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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations transformation to dQMs leveraging health IT standards. While we stated that we would not be responding to specific comments submitted in response to this Request for Information in the FY 2022 Hospice Wage Index final rule, we will actively consider all input as we develop future regulatory proposals or future sub-regulatory policy guidance. Any updates to specific program requirements related to quality measurement and reporting provisions would be addressed through separate and future noticeandcomment rulemaking, as necessary.
Comments: We received many comments expressing support for the adoption of a standardized definition of dQM in the hospice setting and the use of Fast Healthcare Interoperability Resources FHIR to support quality measurements in the HQRP. Many commenters noted that there is a great deal of variation among FHIR systems, which could impede the adoption of a standard system across hospices.
Commenters also expressed issues surrounding interoperability capabilities of EHR vendor systems noting that currently, some EHR vendors do not include features important for interoperability as a part of their base product, which would represent additional costs for hospices which can lead to affordability issues for many providers. Furthermore, commenters noted that interoperability challenges lead to complications when sharing health information with other providers.
They encouraged HHS to continue pursuing adoption of FHIR APIs for health IT vendors.
We also received several comments responding to how CMS should incentivize the use of HIT. Commenters noted that hospices were not included in the EHR Incentive Program, which provided grants to hospices to develop HIT systems. We received many comments emphasizing that financial incentives would encourage providers to adopt new HIT systems and work to reduce burden using FHIR and EHR.
Commenters also encouraged CMS to provide early testing and education for providers on HIT and to provide a structured FHIR transition framework for key stakeholders.
We also received several comments explaining the various EHR/HIT systems currently in use, as well as discussions surrounding health information exchange with other providers.
Response: While we stated that we would not be responding to specific comments submitted in response to this RFI in the FY 2022 Hospice Wage Index final rule, we appreciate all of the comments and interest in this topic. We
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will continue to take all concerns, comments, and suggestions into account as we consider Fast Healthcare Interoperability Resources FHIR in support of Digital Quality Measurement in Post-Acute Care Quality Reporting Programs.
B. Closing the Health Equity Gap in Post-Acute Care Quality Reporting ProgramsRequest for Information While hospice is not included in the Improving Medicare Post-Acute Care Transformation Act of 2014 IMPACT
Act of 2014 Pub. L. 113185, we sought comment on the possibility of revising measure development, and the collection of other data that address gaps in health equity in HQRP 86 FR
19766. Any potential health equity data collection or measure reporting within a CMS program that might result from public comments received in response to this solicitation would be addressed through a separate notice-and-comment rulemaking in the future. We invited public comment on the following:
Recommendations for quality measures, or measurement domains that address health equity, for use in the HQRP.
Suggested parts of SDOH
standardized patient assessment data elements adoption that could apply to hospice in alignment with national data collection and interoperable exchange standards. This could include collecting information on race, ethnicity, and certain SDOH, including preferred language, interpreter services, health literacy, transportation and social isolation. This could also include guidance on any additional items, including standardized patient assessment and data elements that could be used to assess health equity in the care of hospice patients, for use in the HQRP.
Ways CMS can promote health equity in outcomes among hospice patients. We were also interested in feedback regarding whether including facility-level quality measure results stratified by social risk factors and social determinants of health and relevant proxies, such as dual eligibility for Medicare and Medicaid, and race in confidential feedback reports could allow facilities to identify gaps in the quality of care they provide. For example, methods similar or analogous to the CMS Disparity Methods which provide hospital-level confidential results stratified by dual eligibility for condition-specific readmission measures currently included in the Hospital Readmission Reduction Program 84 FR 42496 through 42500.

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Methods that commenters or their organizations use in employing data to reduce disparities and improve patient outcomes, including the sources of data used, as appropriate.
Given the importance of structured data and health IT standards for the capture, use, and exchange of relevant health data for improving health equity, the existing challenges providers encounter for effective capture, use, and exchange of health information, such as data on race, ethnicity, and other social determinants of health, to support care delivery and decision making.
While we stated that we would not be responding to specific comments submitted in response to this RFI in the FY 2022 Hospice Wage Index final rule, we appreciate all of the comments and interest in this topic. We will continue to take all concerns, comments, and suggestions into account as we continue work to address and develop policies on this important topic. It is our hope to provide additional stratified information to providers related to race and ethnicity if feasible. The provision of stratified measure results will allow hospices to understand how they are performing with respect to certain patient risk groups, to support these providers in their efforts to ensure equity for all of their patients, and to identify opportunities for improvements in health outcomes.
2. Public Comments Summarized We received many comments about the use of standardized patient assessment data in the hospice setting to assess health equity and social determinants of health SDOH. Many commenters noted a 2019 Abt Associates and RAND Corporation study which excluded hospices from the standardized data elements for patient assessment denominator, citing that hospice patients have a different goal of care which does not align with standardized data elements for patient assessment. Commenters encouraged CMS to only utilize certain aspects of standardized data elements for patient assessment specifically, Z-codes 5565
in collecting health equity data. We also received some comments which expressed that standardized data elements for patient assessment does not currently capture the current understanding of SDOH.
We also received feedback from several commenters about additional factors which should be considered when collecting data about health equity and disparities. We noted several categories, including: culture, spiritual beliefs, food insecurity, access to interpreter services, health literacy,
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