Response to Comment document

CMS-10870 Response to Public Comments

The following is a summary of the one comment received and the response.

Comment:  A commenter stated their opinion 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 impacted 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 Rural Emergency Hospital (REH)’s EHR system as part of the REH’s patient workflow, the burden estimates provided in this final rule include only the time associated with submission of data to CMS. However, as noted in the Regulatory Impact Analysis in section XXV.C.4.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.