Response to OMB comments on Barriers to Meaningful Use in Medicaid Project

Thank you for taking the time to speak with us on Thursday, August 11^th about the Barriers to Meaningful Use in Medicaid project. Below is a summary of the issues that you raised on the call and the steps we took to address them.

1. It is unclear where this project fits in the larger rule-making effort for the Medicaid EHR Incentive Program. Please clarify the timing of this project and demonstrate where it fits into Stages 2 and 3 of the Incentive Program.

The goals of this project are to: identify the barriers to eligibility for incentive payments; barriers to adoption, implementation or upgrading of EHR systems; and barriers to achieving meaningful use; and develop recommendations for technical assistance. AHRQ is seeking this information to better inform the technical assistance it provides to Medicaid and CHIP agencies and to help educate these agencies on barriers experienced by their providers and what they can do to ameliorate them.

Although the Centers for Medicare and Medicaid Services (CMS) expressed interest in reviewing the final report from this project, it is a secondary use of the information. CMS will receive input from numerous sources during the development of the Stage 2 Meaningful Use Criteria. These sources include: recommendations from the Health IT Policy Committee, recommendations from the Office of the National Coordinator for Health Information Technology, public comments in response to the Notice of Proposed Rule Making (NPRM) for the EHR Incentive Program’s Stage 2 Meaningful Use criteria, CMS’ own experience with Stage 1 of the incentive program, and numerous other formal and informal sources. This report would be one small source of information in a much larger process that takes into account research, expert opinion, public comment, and general experience.

Based on our current timeline, we expect to release the final analysis report in February, 2012. CMS expects to release the NPRM with the Stage 2 Meaningful Use criteria at the end of January 2012. The NPRM will be open for public comment for 90-days starting the day of its release. During that time and afterwards, CMS will be reviewing the public comment and other available data to make decisions on the changes to the NPRM that will be made in its final rule. Since the final analysis report will be available during the 90-day comment period, before the final rule is released, it is possible for CMS to use the report as one of its many information sources.

2. Why are you not collecting similar data for Medicare eligible professionals (EPs)?

As noted above, this project will inform the technical assistance provided to Medicaid and CHIP agencies and subsequently their providers. Therefore, it was not appropriate to include Medicare providers in our sample. Although it is likely that Medicare and Medicaid providers share some common barriers to achieving the meaningful use of EHRs, Medicaid providers will likely experience unique barriers because of the populations they serve. Also, unlike the Medicare program, which is administered by CMS, Medicaid programs are administered by States. As a result, CMS, and subsequently AHRQ, often struggle to gather information on the Medicaid providers and use the few sources it can find to understand those providers’ experiences.

3. The goals, as described on page 4 of Supporting Statement A appear too broad or narrow for the effort. It appears the project seeks to understand two separate topics: 1) barriers to specific Meaningful Use criteria for Medicaid providers and 2) barriers experienced by non-users of EHRs related to adoption. Please explain why there are few focus groups for non-users and why those focus groups are shorter than the users groups and ask different questions.

Thank you for the opportunity to clarify the objectives for the study. As you may be aware, to qualify for payments in their first year of participation in the Medicaid EHR Incentive Program, Medicaid providers must adopt, implement, upgrade or demonstrate the meaningful use of EHRs. In all subsequent participation years Medicaid providers must demonstrate the meaningful use of EHRs. Providers demonstrate the meaningful use of EHRs by: meeting 20 of the 25 meaningful use objectives and reporting on 6 clinical quality measures. Therefore, evaluating the barriers for qualifying for incentive payments must focus on both non-users who are and are not in the process of adopting and implementing EHRs as well as those current users who are upgrading to certified EHRs and will soon be demonstrating the meaningful use of EHRs. For that reason we have kept the first part of the goal to: identify the barriers to eligibility for incentive payments; barriers to adoption, implementation, and upgrading of EHR system; and barriers to achieving meaningful use.

After considering your comments we made adjustments to our study design and data collection instruments to provide greater equity across the focus groups for the users and non-users and increase the number of non-users interviewed. We are therefore proposing to add two (2) additional non-users focus groups for a total of 6 non-user focus groups and 15 total focus groups for the project. Based on the rule of thumb for focus groups from Krueger’s 1994 book, “Focus Groups: A Practical Guide for Applied Research”, 3-5 focus groups should be enough to allow us to draw reasonable conclusions. However, to address your concerns and ensure we have enough input from the range of provider types and sites we have added the two additional groups.

We have developed a separate moderator’s guide for the non-users focus groups because, although some questions for EHR users and non-users will be identical, we will ask the non-users questions about the barriers they’ve experienced that have kept them from adopting an EHR, which would not be relevant to those currently using an EHR. The moderator’s guide for the non-user focus groups is structured to ensure the participants discuss topics in four sections: 1) their general views of EHRs and their intention to adopt; 2) the effect of the incentive programs on EHR selection, adoption, and use; 3) factors that may facilitate meaningful use; and 4) technical assistance. Although there are questions in section 1 that are unique to the non-users, the questions in sections 2-4 are identical to those included in the moderator’s guide for the EHR-users focus groups. Additionally, the moderator’s guide for EHR users contains a fifth section (not included in the guide for non-users) with questions on the specific uses of EHRs. These questions ask the EHR users to describe their experience with features such as structured data and the specific functions necessary to meaningfully use an EHR. These questions are not asked of non-users since they would have little relevance to them given their lack of experience with EHRs.

In addition to increasing the number of non-users included in the study, we have also revised the moderator’s guide to include four questions that are comparable to questions in the EHR-users moderator’s guide, specifically questions I-A-1-a, I-A-8, I-A-3-c, and I-A-9-a. These questions would help us understand a bit more about the factors influencing their decision to purchase an EHR and the effect of the incentive program on the type of EHR they might purchase.