Cerner commends the Centers for Medicare & Medicaid Services (CMS) on the creation of measure 499 “Access to Quality Advance Care Plans”. After careful review of the measure and the details within, we would like to propose some modification to what the initial measure is looking for. It is our recommendation that hospital systems and clinicians not only document whether or not a patient has an advance care plan, but have a conversation with the patient and their family, if applicable, about treatment options, patient goals, preferences and values and whether or not documents are up-to-date. Currently today, the documents are scanned into the EMR and found as file attachments. While it is an admitting responsibility to ask whether or not a patient has an Advanced Directive, there is no contingency on how the patient answers the question. The current workflow for assuring the presence of those documents does not add the value that the measure intends.

We support the presence of documentation of patient preferences for care (such as an advance directive or living will), identification of a surrogate decision-maker and transferable orders addressing life-sustaining treatment (such as a Physician Order for Life-Sustaining Treatment). Those items are captured within the normal clinical workflow and can be discretely reported. The challenge with the measure is that many of those document details currently exist on paper and as previously mentioned, would require scanning into the EMR. In order for the measure to truly add value, there needs to be the evolvement of these documents to move from paper-based formats to electronic formats. Then the data can be captured discreetly and reported against, a task that is currently very difficult to accomplish. As a global company, we are also challenged by each state and country having their own set of legal advance care planning documents and individual laws that have to be taken in to consideration when creating a broad technical solution. We are actively working towards improved interoperability of advance care plans so that they are visible to clinicians and patients, but there first needs to be an initiative to drive industry standards around establishing ACPs.

We encourage you to think more upstream in the workflow and consider that the majority of Americans do not have that documentation, even if the status of their health is declining. This measure would add greater value if it encouraged organizations to support their clinical staff to have the conversation with patients about establishing an ACP, especially those with chronic conditions or serious illnesses. Then this measure could be multi phased. The initial phase would include metrics to evaluate the effort of an organization to educate patients and/or establish ACPs then the second phase would evaluate the presence of ACPs, as the measure reads today.