come with a support channel – community forum (at minimum) and/or ideally dedicated support staff.

In addition, we recommend that Secure Messaging be included within the ONC-certified API Scope & Definition.

As digital health matures, electronic communications between healthcare providers and patients will only become more common. We believe that it makes sense for these communications to be included in the core data set for ready access via an ONC-certified API. Secure Messaging provides a means for patients to consolidate critical information, education, or resources across multiple providers, clinics and geographies. An API that does not support Secure Message interoperability/exchange between vendor systems would be in direct contrast to the realization of better outcomes through digitized health, by further propagated the isolation of each patient-provider encounter. We recommend that ONC broaden the definition of the core data set covered by the proposed API to include the essential functions of accessing, sending, receiving and responding to Secure Messages between patients and providers.

APIs should be a requirement for vendors obtaining CEHRT certification.

In regards to Measure 1, we recommend Alternate C. We believe strongly that APIs should be a requirement for vendors obtaining CEHRT certification and for providers attesting to this stage 3 measure. Without this mandate, there exists a strong incentive for CEHRT vendors that are currently dominant to remain focused on their own product and business priorities, at the ongoing expense of information portability and the patient’s ability to access and consolidate personal health information outside of a particular vendor’s specific toolset. Navigating Cancer is optimistic that providing increased secure access to a patient’s health information will result in increased innovation and competition in the realm of patient-focused health IT, resulting in a variety of new solutions and boosting patient engagement. Thus, we strongly encourage CMS to adopt “Alternate C,” which would require the provision of an ONC-certified API that can be used by third-party applications or devices to provide patients (or patient-authorized representatives) access to their health information within 24 hours of its availability to the provider. In this scenario, as noted in the document, the core objective of enabling access to patient health information is addressed, while also allowing providers increased flexibility to offer a separate view, download, and transmit function.

The interoperability that will come from the use of well-specified APIs is vital to the evolution of Healthcare IT.

As described in ONC’s 2015 Report to Congress on Health Information Blocking, economic and market conditions have resulted in business incentives for some entities to exercise control over electronic health information in ways that unreasonably limit its availability and use. As the report states, “While the evidence is in some respects limited, there is little doubt that information blocking is occurring and that it is interfering with the exchange of electronic health information.” The failure to publish APIs for data elements that are required to be exchanged under the EHR Incentive Program is one example of information blocking cited in the report.

Navigating Cancer has experienced information blocking and anti-competitive tactics first-hand, by EHR companies who have refused to interface with our application, even with signed contracts in place from healthcare professionals. This restricts patients who want to access their electronic health information to the use of suboptimal products.

We appreciate the initiative and consideration that the Health Information Technology Policy Committee (HITPC) and staff of both the Center’s for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC), have given to introducing the API requirement into the Proposed Rule for Electronic Health Record Incentive Program Stage 3. Our organization views API standardization as a unique opportunity to revolutionize product development in healthcare technology, spur innovation and competition among software developers and dramatically improve the patient experience.

Thank you for the opportunity to submit our comments.

Gena Cook
Founder & CEO
Navigating Cancer, Inc.
1200 Post Alley
Seattle, WA

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