Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. MDS Stakeholder Letters

12/01/2011

July 25, 2003

Barbara Paul, MD
Director
Quality Measurement and Health Assessment Group
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Dr. Paul:

The undersigned organizations, representing key constituencies in the Resident Assessment Instrument (RAI) process, would like to request a meeting with you and any staff members you choose to include.

We believe it is critical that we discuss a number of issues regarding revision of the MDS as soon as possible. From our vantage point, the current direction for the instrument’s evolution appears to be leading toward a tool that is increasingly driven primarily by program support needs. We firmly believe that the MDS must retain a resident focus and that the paramount objective in redesign must be to improve the quality of information to facilitate accurate, comprehensive resident assessment and care planning, consistent with the law, current regulations, current standards of practice and the best available science on quality care for the populations served in nursing homes.

While keeping this goal primary in our minds, we must also strive to ensure that the critical information is being collected not only to support current quality measurement and payment needs, but also to ensure that revisions to the system give us the capacity to improve and strengthen these systems in the future through the collection of better data that provides more robust information for these purposes.

Specifically, we would like to address the following issues with you:

  • The need to re-assess the major goals for the instrument and engage with key stakeholder groups in a clear articulation of a unified vision and objectives for the MDS.

  • The need to assess the current charge for the contract team engaged to work with CMS on this effort, in light of a clear consensus on vision and direction, as well as whether the resources devoted to this effort and the timeline for its completion are realistic.

  • The need to coordinate this activity with the rapidly unfolding HHS efforts to facilitate improved information technology capacity and the widespread adoption of electronic health information systems.

We are very concerned that if these key issues are not addressed prior to finalizing major MDS 3.0 design decisions, the new instrument will fall short of its potential and lack stakeholder support. Given the investment of significant resources on the part of all concerned parties to make this transition, it would be most unfortunate if this historic opportunity to significantly improve the process were lost.

We are eager to meet with you prior to the planned August 25-26 meeting of the Technical Expert Panel that will be advising the contract team on their work. We would like to suggest a date sometime during the weeks of August 4th or 11th.

Please contact Ruta Kadonoff at (202) 508-9450, rkadonoff@aahsa.orgor, during the week of July 28-August 1, Evvie Munley at (202) 508 9478, emunley@aahsa.org, who will be happy to work with you or a member of your staff to coordinate a mutually convenient date and time. We look forward to your response.

Sincerely,

American Association of Homes and Services for the Aging
American Association of Nurse Assessment Coordinators
American Hospital Association
American Health Care Association
Catholic Health Association
National Association of Directors of Nursing Administration in Long-Term Care
National Association of Subacute and Post-Acute Care
National Citizens Coalition for Nursing Home Reform
National Hospice and Palliative Care Association

Cc: Tom Scully, CMS Administrator

 

May 21, 2004

Sean Tunis, MD
Chief Clinical Officer and Director, Office of Clinical Standards and Quality
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Dr. Tunis:

The undersigned organizations, representing key constituencies in the Resident Assessment Instrument (RAI) process, would like to express our continuing concerns about plans for development of the Minimum Data Set (MDS), version 3.0. We would appreciate the opportunity to meet with you and key staff working on this project as soon as possible.

As you are likely aware, we approached CMS in August of last year to voice our concerns with regard to the direction of the MDS 3.0 development process and to make recommendations on revising the project in order to better meet the needs of key stakeholders.

We appreciate the update that was provided on April 7th of this year, detailing CMS work since August, primarily on one of the key issues that was raised in our August meeting. We are pleased with the extensive efforts to better coordinate the MDS revision process with concurrent work on development of electronic medical records technology and standards. Ultimately, the seamless integration of the MDS with electronic medical records systems will greatly reduce the paperwork burden on professional nursing care staff and improve quality of care for residents as well as accurate information for CMS program objectives. CMS efforts to ensure that the next iteration of the MDS helps to begin moving providers in the direction of this ultimate goal are critical to fostering these evolving technologies and their diffusion in the long-term care setting.

We remain concerned, however, that other key issues that we raised in our August meeting do not seem to be figuring prominently in the current plans, as conveyed to us on April 7th.

We reiterate our firm belief that the MDS must be resident-focused and that the paramount objective in making revisions must be to improve the quality of information collected to facilitate accurate, comprehensive resident assessment and care planning, consistent with the law, current regulations, current standards of practice and the best available science on quality care for the populations served in nursing homes.

While keeping this goal primary in our minds, we must also strive to ensure that the critical information is being collected not only to support current quality measurement and payment needs, but also to ensure that revisions give us the capacity to improve and strengthen these systems in the future through the collection of better data that provides more robust information for these purposes.

In particular, the following three issues, which we raised with CMS last August, do not appear to be a part of the current work plans as we understand them.

  • The vision, goals and objectives for the MDS must be clearly defined. Objectives must be prioritized, in order to ensure that decisions about items that are/are not to be included are based on a clear and rational set of criteria specifying how competing priorities are to be reconciled. The methodology that will be used for achieving and maintaining the clinical relevance of the MDS in accordance with evolving standards of care must also be defined.

  • The current effort fails to take into account and prioritize all of the purposes that the MDS data are expected to serve. The first step in the process of re-design should be to pose open-ended questions about what information, if collected, could improve the instrument’s utility for one or more of its primary or secondary purposes -- assessment, care planning, quality measurement, payment, support of regulatory activities, and research.

  • We must strive to improve the instrument’s ability to meet the needs of specific types of residents (e.g., long-term, post-acute, end-of-life/palliative care, non-elderly adults, pediatric) by targeting specific questions through the use of skip patterns or a modular approach to the form. The diverse residents in nursing homes are not well-served by a one-size-fits-all approach to assessment.

Finally, we would like to see CMS working in greater collaboration with key stakeholders. The time span between our initial meeting in August of 2003 and the first follow-up in April of 2004 concerns us, as does the latest communication we received from Bob Connolly. In his recent e-mail to our group, Connolly notes that an every-other-month or quarterly schedule of calls/meetings had been proposed by many of the stakeholders on the April 7th call. He went on to state that, “we likely won’t have much to report in the next 2-3 months,” and that CMS would not yet be scheduling another follow-up.

We urge CMS to engage more directly with our groups and other stakeholders as partners in this effort. We would appreciate being a part of design and planning efforts, with an opportunity to engage in dialogue and planning with CMS rather than merely reacting to reports on the work completed. We believe this would also be to CMS’ advantage, in that it would help to guide this effort in a direction that will be more likely to achieve the support and buy-in from the ultimate users and beneficiaries of this work, which will be critical to its acceptance.

We continue to be very concerned that if the key issues we have raised are not addressed prior to finalizing major decisions about the design of MDS 3.0, the new instrument will fall short of its potential and lack support. Given the investment of significant resources on the part of all concerned parties to make this transition, it would be most unfortunate if this historic opportunity to significantly improve the process were lost.

Accompanying this letter are our thoughts on proposed vision and mission statements for MDS, as well as a copy of the memo we provided at our August meeting, which summarizes our issues and makes specific recommendations as to how they might be addressed. We continue to believe that these recommendations outline critical steps that must take place prior to investment in field testing of an instrument. Key questions remain unaddressed in the process as we have seen it unfold to date -- what information do we need, about which residents, for what purposes? We need experts in clinical care, quality measurement and payment/resource utilization to come to consensus on answers to these questions first, then identify how each of the needed elements should ideally be collected -- via the MDS, via some other data collection tool (e.g., an independent, quality of life/satisfaction resident survey), or via electronic health records at a point when they are widely adopted.

We would appreciate the opportunity to meet with you as soon as possible to discuss these issues and develop plans for how they might be addressed. Please contact Ruta Kadonoff at (202) 508-9450, rkadonoff@aahsa.org, who will be happy to work with you or a member of your staff to coordinate a mutually convenient date and time. We look forward to your response.

Sincerely,

American Association of Homes and Services for the Aging
American Association of Nurse Assessment Coordinators
American Health Care Association
American Hospital Association
American Medical Directors Association
Catholic Health Association
National Association of Directors of Nursing Administration in Long-Term Care
National Citizens’ Coalition for Nursing Home Reform
National Hospice and Palliative Care Organization

Cc: Trent Haywood
Lisa Hines

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