January 02, 2009
Mr. Tom Daschle
Mr. Tom Perez
Mr. Bill Corr
Ms. Nicole Lurie
Ms. Margaret Hamburg, MD
Re: Immediate policy issue for HHS/CMS, critical to advancing interoperable health
information technology (HIT) in long-term care, maintaining essential services, and not
wasting public & private resources
Dear Leaders of the Obama Transition:
This is to bring to your attention a critical need to change plans developed by the Centers for Medicare
and Medicaid Services (CMS) for implementing a required form in nursing homes in 2009. While we fully
support the use of this form (the “MDS 3.0”), current implementation plans call for use of a proprietary
format (impeding interoperability and wasting resources) and a timeline that doesn’t allow for the
development/installation of software. These problems can be solved by a needed change in current
policy (as described below). Doing so is essential to the new Administration’s agenda for advancing
Health Information Technology in long term care—a field where nursing homes alone accounted for over
$19B in Medicare spending & over $44B in Medicaid spending in 2005.
We write to you as enthusiastic supporters of the new Administration’s agenda for HIT, who represent
national associations representing America’s nursing homes, other providers across the aging services
continuum, physicians and nurses who care for nursing home residents, and vendors who develop and
supply software and other services to the field.
Issue 1: Interoperability and efficiency with use of standards for the MDS 3.0
Overview of MDS and the importance of standards: The MDS (Minimum Data Set) is a patient-
centric assessment form federally-mandated for use in nursing homes. The current version (MDS
2.0) is slated to be updated with a newer, better version 3.0. This assessment form contains patient
information used for essential care-planning and quality monitoring activities in nursing homes, for
state and federal payment systems, and for federally-mandated quality indicators. When the first
version was implemented 20 years ago, the nationally uniform assessment (then paper and pencil)
was a revolution in advancing quality. Electronic submission of these data to CMS was mandated in
1998. And today, in part because of these federal requirements, nursing home adoption of electronic
medical records compares favorably with that in hospitals and physician offices--but these EMRs are
still largely not interoperable. Interoperability requires the utilization of standards. The
implementation of MDS 3.0 is a unique opportunity to advance interoperability, requiring only that the
federal government itself adopt standards for this mandated assessment form. These standards
exist, but CMS currently does not plan to adopt them for MDS 3.0. Instead, CMS plans to continue to
collect MDS data using proprietary data exchange formats that are not interoperable. This will
substantially impair needed quality of care enhancements and increase costs for providers and
ultimately public and private payers, including CMS. Furthermore state Medicaid agencies will be
forced to spend scare resources to update a non-standard, proprietary data system, rather than using
those resources to advance standardization.
HHS has adopted the Consolidated Health Information (CHI) standards for functional status
assessments. Further, the Health Information Technology Standards Panel (HITSP) has endorsed
the use of CHI standards as well.
Clinical Document Architecture (CDA): The MDS 3.0, as currently specified by CMS, is a
proprietary document. The CDA is a CHI-standard document that was developed by Health Level 7
(HL7), an internationally accepted standards development organization. HHS ASPE is developing a
CDA implementation guide and specification for the MDS 3.0 that could be put to use, allowing the
MDS 3.0 to be shared among the providers in the continuum. The CDA assessment implementation
guide based on the MDS 3.0 is currently under ballot by HL7 and will become a recognized standard.
Coding and Semantic Matching: CHI standards have been developed to ensure sharable clinical
content as well. HL7 has developed demographic standards. Logical Observation Identifiers Names
and Codes (LOINC) provide standardized coding and are available in the initial version. Systemized
Nomenclature of Medicine – Clinical Terms (SNOMED-CT) provide semantic standardization.
Recommendation: We recommend that CMS implement applicable CHI standards. In particular,
we propose CMS accept the MDS 3.0 in CDA format versus the currently proposed proprietary
Issue 2: Timing of the MDS 3.0
Original Published Timeline: When the original MDS 3.0 timeline was presented in earlier in 2008,
full draft specifications were to be published in October, 2008 with the final regulations to be
published on March 1, 2009 preceding an implementation date of October 1, 2009. The original
timeline published on the CMS website is attached as a reference. The timeline allowed seven
months from final notice to implementation. While the timeline was aggressive, the long-term care
industry was willing and able to accommodate.
Revised Timeline: However, recent events and communications have deviated from the original
timeline. We have learned that Resource Utilization Group (RUG) regulations will be published as
late as May 2009, likely due to analysis of the Staff Time and Resource Intensity Verification
(STRIVE) data. With the required 60 day comment period, the new target for releasing the final
regulation is now July 2009. The timeframe to implement complex systems and clinical process
changes have been reduced by more than half. When the MDS 2.0 was implemented in 1998, there
was a six month period between the publication of the final regulation and the compliance date.
Provider Concerns: The MDS 3.0 represents a significant cultural and process change from the
MDS 2.0. Four sections are now designed to be captured via resident interview. Each section is
significantly different from the MDS 2.0. Most importantly, long-term care electronic health record
systems have improved and evolved over time. As a result, the MDS has become a vital, integrated
component of the medical record.
Supplier Concerns: For software changes of this magnitude, programming the new requirements
are a small part of the process. Software must be tested for accuracy and compliance, both in the lab
and in the field. Providers will require training and planning for integration with their clinical
processes. As noted above, the MDS changes affect much more than the form itself. The
modifications are pervasive throughout the medical record and reimbursement areas.
State-specific Concerns: At this point, it is also unclear how state Medicaid organizations will be
able to adapt to the change. Many states have adopted MDS 2.0 case mix and RUG-based
reimbursement models. It is likely that long-term care providers may need to complete both
instruments until the states are able to adapt.
Recommendation: In light of the above concerns, we recommend a delay in MDS 3.0
implementation until at least February 1, 2010. This gives the industry a minimum of six months from
the final release of RUG information in July 31, 2009. This new timeframe will provide the industry an
opportunity to properly change systems and processes in a quality manner. It will allow time for the
state-specific issue to become clearer. It will also allow time for CMS to incorporate interoperability
initiatives, described above.
We are happy to meet with you in person or by phone to discuss our recommendations and develop
strategies that will result in an accurate, quality implementation of this important clinical instrument.
AAHSA ~ Barbara Manard at: 202-508-9435 or firstname.lastname@example.org
AHCA/NCAL ~ Todd Smith at: 202-898-2854 or email@example.com
AHIMA ~ Dan Rode at: 202-659-9440 ext. 11 or firstname.lastname@example.org
CAST ~ Majd Alwan at: 202-508 9463 or email@example.com
NASL ~ Dan Cobb at: 417-449-3310 or firstname.lastname@example.org
cc: Robert Kolodner,MD, National Coordinator, ONC
Charles Friedman, PhD, Deputy National Coordinator, ONC
Yael Harris, PhD, MHS, ONC
Jim Scanlon, ASPE/OSDP
Ruth Katz, ASPE/DALTCP
Jennie Harvell ASPE/DALTCP
MDS 3.0 Timeline from the CMS website: