AMIA Supports Informatics Policies in CMS Payment Proposals

Tuesday, September 6, 2016

MU alignment for hospitals welcome; additional work needed for ‘Appropriate Use’ policies, informatics experts say

(BETHESDA, MD) — In comments submitted to the Centers for Medicare & Medicaid Services (CMS) today, the nation’s leading clinical informaticians submitted several recommendations, across a pair of proposed rules, meant to improve the use of health IT in providing better, safer care.

In comments regarding the 2017 Physician Fee Schedule, officials from the American Medical Informatics Association (AMIA) urged CMS to target 2019 for the implementation of a complex, new program called the Medicare Appropriate Use Criteria (AUC) Program. Separately, the organization supported CMS efforts to improve participation in and align EHR Incentive Program requirements for hospitals with similar proposals for physicians participating in MIPS beginning in 2017.

For the last two years, CMS has sought input from stakeholders through the Physician Fee Schedule on how to implement the Medicare AUC Program, mandated by the Protecting Access to Medicare Act of 2014. The Medicare AUC Program requires professionals ordering imaging diagnostics for specific clinical conditions to consult computer-based “appropriate use criteria,” called AUC, which are supported by informatics tools, called clinical decision support mechanisms (CDSMs). The 2014 law also requires that information be reported on the claim form as to whether the service adhered to the AUC, in order for rendering professionals – such as radiologists – to be paid for the service. 

“AMIA supports the use of computer-based decision support to guide image ordering as an exemplar of how informatics tools and applications can assist clinicians at the point-of-care,” the organization said in comments. “By leveraging clinical decision support, founded on a range of data available through electronic health records, we believe the AUC Program can be a model for other informatics-informed approaches to improve health outcomes and lower costs.” 

However, AMIA officials warned CMS that its target date of 2018 for nationwide implementation would be difficult, if not impossible, for many organizations. “AMIA members voice strong concerns with the proposed timelines for implementation – from a policy-making, technology development and workflow integration perspective,” the comments stated. “AMIA strongly recommends CMS reconsider its timeframe for implementation, and target 2019 as the first year…of the Medicare AUC Program.”

Several aspects of the Medicare AUC Program are as yet unknown, such as how AUC scores will be presented to ordering professionals, or how they should be rendered on the claims form for furnishing professionals.  Additionally, CMS has proposed a system of recognizing “qualified” CDSMs for use in the program, but it is unclear how difficult it will be to gain this recognition and, subsequently, implement this functionality into clinicians’ workflows.  Ultimately, this program is meant to identify “outlier” clinicians who order excessive imaging diagnostics that do not meet evidenced-based appropriateness criteria, thus subjecting these clinicians to prior authorization requirements. For furnishing clinicians who do not follow AUC guidelines, CMS will ultimately refuse reimbursement.

“This program, while limited to specific orders, could have profound implications for how healthcare delivery is informed by informatics tools at the point of care,” said AMIA President & CEO Douglas B. Fridsma, M.D., Ph.D., FACP, FACMI.  “Further, this program represents a new front in payment reform by withholding reimbursement for services not considered ‘appropriate.’  We must proceed diligently.”

Through separate rulemaking for hospital payments CMS proposed a shortened 90-day reporting period for eligible hospitals and critical access hospitals participating in the EHR Incentive Program in 2016. The agency also suggested several changes to better align the program with proposed requirements for eligible clinicians participating in MIPS.

“AMIA generally supports reducing reporting burden and therefore supports eliminating the CDS and CPOE objectives and measures as CMS considers these objectives and measures to be ‘topped out.’ We also support CMS’ effort to ensure that the hospital reporting requirements are as consistent as possible with the EP requirements, which will minimize burden and confusion among both vendors and clinicians,” comments said.

CMS also asked stakeholders for feedback on how future years of the program should evolve for hospitals.  AMIA recommend that CMS augment future measures of meaningful use “based on proven functionalities, supported with clear evidence that such functionalities will improve care to patients. Future years of the program should seek to propagate new uses of health IT based on implementation experience across various settings, geographies and patient populations – not reflexively seek to usher unproven or unpiloted functionalities nationwide. Further, we encourage CMS to seek measures that benefit population health and research without encumbering individual patients or their clinicians.”

Click here for AMIA comments regarding the Physician Fee Schedule and the Medicare AUC Program. 

Click here for AMIA comments regarding the 2017 Outpatient Prospective Payment System.


AMIA, the leading professional association for informatics professionals, is the center of action for 5,000 informatics professionals from more than 65 countries. As the voice of the nation’s top biomedical and health informatics professionals, AMIA and its members play a leading role in assessing the effect of health innovations on health policy, and advancing the field of informatics. AMIA actively supports five domains in informatics: translational bioinformatics, clinical research informatics, clinical informatics, consumer health informatics, and public health informatics.