[Federal Register Volume 81, Number 68 (Friday, April 8, 2016)]
[Notices]
[Pages 20651-20655]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-08134]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES


Office of the National Coordinator for Health Information 
Technology; Medicare Access and CHIP Reauthorization Act of 2015; 
Request for Information Regarding Assessing Interoperability for MACRA

AGENCY: Office of the National Coordinator for Health IT (ONC), HHS.

ACTION: Request for information.

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SUMMARY: In section 106(b)(1) of the Medicare Access and CHIP 
Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 
2015), Congress declares it a national objective to achieve widespread 
exchange of health information through interoperable certified 
electronic health record (EHR) technology nationwide by December 31, 
2018. Section 106(b)(1)(C) of the MACRA provides that by July 1, 2016, 
and in consultation with stakeholders, the Secretary of Health and 
Human Services (HHS) shall establish metrics to be used to determine if 
and to the extent this objective has been met.
    ONC intends to consider metrics that address the specific 
populations and aspects of interoperable health information described 
in section 106(b)(1)(B) of the MACRA. ONC is issuing this RFI is to 
solicit input on the following three topics: (1) Measurement population 
and key components of interoperability that should be measured; (2) 
current data sources and potential metrics that address section 
106(b)(1) of the MACRA; and (3) other data sources and metrics ONC 
should consider with respect to section 106(b)(1) of the MACRA or 
interoperability measurement more broadly.

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 June 3, 2016.

ADDRESSES: In commenting, refer to file code ONC xxxx. Because of staff 
and resource limitations, ONC cannot accept comments by facsimile (FAX) 
transmission. You may submit comments in one of four ways (please 
choose only one of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the ``Submit a 
comment'' instructions. Attachments should be in Microsoft Word, 
Microsoft Excel, or Adobe PDF; however, we prefer Microsoft Word.
    2. By regular mail. Please allow sufficient time for mailed 
comments to be received before the close of the comment period. You may 
mail written comments to the following address: Department of Health 
and Human Services, Office of the National Coordinator for Health 
Information Technology, Attention, RFI Regarding Assessing 
Interoperability for MACRA, 330 C Street SW., Room 7025A, Washington, 
DC 20201. Please submit one original and two copies.
    3. By express or overnight mail. You may send written comments to 
the following address: Department of Health and Human Services, Office 
of the National Coordinator for Health Information Technology, 
Attention, RFI Regarding Assessing Interoperability for MACRA, 330 C 
Street SW., Room 7025A, Washington, DC 20201. Please submit one 
original and two copies.
    4. By hand or courier. Alternatively, you may deliver (by hand or 
courier) your written comments ONLY to the following address: 
Department of Health and Human Services, Office of the National 
Coordinator for Health Information Technology, Attention, RFI Regarding 
Assessing Interoperability for MACRA, 330 C Street SW., Room 7025A, 
Washington, DC 20201.
    If you intend to deliver your comments to this address, contact 
202-205-8417 in advance to schedule your arrival with one of our staff 
members.

[[Page 20652]]

Comments erroneously mailed to the addresses indicated as appropriate 
for hand or courier delivery may be delayed and received after the 
comment period.
    Enhancing the Public Comment Experience: We will make a copy of 
this document available in Microsoft Word format in order to make it 
easier for commenters to access and copy portions of the RFI for use in 
their individual comments. Additionally, a separate document will be 
made available for the public to use to provide comments. This document 
is meant to provide the public with a simple and organized way to 
submit comments and respond to specific questions posed in the RFI. 
While use of this document is entirely voluntary, we encourage 
commenters to consider using the document in lieu of unstructured 
comments or to use it as an addendum to narrative cover pages. We 
believe that use of the document may facilitate our review and 
understanding of the comments received. The Microsoft Word version of 
this RFI and the document that can be used for providing comments can 
be found on ONC's Web site (http://www.healthit.gov).

FOR FURTHER INFORMATION CONTACT: Talisha Searcy, Office of Policy, 
Evaluation & Analysis, ONC, 202-205-8417, [email protected]. 
Vaishali Patel, Office of Policy, Evaluation & Analysis, ONC, 202-603-
1239, [email protected].

SUPPLEMENTARY INFORMATION:
    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. 
Follow the search instructions on that Web site to view public 
comments.
    Comments received timely will also be available for public 
inspection, generally beginning approximately 3 weeks after publication 
of a document at Office of the National Coordinator for Health 
Information Technology, 330 C Street SW., Room 7025A, Washington, DC 
20201. Contact Talisha Searcy, listed above, to arrange for inspection.

I. Background

Overview of MACRA Section 106(b)(1)

    In section 106(b)(1) of the Medicare Access and CHIP 
Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 
2015), Congress declares it a national objective to achieve widespread 
exchange of health information through interoperable certified 
electronic health record (EHR) technology nationwide by December 31, 
2018. Section 106(b)(1)(C) of the MACRA provides that by July 1, 2016, 
and in consultation with stakeholders, the Secretary of Health and 
Human Services (HHS) shall establish metrics to be used to determine if 
and to the extent this objective has been met. Section 106(b)(1)(D) of 
the MACRA provides that if the Secretary determines that this objective 
has not been achieved by December 31, 2018, then by December 31, 2019 
the Secretary shall submit a report to Congress that identifies 
barriers to this objective and recommends actions that the Federal 
Government can take to achieve it.
    The Secretary of HHS will delegate authority to carry out the 
provisions of section 106(b)(1) of the MACRA to the Office of the 
National Coordinator for Health Information Technology (ONC). ONC is 
committed to advancing interoperability of health information and has 
developed a roadmap with stakeholder input, entitled Connecting Health 
and Care for the Nation: A Shared Nationwide Interoperability Roadmap 
(Interoperability Roadmap), which lays out the milestones, calls to 
action and commitments that public and private stakeholders should 
focus on achieving.1 2 The Interoperability Roadmap also 
specifies that ONC will report on the nation's progress towards 
interoperability.
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    \1\ Connecting Health and Care for the Nation: A Shared 
Nationwide Interoperability Roadmap Version 1.0. https://www.healthit.gov/policy-researchers-implementers/interoperability.
    \2\ Connecting Health and Care for the Nation: A Shared 
Nationwide Interoperability Roadmap--Version 1.0, BuzzBlog. http://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/interoperability-electronic-health-and-medical-records/connecting-health-care-nation-shared-nationwide-interoperability-roadmap-version-10.
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    ONC is issuing this RFI is to solicit input on the following three 
topics, which are described in the comments section (Section II) of the 
RFI:
    (1) Measurement population and key components of interoperability 
that should be measured;
    (2) Current data sources and potential metrics that address section 
106(b)(1) of the MACRA; and
    (3) Other data sources and metrics ONC should consider with respect 
to section 106(b)(1) of the MACRA or interoperability measurement more 
broadly.

II. Solicitation of Comments

Scope of Measurement: Defining Interoperability and Population

    In order to establish metrics that will assess whether, and the 
extent to which, widespread exchange of health information through 
interoperable certified EHR technology nationwide has occurred, ONC 
needs to first define the scope of measurement.
    Section 106(b)(1)(B) of the MACRA describes key components of 
interoperability that should be measured and the population that should 
be the focus of measurement. Section 106(b)(1)(B)(ii) of the MACRA 
defines interoperability as the ability of two or more health 
information systems or components to: (1) Exchange clinical and other 
information and (2) use the information that has been exchanged using 
common standards to provide access to longitudinal information for 
health care providers in order to facilitate coordinated care and 
improve patient outcomes. We believe appropriate metrics should address 
both of these aspects of interoperability. Section 106(b)(1)(B)(i) of 
the MACRA defines ``widespread interoperability'' as interoperability 
between certified EHR technology systems employed by meaningful EHR 
users under the Medicare and Medicaid EHR Incentive Programs and other 
clinicians and health care providers on a nationwide basis.
    ONC intends to consider metrics that address the specific 
populations and aspects of interoperable health information as 
described above and in section 106(b)(1)(B) of the MACRA. Thus, ONC 
plans to assess interoperability among ``meaningful EHR users'' and 
clinicians and health care providers with whom they exchange clinical 
and other information--their exchange partners. Note that the exchange 
partners do not have to be ``meaningful EHR users'' themselves. 
Additionally, ONC plans to measure interoperability by identifying 
measures that relate to both exchange of health information as well as 
use of information that has been exchanged using common standards. More 
specifically, ONC seeks to measure the interoperable exchange and use 
of information by examining the following:

[[Page 20653]]

electronically sending; receiving; finding (e.g., request or querying); 
integrating (e.g., incorporating) information received into a patient's 
medical record; and the subsequent use of information received 
electronically from outside sources.
    ONC expects that the scope of the metrics established pursuant to 
section 106(b)(1)(C) of the MACRA will support overarching 
interoperability measurement. However, ONC recognizes the need to 
measure interoperability across populations and settings beyond those 
specified by section 106(b)(1)(B) of the MACRA. The last chapter of the 
Interoperability Roadmap details ONC's plans for measuring 
interoperability across a variety of populations and settings, 
including proposed measures and accompanying timeframes.\3\
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    \3\ Connecting Health and Care for the Nation: A Shared 
Nationwide Interoperability Roadmap Version 1.0. https://www.healthit.gov/policy-researchers-implementers/interoperability.
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    In summary, under section 106(b)(1)(B)(i) of the MACRA, ONC 
believes the scope of the measurement should be limited to ``meaningful 
EHR users'' and their exchange partners. ONC believes this should 
include eligible professionals, eligible hospitals, and critical access 
hospitals (CAHs) that attest to meaningful use of certified EHR 
technology under CMS' Medicare and Medicaid EHR Incentive Programs. ONC 
would measure interoperability for section 106(b)(1)(B) of the MACRA by 
assessing the extent to which ``meaningful EHR users'' are 
electronically sending, receiving, finding, integrating information 
that has been received within an EHR, and subsequently using 
information they receive electronically from outside sources. Thus, 
this RFI focuses on obtaining input on measures that address these 
aspects of interoperability for the specified populations. Although 
this RFI seeks to obtain input on proposed measures that address 
section 106(b)(1)(B) of the MACRA, ONC also plans to measure 
interoperability across a variety of settings and populations, as well 
as barriers to interoperability in order to evaluate progress for the 
Interoperability Roadmap. ONC is requesting input regarding the 
provisions of section 106(b)(1) of the MACRA. Below are a specific set 
of questions related to those provisions.
    Questions: We would appreciate comments you may have in response to 
some or all of the questions below. We also welcome any additional 
comments related to Section 106(b)(1) of the MACRA that you may want us 
to consider.
     Should the focus of measurement be limited to ``meaningful 
EHR users,'' as defined in this section (e.g., eligible professionals, 
eligible hospitals, and CAHs that attest to meaningful use of certified 
EHR technology under CMS' Medicare and Medicaid EHR Incentive 
Programs), and their exchange partners? Alternatively, should the 
populations and measures be consistent with how ONC plans to measure 
interoperability for the assessing progress related to the 
Interoperability Roadmap? For example, consumers, behavioral health, 
and long-term care providers are included in the Interoperability 
Roadmap's plans to measure progress; however, these priority 
populations for measurement are not specified by section 
106(b)(1)(B)(i) of the MACRA.
     How should eligible professionals under the Merit-Based 
Incentive Payment System (MIPS) and eligible professionals who 
participate in the alternative payment models (APMs) be addressed? 
Section 1848(q) of the Social Security Act, as added by section 101(c) 
of the MACRA, requires the establishment of a Merit-Based Incentive 
Payment System for MIPS eligible professionals (MIPS eligible 
professionals).
     ONC seeks to measure various aspects of interoperability 
(electronically sending, receiving, finding and integrating data from 
outside sources, and subsequent use of information electronically 
received from outside sources). Do these aspects of interoperability 
adequately address both the exchange and use components of section 
106(b)(1) of the MACRA?
     Should the focus of measurement be limited to use of 
certified EHR technology? Alternatively, should we consider measurement 
of exchange and use outside of certified EHR technology?

ONC's Available Data Sources and Potential Measures

    ONC is considering using a combination of the data sources to 
evaluate interoperability from two different perspectives: (1) By 
provider, based upon the proportion of ``meaningful EHR users'' 
exchanging information with other clinicians and health care providers 
and subsequently using electronic health information that has been 
exchanged; and (2) by transactions (e.g., volume of exchange activity), 
based upon the proportion of care transitions and encounters where 
information is electronically exchanged and used. ONC's currently 
available data sources that will enable evaluation from these two 
perspectives include: (1) National survey data from key stakeholder 
organizations and federal entities; and (2) CMS's Medicare and Medicaid 
EHR Incentive Programs data. We describe these data sources further 
below.
    ONC recognizes that its currently available data sources might not 
be sufficient to fully measure and determine whether the goal of 
widespread exchange of health information through interoperable 
certified EHR technology has been achieved. ONC's currently available 
data sources are largely limited to eligible professionals, eligible 
hospitals, and CAHs as defined under the current Medicare and Medicaid 
EHR Incentive Programs. Therefore, ONC is requesting input on these 
measures and data sources, and is requesting feedback on additional 
national data sources which may be available for this purpose.

Measures Based Upon National Survey Data

    ONC is considering using nationally representative surveys of 
hospitals and office-based physicians to evaluate progress related to 
the interoperable exchange of health information from the health care 
provider perspective. ONC collaborates with the American Hospital 
Association (AHA) to conduct the AHA Health IT Supplement Survey and 
with the National Center for Health Statistics (NCHS) to conduct the 
National Electronic Health Record Survey of office-based physicians. 
Both surveys have relatively high response rates and convey health care 
providers' perspectives on exchange and interoperability (e.g., 
proportion of health care providers exchanging and subsequently using 
health information that has been exchanged). The survey measures 
electronic exchange with ``outside'' providers not part of their 
organization. The measures of electronic exchange specifically exclude 
e-fax, scanned documents or other forms of unstructured data. In 
addition, multiple years of survey data will be available for both 
populations, which will support examining trends. However, these self-
reported data are subject to potential biases, do not reflect all types 
of health care providers, and do not report on transaction-based 
measures of exchange activity.
    Using these national survey data, ONC is considering the following 
measures below for both hospitals and office-based physicians.
     Proportion of health care providers who are electronically 
sending, receiving, finding, and easily integrating key health 
information, such as summary of care records. This can be a

[[Page 20654]]

composite measure (engaging in all four aspects of interoperable 
exchange) or separate, individual measures.
     Proportion of health care providers who use the 
information that they electronically receive from outside providers and 
sources for clinical decision-making.
     Proportion of health care providers who electronically 
perform reconciliation of clinical information (e.g. medications).
    Based upon data collected in 2014, approximately one-fifth of non-
federal acute care hospitals electronically sent, received, found 
(queried) and were able to easily integrate summary of care records 
into their EHRs.\4\ Similar data for office-based physicians will be 
available in 2016. Starting in 2015 for hospitals and 2016 for office-
based physicians, the surveys will also collect information on the 
subsequent usage of information that is received from outside sources. 
These data will be available in 2016 and 2017 for hospitals and office-
based physicians, respectively. Given that the response rate of survey 
items that assess the use of information from outside sources is 
unknown, an alternative measure to assess downstream use of information 
that is exchanged relates to reconciliation of clinical information. 
The reconciliation measure has been available since 2014 for office-
based physicians. For hospitals, the survey has assessed capability to 
electronically conduct reconciliations since 2014; the survey has not 
assessed whether hospitals have used that functionality. If this 
measure were to be selected, this new measure would have to be added to 
the 2016 hospital survey, which would be available in 2017.
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    \4\ Charles D, Swain M Patel V. (August 2015) Interoperability 
among U.S. Non-federal Acute Care Hospitals. ONC Data Brief, No. 25 
ONC: Washington DC. https://www.healthit.gov/sites/default/files/briefs/onc_databrief25_interoperabilityv16final_081115.pdf.
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    ONC could also use data from national surveys to evaluate whether 
hospitals and office-based physicians are unable to widely share and 
use health information, and to identify what barriers to interoperable 
exchange exist. This would provide contextual information regarding 
whether interoperability is progressing as expected. For example, in 
2014, hospitals reported a number of barriers they faced in exchanging 
and using interoperable health information.\5\
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    \5\ Ibid.
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Questions

     Do the survey-based measures described in this section, 
which focus on measurement from a health care provider perspective (as 
opposed to transaction-based approach) adequately address the two 
components of interoperability (exchange and use) as described in 
section 106(b)(1) of the MACRA?
     Could office-based physicians serve as adequate proxies 
for eligible professionals who are ``meaningful EHR users'' under the 
Medicare and Medicaid EHR Incentive Programs (e.g. physician assistants 
practicing in a rural health clinic or federally qualified health 
center led by the physician assistant)?
     Do national surveys provide the necessary information to 
determine why electronic health information may not be widely 
exchanged? Are there other recommended methods that ONC could use to 
obtain this information?

CMS Medicare and Medicaid EHR Incentive Programs Measures

    CMS Medicare and Medicaid EHR Incentive Program data could 
potentially be a useful data source as it consists of the population 
and measures aspects of interoperability as described in section 
106(b)(1)(B) of the MACRA. However, there are limitations associated 
with these data for addressing both the exchange and use components of 
section 106(b)(1) of the MACRA. One primary limitation is that 
differences exist in how CMS currently receives performance data from 
each of the Medicare and Medicaid EHR Incentive Programs. Currently, 
Medicare collects and reports on performance data for each individual 
eligible professional, eligible hospital, and CAH. However, performance 
data is not available for each individual Medicaid eligible 
professional, eligible hospital, or CAH as the Medicaid EHR Incentive 
Program is operated by the states. Thus, ONC would not be able to 
evaluate interoperability across individual health care providers or 
transactions for the Medicaid EHR Incentive Program, unless it obtained 
these data from each state individually.
    Additionally, not all aspects of health information exchange can be 
measured using the CMS EHR Incentive Programs data. The purpose of this 
meaningful use objective is to ensure a summary of care record is sent 
to the receiving provider when a patient is transitioning to a new 
provider. However these data do not assess whether a summary of care 
record was electronically received by the receiving provider.
    Based upon CMS EHR Incentive Programs data, ONC is considering the 
following measures listed below.\6\ These measures could be used to 
evaluate the exchange and use aspects of interoperability as described 
in section 106(b)(1)(B) of the MACRA.
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    \6\ Medicare and Medicaid Programs; Electronic Health Record 
Incentive Program-Stage 3 and Modifications to Meaningful Use in 
2015 Through 2017. https://www.federalregister.gov/articles/2015/10/16/2015-25595/medicare-and-medicaid-programs-electronic-health-record-incentive-program-stage-3-and-modifications.
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     Proportion of transitions of care or referrals where a 
summary of care record was created using certified EHR technology and 
exchanged or transmitted electronically.
     For 2017 and subsequent years, the proportion of 
transitions or referrals and patient encounters in which the health 
care provider is the recipient of a transition or referral or has never 
before encountered the patient, and where the health care provider 
(e.g., eligible professional, eligible hospital, or CAH) receives, 
requests or queries for an electronic summary of care document to 
incorporate into the patient's record.
     Proportion of transitions of care where medication 
reconciliation is performed.
     For 2017 and subsequent years, the proportion of 
transitions or referrals received and patient encounters in which the 
health care provider is the recipient of a transition or referral or 
has never before encountered the patient, and the health care provider 
performs clinical information reconciliation for medications, 
medication allergies, and problem lists.
    Reconciliation may include both automated and manual processes to 
allow the receiving provider to work with both electronic data and with 
the patient to reconcile their health information. The assumption 
underlying including this measure is that although some portion of the 
medication reconciliation processes may be occurring manually, it 
should be facilitated by the electronic exchange of clinical data, and 
therefore may serve as an adequate proxy for assessing use of 
information that is exchanged.\7\
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    \7\ Medicare and Medicaid Programs; Electronic Health Record 
Incentive Program-Stage 3 and Modifications to Meaningful Use in 
2015 Through 2017. https://www.federalregister.gov/articles/2015/10/16/2015-25595/medicare-and-medicaid-programs-electronic-health-record-incentive-program-stage-3-and-modifications. See page 62810.
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Questions

     Given some of the limitations described above, do these 
potential measures adequately address the ``exchange'' component of 
interoperability required by section 106(b)(1) of the MACRA?

[[Page 20655]]

     Do the reconciliation-related measures serve as adequate 
proxies to assess the subsequent use of exchanged information? What 
alternative, national-level measures (e.g., clinical quality measures) 
should ONC consider for assessing this specific aspect of 
interoperability?
     Can state Medicaid agencies share health care provider-
level data with CMS similar to how Medicare currently collects and 
reports on these data in order to report on progress toward widespread 
health information exchange and use? If not, what are the barriers to 
doing so? What are some alternatives?
     These proposed measures evaluate interoperability by 
examining the exchange and subsequent use of that information across 
encounters or transitions of care rather than across health care 
providers. Would it also be valuable to develop measures to evaluate 
progress related to interoperability across health care providers, even 
if this data source may only available for eligible professionals under 
the Medicare EHR Incentive Program?

 Identifying Other Data Sources to Measure Interoperability

    ONC acknowledges that other data sources might exist that could aid 
in the measurement of interoperability. For example, other potential 
data sources are Medicare Fee-For-Service (FFS) claims data as well as 
performance data from other programs. Section 1848(q)(2)(B) of the 
Social Security Act, as added by section 101(c) of the MACRA, describes 
the measures and activities for each of the four performance categories 
under the Merit-Based Incentive Payment System (MIPS), which includes 
meaningful use of certified EHR technology. These measures may also 
serve as a potential data source for assessing progress related to 
interoperability for MIPS eligible professionals. As the MIPS Program 
is implemented, ONC will be assessing whether any measures could be 
used for this purpose. Additionally, some of the information used to 
evaluate the performance of eligible professionals who participate in 
the alternative payment models (APMs) may also help inform progress 
related to interoperability.
    Additionally, ONC is considering use of electronically-generated 
data from certified EHR technology or other systems, such as log-audit 
data, or leveraging surveys of entities that enable exchange to 
evaluate progress related to widespread electronic information exchange 
and use. ONC recognizes this will require collaboration and 
coordination with federal entities and stakeholders across the 
ecosystem including entities that enable exchange and interoperable 
health information use, such as technology developers, Health 
Information Organizations (HIOs) and Health Information Service 
Providers (HISPs).

Overarching Questions

     Should ONC select measures from a single data source for 
consistency, or should ONC leverage a variety of data sources? If the 
latter, would a combination of measures from CMS EHR Incentive Programs 
and national survey data of hospitals and physicians be appropriate?
     What, if any, other measures should ONC consider that are 
based upon the data sources that have been described in this RFI?
     Are there Medicare claims based measures that have the 
potential to add unique information that is not available from the 
combination of the CMS EHR Incentive Programs data and survey data?
     If ONC seeks to limit the number of measures selected, 
which are the highest priority measures to include?
     What, if any, other national-level data sources should ONC 
consider? Do technology developers, HISPs, HIOs and other entities that 
enable exchange have suggestions for national-level data sources that 
can be leveraged to evaluate interoperability for purposes of section 
106(b)(1) of the MACRA (keeping in mind the December 31, 2018 deadline) 
or for interoperability measurement more broadly?
     How should ONC define ``widespread'' in quantifiable terms 
across these measures? Would this be a simple majority, over 50%, or 
should the threshold be set higher across these measures to be 
considered ``widespread''?

III. Collection of Information Requirements

    This document does not impose information collection requirements, 
that is, reporting, recordkeeping or third-party disclosure 
requirements. Consequently, there is no need for review by the Office 
of Management and Budget under the authority of the Paperwork Reduction 
Act of 1995 (44 U.S.C. 3501 et seq.).

IV. Response to Comments

    ONC typically receives a large public response to its published 
Federal Register documents. ONC will consider all comments received by 
the date and time specified in the ``DATES'' section of this document, 
but will not be able to acknowledge or respond individually to public 
comments.

    Dated: April 1, 2016.
Karen DeSalvo,
National Coordinator, Office of the National Coordinator for Health 
Information Technology.
[FR Doc. 2016-08134 Filed 4-7-16; 8:45 am]
 BILLING CODE 4150-45-P