Admission, Discharge, and Transfer Notifications

Proposals:CMS proposes to require Medicare- and Medicaid-participating hospitals and Critical Access Hospitals that utilize electronic health records (EHR) systems to send electronic notifications of patient’s admission, discharge, and/or transfer (ADT) to another healthcare facility or another community provider. The notification must contain “minimum patient health information” and could be sent through an intermediary, like a health information exchange (HIE), or directly to community providers. The notifications would be required immediately prior to or at the time of the patient’s discharge or transfer from the hospital. A hospital would only need to send notifications to those practitioners who have an “established care relationship” with the patient relevant to his or her care and for whom the hospital has “reasonable certainty of receipt.”

Comments:
NAACOS is very supportive of this proposed change and urges CMS to finalize it after adopting a few adjustments. Requiring these notifications would alert ACOs to important changes in patients’ health status and care management. Proper care coordination requires providers know where patients receive care and then work together to coordinate care. Because Medicare ACO programs allow seniors the freedom to visit any provider they choose, care delivery teams are often in the dark about other providers whom beneficiaries visit. Yet ACOs are still held financially accountable for these patients without knowledge about key encounters like hospitalizations and ED visits that allow care teams to follow-up with discharge instructions and ensure a more effective transition of care. 

ADT information is vital to ACOs’ success, and CMS should not delay the sharing of these vital notifications with providers who need it most to improve patient care. This policy supports CMS’s efforts to promote value-based care, and the agency points to several peer-reviewed studies in the proposed rule citing this is a patient-safety issue. 

That being said, there are ways to optimize the proposal. We urge CMS to adopt the below changes before finalizing this requirement. 

ACOs as an Entity with Which to Share ADT Notifications
CMS proposes that notifications be sent “to licensed and qualified practitioners, other patient care team members and post-acute care services providers and suppliers…that receive the notification for treatment, care coordination, or quality improvement purposes.” It’s not crystal clear that ACOs would fall into that definition, making them eligible to receive ADT notifications. Federal regulations define ACOs as a legal entity comprised of Medicare providers and suppliers.^[3] They are not providers or suppliers themselves. CMS should make clear that ACOs, which represent groups of providers and suppliers and work directly on their behalf, are eligible to receive ADT notifications. As such, we recommend language in §482.24 and similar sections be revised to include “intermediaries, such as ACOs,” or to include reference to “intermediaries, such as legal entities comprised of Medicare providers and suppliers.” Without this important change, ACO care management teams would be forced to wait on a physician’s office to get a notification. Relaying that notification would add an additional burden to the physician. 

“Reasonable Certainty of Receipt”
Among the stipulations that must be met to require an ADT alert be sent, hospitals must have a “reasonable certainty” the patient’s community provider can receive a notification. While we agree that an exception may be needed when technical issues beyond a hospital’s control prevent successful receipt and use of a notification, we are concerned that the “reasonable certainty” standard may not be specific enough to ensure the requirement has the intended effect on information sharing. This vague condition would be difficult for a hospital to determine on its own and could pose an additional burden on them to be liable for knowing this. NAACOS recommends CMS not finalize the “reasonable certainty” requirement. 

In conjunction with the recommendation immediately above, CMS should consider other options replacing the “reasonable certainty” standard in the proposed regulation with an alternative option. Specifically, NAACOS encourages CMS to deem a hospital compliant if they send ADT alerts to an intermediary for distribution to their provider networks as long as that intermediary isn’t found in violation of ONC’s information blocking rules. A hospital would be compliant with the new requirement if they: 1) attest that they are not information blocking through the Promoting Interoperability Program; and 2) generate a notification and share it with the intermediary, but it is not ultimately sent because there is no subscribing provider. 

This is an important clarification that ensures hospitals receive credit if they are unable to comply through no fault of their own. The exclusive use of an intermediary is not a delegation of a hospital’s responsibilities but does meet the CoP if the intermediary facilitates exchange of notifications in a way that meets the requirements. We also recommend CMS monitor the methods by which hospitals send ADT alerts and the associated costs for providers outside of the hospital who may have to utilize an intermediary to access the information. 

Additional Event Notifications, Such as Alerts on Emergency Department (ED) Presentations
CMS is correct to state that ADT alerts could open the door for a wider set of hospital event notification including for patient visits to EDs. NAACOS and other groups last year called on CMS to include ED visits in event notifications as part of the agency’s request for information on ADT alerts.^[4]We reiterate those calls noting that the technology in place for ADT notification can be applied to other event notifications such as ED visits. 

Timeframe for Implementation
The proposed rule is unclear when the proposed new CoP would take effect. Manyhospitals should be able to comply with these requirements today, and CMS should work to implement this new requirement expeditiously. CMS should not wait to enact this CoP concurrently with many of the proposed requirements in the companion ONC rule. Furthermore, ADT alerts would be an invaluable tool for ACOs’ ability to manage population health as CMS moves to place ACOs at higher levels of financial risk. If CMS wants to put ACOs under risk, they should give them resources needed to succeed. 

Clarification on Compliance Options
CMS gives necessary flexibility to hospitals to comply with this rule, for example, by limiting it to hospitals with EHRs that have the capability to generate ADT notifications. The agency also listened to the calls of NAACOS when giving hospitals technology-neutral options to send alerts, including directly or through intermediaries like HIEs.^[5] Some ACOs today connect directly with hospitals to receive ADT feeds. While some HIEs are highly used in certain markets, many areas of the country lack a well-functioning HIE. We recommend hospitals have multiple options to comply with the proposed requirement so they may pick the best option for working with their community providers. 

But the open-endedness of the proposed new CoP might leave hospitals unfamiliar with how they’ll comply with the new requirement, making them nervous since their participation in Medicare and Medicaid is at risk. Therefore, additional written clarification from CMS is needed on the options hospitals have to share ADT alerts. This could be done either through sub-regulatory guidance or the preamble of a final rule. 

Future Standards Work
The proposed rule points to ONC data showing an ADT messaging standard has been widely adopted by EHRs.^[6] This should be viewed as further evidence that most hospitals should be able to comply with the proposed requirement. But further development of this ADT message-sharing standard should be considered. As the process of sending ADT notifications matures, work may need to be undertaken by standards-setting bodies like HL7, convened by HHS, to develop a more robust standard that would support the sharing of additional data points, including those outlined by CMS in the proposed rule. For now, hospitals should be given options for sharing ADT messages, and CMS’s requirements for data shared with notifications should be considered a floor, not a ceiling. 

Future Oversight
This important policy will need proper oversight to ensure it’s carried out as intended, which is why CMS should clarify how this CoP will intersect with ONC’s proposed “information blocking” rules. That work from ONC seeks to limit the purposeful hindering of flowing patient data. CMS doesn’t state how, or if, sharing of ADT alerts will be subject to information blocking rules, and it warrants the agency’s consideration. Furthermore, CMS should consider a feedback mechanism for ACOs and community providers that have the ability to receive ADT alerts but have faced obstacles to timely notifications.