One of the many stipulations of the Centers for Medicare & Medicaid Services’ (CMS) interoperability and patient access regulation that was finalized last year is that hospitals must electronically share patient event notifications with all providers primarily responsible for a patient's care.
Specifically, as CMS laid out, hospitals and health systems with electronic health records (EHR) are required to send electronic notifications about patient admissions, discharges, and transfers (ADT) to primary care providers, physicians, post-acute providers, and suppliers. What’s more, hospitals must comply with the patient event notification Condition of Participation (CoP) by the April 30, 2021 deadline to continue receiving Medicare funding. Compliance with the rule was originally supposed to begin last fall, but was pushed back due to the pandemic.
As Healthcare Innovation has previously reported, “In its final rule document, CMS noted that it received more than 600 public comments on the section specific to patient event notification requirements. Many were positive. One commenter noted that the statewide requirement for hospitals in Maryland to transmit notifications has been an important policy supporting care coordination in the state. Others noted it is especially important for the success of value-based payment models such as accountable care organizations (ACOs), where participants may be financially at risk for costs associated with poor care transitions.”
At the same time, some raised concerns about making event notifications mandatory conditions of participation to receive Medicare funding, stating that it would increase regulatory burden at a time when the federal government is working in other areas to decrease regulatory burden on provider organizations. CMS pushed back, asserting that if small, rural hospitals don’t have an EHR that can share event notification data, they are exempt from the new rule. CMS also claimed there are many ways for hospitals to minimize the burden through use of health information exchanges (HIEs).
“It’s a condition of participation for Medicare, which is different than what CMS [requires] for its Promoting Interoperability [PI] program [that provides incentive payments to hospitals for developing and updating certified EHR systems], where if you don’t meet the stipulation, they may cut your rate,” explains Jordan Tannenbaum, M.D., vice president, CIO and CMIO officer at Saint Peter’s Healthcare System based in New Brunswick, N.J. “But the conditions of participation in this final rule means if you don’t meet it you don’t get a Medicare payment at all, so that’s a very big deal,” he adds.
As such, in response to the final rule, the health system has turned to technology from care coordination solutions company CarePort. To reduce the burden of fulfilling these requirements, CMS’ final rule explicitly recognizes the ability of a third-party or intermediary to facilitate the patient event notifications on behalf of hospitals. According to officials, the CarePort Interop tool will enable Saint Peter’s to notify all required recipients about patient admissions, discharges, and transfers, in accordance with the CoP. They noted that CarePort Interop helps hospitals like Saint Peter’s reach a range of stakeholders—including in-network or out-of-network post-acute providers, suppliers such as durable medical equipment (DME) and infusion providers, and patients’ designated physicians.
Leveraging CarePort’s new solution, Saint Peter’s can identify and notify a patient’s established care providers across CarePort’s national network that connects 850,000 Direct message-enabled physicians and more than 110,000 post-acute providers. Company officials stated that CarePort’s end-to-end care coordination network captures more than 30 percent of post-acute transitions in the U.S., equating to more than 20 million referrals sent annually. The number of post-acute providers on the network is significant, CarePort’s leaders say, because when a patient is discharged from a hospital, per CMS’ rule, the hospital is required to notify every post-acute provider–even those out of network.
Tannenbaum explains that while some HIEs do alert their members to admissions and changes in status, most of those technology platforms are still based on “pulling,” meaning if a providers wants information about a patient, he or she has to pull it from the HIE. But what CarePort provides is a “push” notification, so it’s passive, he says. “I would say that is the big difference with the caveat that I know that some HIE s do already have this function,” he acknowledges.
Tannenbaum notes that Saint Peter’s uses Allscripts’ Paragon EHR product on the inpatient side, and had been looking for a platform that could easily integrate into the EHR and reach out into the external universe of providers to send the ADT notifications. So they chose CarePort, who collaborated with Allscripts, and since its network already had so many Direct-enabled physicians on ONC-certified EHRs via direct message, CarePort could simply take the health system’s ADT HL7 feed and send the message to providers, Tannenbaum explains. “Of course we have to record the provider in the EHR so the [system] knows where to take it, but it’s really been a seamless integration into the ecosystem we already had between CarePort and Allscripts,” he adds.
Those who are in support of the requirement—and the severe consequences of noncompliance—say that ADT notifications will prevent hospital readmissions and in turn lower costs. Historically, it’s been common for providers to be unaware of their patients' hospitalizations, so in theory, event notifications can help fill that gap. On the ground, research has backed up this concept, too; one analysis of thousands of hospital admissions in the Bronx, N.Y., published in 2017, found that the unadjusted 30-day readmission rate when event notifications were not active was 29.5 percent compared to 26.5 percent when alerts were active. Regression estimates indicated that active hospitalization alert services were associated with a 2.9 percentage point reduction in the likelihood of readmission, according to that study. It should also be noted that this hospital admission data was collected between 2010 and 2014, meaning with better technology and more providers engaging in care coordination efforts, it’s certainly plausible that event notifications are even more effective today in reducing readmissions.
However, one challenge noted by Tannenbaum is that many post-acute providers are still not ready to receive and process these alerts, especially in the case of EHRs at private physician practices. “So the practice EHR will get hit with a Direct message, but Direct has not been well embraced on the private practice side. Do they know what to do with it? Do they know how to process it? Do they know what it means? Those are still the questions I have,” he says. He adds that it will interesting to see how the post-acute side—not so much nursing home and rehab centers—but the primary care physicians and specialties that are getting these messages handle this new regulation. Interestingly, he further points out post-acute providers can “opt out” of the notification that comes from the hospital if they choose. However, he says that even if that does happen, that won’t impact the hospital’s compliance from CMS’ perspective, so long as they sent the message out.
Going forward, Tannenbaum says that progress will be measured first from a technology perspective, in terms of making sure that data is flowing, but on a national level, the goal is improved care coordination. “People should know what's happening, and there should be a smooth transition from acute care to post-acute care, no matter who that post-acute care provider is. In a lot of cases that doesn't happen as smoothly as we would like, and apparently not as smoothly as CMS would like. Is this [regulation] going to improve that? Even if everything is [working] on the technology front, you still need to have effective interventions from those notifications,” he asserts.
While some stakeholders have taken issue with certain aspects of what CMS is requiring hospitals to electronically send out, Tannenbaum believes the initial ask for the basic ADT information is reasonable. “We have to remember that part of the evolution of this rule, and the information blocking rules, all [stem] from a failure of the industry itself to come to a cohesive standard to allow all this interchange. So the government had to step in and make all these rules because some of the vendors were blocking the ability to exchange data. This is a symptom of the failure of the industry to establish its own standards.”