Analysis: CMS Interoperability and Patient Access Final Regulation

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Provisions Related to Conditions of Participation for Hospitals and Critical Access Hospitals: A HIMSS Analysis.

What Hospitals Should Know in Order to Be Compliant with the Final Regulation

Hospitals and Critical Access Hospitals (CAHs) will be required to send electronic patient event notifications of a patient’s admission, discharge and/or transfer (ADT) to another healthcare facility or to another community practitioner as one of their Conditions of Participation (CoP) for the Medicare and Medicaid Programs. At a minimum, The Centers for Medicare & Medicaid Services (CMS) requires hospitals to convey the patient’s basic personal or demographic information, as well as the name of the sending institution and, if not prohibited by other applicable law, the patient’s diagnosis. CMS is requiring these notifications to start six months after the Final Regulation is published in the Federal Register.

CMS notes that, at the time of this applicability date, this provision is limited to a hospital that currently possesses an Electronic Health Record (EHR) system with the technical capacity to generate the basic patient personal or demographic information for electronic patient event notifications.

Compliance with CoP would be determined by the hospital demonstrating to a CoP Surveyor or accrediting organization that its system:

  • Is fully operational and operates in accordance with all state and federal statutes and regulations regarding the exchange of patient health information
  • Utilizes the context exchange standard specified by CMS
  • Sends notifications that would have to include the minimum patient health information
  • Sends notifications directly or through an intermediary that facilitates exchange of health information and at the time of the patient’s admission to the hospital and either immediately prior to or at the time of the patient’s discharge and/or transfer from the hospital

Outstanding Questions

How should hospitals address challenges due to a possible lack of required functionality that would be available on the receiving end for these event notifications?

Is the technical ability in place at this point to identify information about whom a hospital or CAH is expected to notify?

Summary and Analysis

Background and Relevant Changes Leading Up To the Final Regulation

CMS has long expressed interest in how it could use the CoP, Conditions for Coverage and other established requirements to further advance electronic exchange of information that support safe, effective transitions of care between hospitals and providers along the continuum of care. The agency has looked at how to require hospitals to transfer medically necessary information to another facility upon a patient transfer or discharge, and do so electronically. Such actions would necessitate that hospitals electronically send required discharge information to a community provider via electronic means if possible, and if a community provider can be identified, require that hospitals make certain information available to patients or a specified third-party application via electronic means, if requested.

The recently finalized Medicare and Medicaid Discharge Planning Final Regulation also supports CMS’ overarching interoperability efforts alongside this Final Regulation and complements its efforts. The Discharge Planning Final Regulation revises the discharge planning requirements that hospitals and home health agencies follow, and it supports CMS’ interoperability efforts by requiring that all of the patient’s necessary medical information (including post-discharge goals of care and treatment preferences) must be documented in the patient’s medical record and transferred along with the patient at the time of discharge to an appropriate receiving healthcare facility.

The Discharge Planning Final Regulation does not require that providers notify the appropriate providers, suppliers and practitioners receiving the necessary medical information of the patient’s discharge as is now required in this CoP Final Regulation. Specifically, this new standard of ADT notifications requires that an event notification is triggered by a change in disposition of the patient’s status.

CMS notes at a minimum, each hospital is to convey:

  • The patient’s basic personal or demographic information
  • The name of the sending institution (the hospital)
  • The patient’s diagnosis, if not prohibited by other applicable law

In its comments in the CoP Final Regulation, CMS also encouraged both hospitals, the receiving setting/individual provider and the patient to offer the most complete picture of the patient’s clinical data upon request and in accordance with applicable privacy laws. To this point, CMS notes that the revisions that have been finalized do not conflict with existing standards and likely will not conflict with future standards yet to be created.

CMS acknowledged that today there exists significant variation in how hospitals have utilized the ADT messages for the purposes of patient event notifications. CMS does not place restrictions on hospitals from going above the basic information required in this Final Regulation for patient notifications, as the guidance set forth in the Final Regulation essentially establishes a floor.

Additional Commentary and Analysis

In its Comments on the CMS Proposed Regulation, HIMSS supported the intent behind the original proposal to revise CoP for Medicare and Medicaid participating hospitals to include a requirement for sending electronic notifications upon a patient's ADT to a healthcare facility or provider.

Along with many other stakeholders that commented on the proposal, HIMSS consistently supports the goal of increasing interoperability across the care continuum. In line with that sentiment, HIMSS acknowledged not only the important role the hospital plays in initiating the care experience with an acute stay, but also equally respects the importance of the transition of care that a patient experiences and the critical nature of getting the right information about the patient to the providers in the next phase of care. However, one area of concern raised in public comment letters was whether this method of implementing policy changes through CoP would generate an increase in compliance burden for hospitals.

In this Final Regulation, CMS’ response begins with the premise that “the capability to send patient event notifications should be a fundamental feature of hospital medical record systems to support effective care transitions and promote patient safety during transitions.” Furthermore, CMS notes that “the patient event notification requirements that [CMS] is finalizing require a hospital to send only a minimal amount of patient information in order to be in compliance with the provisions. These requirements are consistent with [CMS’] belief that existing patient event notification systems have demonstrated that a minimal set of information can achieve the desired effect of improving care coordination while imposing minimal burden on providers.”

We are cognizant that this update to the CoP affects hospitals, individual practitioners and patients uniquely, and we encourage interested parties with more insights and ideas to engage in the conversation with us. Please contact to find out more ways to become involved with HIMSS’ efforts on this issue.

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