To put our comments in perspective, we would like to provide some background on Emdeon and our role in connecting every facet of the U.S. healthcare system today. Emdeon is a health information intermediary that connects consumers, providers, pharmacies and payers to facilitate financial, administrative and clinical health information exchange. We are the largest financial and administrative healthcare information exchange in the nation, and our clinical exchange volumes are growing dramatically with an annual run rate of 100 million e-prescriptions and 30 million clinical messages (test orders and results) per year. In total, we facilitate over 5 billion healthcare information exchanges each year. The Emdeon network connects 155 million consumers, 500,000 physicians, 81,000 dentists, 55,000 pharmacies, 5,000 hospitals and 1,200 payers. This secure and interoperable network is vital to the daily function of the U.S. healthcare system.

Emdeon takes this role very seriously. We are committed to helping our customers meet the requirements of Meaningful Use and ensuring that there are flexible and cost-effective ways for them to do so. Towards that end, we would like to offer the following recommendations on the proposed rules based on our 30 years of experience in healthcare information technology (HIT) and based on the direct feedback we have received from our customers and business partners regarding the Meaningful Use regulations.

Recommendation 1: Prorated Incentive Payments

A number of organizations that represent our core customer base have expressed significant concerns about the impact of certain provisions in the proposed Meaningful Use definitions and certification criteria. For example, the American Academy of Family Physicians (AAFP) has stated that some aspects of the regulations are "unworkable, excessive or redundant and will actually impede the goals of the legislation." Emdeon supports the AAFP’s concerns, particularly as they relate to the impact on small physician practices. We agree that the "all or nothing" approach to achieving Meaningful Use could serve to discourage practices who cannot meet 100% of the criteria, and we support the idea of offering a "partial incentive for partial Meaningful Use."

Specifically, if an eligible provider or hospital meets 20 out of 25 criteria, we would like to see them receive a prorated incentive payment. We believe that this more flexible approach would encourage more adoption. If an all or nothing approach is taken, providers may not want to take the risk, particularly if the requirements are unclear or viewed as unobtainable.

Recommendation 2: Smaller Baseline Set of Measures for Stage 1; Lower Percentage Thresholds

Along similar lines, we suggest that CMS fine-tune its approach to Meaningful Use to ensure that it will actually incentivize the greatest number of providers to adopt and use interoperable electronic health records (EHRs). We would recommend that CMS begin Stage 1 with a smaller baseline set of measures, plus optional criteria in each of the categories to encourage more providers to start the adoption process earlier. If the requirements are too stringent and detailed in Stage 1, many providers and hospitals may simply opt out because the bar is set too high.

We agree with the observations made by the Health Information Management Systems Society (HIMSS) that the 80% threshold required under many of the criteria is very difficult to attain, particularly when providers and hospitals are having to learn new workflows when implementing EHRs. As noted earlier, we are especially concerned about small physician practices or rural facilities that may not have been exposed to this kind of technology before now. It will be hard to go from zero to 80% electronic transactions during such a short implementation window. Thus, we recommend lowering the percentage threshold to 50% which is more consistent with current industry adoption averages.

Recommendation 3: Leverage Existing Systems to Achieve Meaningful Use

Recently the Medical Group Management Association (MGMA) reported that 68 percent of physician respondents believe that physician productivity will actually decrease with the implementation of a new EHR. While Emdeon believes that EHR systems will ultimately lead to improved quality and efficiency, we understand that in the short-term, cost and complexity remain significant barriers to adoption. Thus, we support efforts offer flexibility to providers, including a modular certification option that allows providers to leverage systems that may already be in place rather than forcing them to buy and implement a single system that might be overly disruptive to their current workflow.

Recommendation 4: Continue to Foster Administrative Simplification

Emdeon supports the inclusion of claims and eligibility transactions as part of the criteria for Meaningful Use. Emdeon believes that the inclusion of these two administrative simplification requirements represent significant progress in how to approach health information exchange as uses for clinical and financial data begin to converge. Furthermore, a significant number of providers and hospitals are already conducting these transactions electronically, so these transactions could actually help providers and hospitals achieve Meaningful Use, even if they are not conducted as part of a single EHR solution.

We agree with the Council for Affordable Quality Healthcare (CAQH) recommendation that CMS clarify that these transactions can occur either inside or outside of an EHR system, including through practice management or other software systems. This will give providers and hospitals the greatest flexibility in meeting the criteria and thus foster higher levels of adoption.

We do, however, recommend lowering the percentage from 80 to 50 for these transactions to be more consistent with industry practices and avoid a disproportionate burden on small or rural practices that lack information technology resources. According to the U.S. Healthcare Efficiency Index™ findings from Phase 1, adoption of electronic eligibility currently stands at about 40% across the industry.

Recommendation 5: Evaluate Meaningful Use Timelines in Context of Other HIT Compliance Deadlines

Emdeon is very concerned about the impact of converging compliance timelines on the medical community, again with particular concern for small physician practices and rural medical facilities. Deadlines for Meaningful Use, associated Standards and Certification Criteria and implementation of X-12 5010, and ICD-10 will create a "perfect storm" of resource requirements that could ultimately hinder adoption of EHRs. We recommend that final deadlines for the stages of Meaningful Use be developed in the context of the other HIT compliance timelines.

Recommendation 6: Work with the Drug Enforcement Agency on Finalizing Rules for e-Prescribing of Controlled Substances

e-Prescribing is an integral part of Meaningful Use, Emdeon understands from our provider and pharmacy customers that there is still a major barrier that exists for adoption of e-prescribing. The Drug Enforcement Agency (DEA) has been working for some time on regulations regarding e-prescribing of controlled substances. These regulations were expected to be released by the end of 2009, but to date, the regulations are still pending. Thus, prescriptions for this class of drugs must be written on paper. This creates a dual tracking requirement for providers that remains a significant barrier to e-prescribing. Since pain medications, for example, represent a significant portion of prescriptions for certain specialties, this barrier will be very difficult to overcome until the regulations are complete. We strongly encourage the Department of Health and Human Services and the Centers for Medicare and Medicaid to work with the White House and the DEA to finalize the controlled substances rule and remove this obstacle for physicians.

As the various agencies work to bring resolution to the controlled substances issue, they can learn from experience in the state of Massachusetts. The Massachusetts Department of Public Health has been awarded a 3-year $1.2M grant to develop and study security systems which would allow the safe, secure, and efficient transmission of electronic prescriptions for controlled substances (specifically Schedule II-V drugs) from the provider to the pharmacy. eRx Network, an Emdeon company, was chosen to provide the e-prescribing network infrastructure for this project.

Once again, we greatly appreciate the opportunity to comment on these proposed rules. We understand the complexity and the challenge associated with implementing such a large-scale effort in such a short period of time. We also understand that the process will be evolutionary based on lessons learned in the early stages of implementation. It is very encouraging to see such an open and participatory process and the high level of engagement among stakeholders across the industry. We look forward to working with you and our industry colleagues to achieve truly "meaningful" Meaningful Use.