By Mark Watts
The U.S. federal government spent $35 billion to create electronic medical records (EMR) and digital information for coordination of care and payment.
This effort helped digitize and document care “in” the health care setting.
Admissions, discharge and transfer (ADT) are the three statuses within the health care EMR.
A patient is “in” a health care setting after admission or registration. If the patient is registered in the emergency room and moved to an inpatient status this is a “transfer” in the EMR, a new location inside the health care provider’s care continuum. When care is completed, the patient is discharged out of the EMR status into the community. The patient is “out.” Now what? Who is care handed off to? Is the patient’s primary care physician aware their patient was treated in a hospital?
In 2018 the Centers for Medicare & Medicaid Services (CMS) issued a new policy. It is 474 pages and is available at http://cms.gov/files/document/cms-9115-f.pdf.
“CMS are dedicated to enhancing and protecting the health and well-being of all Americans. One critical issue in the U.S. health care system is that people cannot easily access their health information in interoperable forms. Patients and the health care providers caring for them are often presented with an incomplete picture of their health and care as pieces of their information are stored in various, unconnected systems and do not accompany the patient to every care setting. Although more than 95 percent of hospitals and 75 percent of office-based clinicians are utilizing certified health IT, challenges remain in creating a comprehensive, longitudinal view of a patient’s health history. This siloed nature of health care data prevents physicians, pharmaceutical companies, manufacturers and payers from accessing and interpreting important data sets, instead, encouraging each group to make decisions based upon a part of the information rather than the whole. Without an enforced standard of interoperability, data exchanges are often complicated and time-consuming.”
“This final rule is the first phase of policies centrally focused on advancing interoperability and patient access to health information using the authority available to the Centers for Medicare & Medicaid Services (CMS). We believe this is an important step in advancing interoperability, putting patients at the center of their health care and ensuring they have access to their health information. We are committed to working with stakeholders to solve the issue of interoperability and getting patients access to information about their health care, and we are taking an active approach to move participants in the health care market toward interoperability and the secure and timely exchange of health information by adopting policies for the Medicare and Medicaid programs.”
The goal is to provide for a longitudinal view of a patient’s health history. This policy calls for ADT status to be sent to patients’ primary physicians. Hospitals need this capability for success in value-based payment programs such as accountable care organizations (ACOs), where participants are financially at risk for costs associated with poor care transitions.
Hospitals must satisfy three conditions relative to ADT event notifications:
- First, its system has a fully operational notification system compliant with state and federal statutes and regulations for securely exchanging patient health information.
- Second, its system sends notifications comprising, at minimum, of the name of the patient, treating practitioner and sending institution. Optional data can include diagnosis when permitted by law. Additional data elements are required when sending a C-CDA to deliver into the provider EHR workflows.
- Third, its system sends notifications directly or indirectly through an intermediary a patient’s name at the time of a patient’s registration in the emergency department or admission to inpatient services, and also prior to, or at the time of, a patient’s discharge and/or transfer from the emergency department or inpatient services to all applicable providers identified by the patient as primarily responsible for his or her care and require such information for treatment, care coordination or quality improvement purposes.
For instances where a hospital cannot identify a primary care practitioner or a post-acute provider for a patient, CMS does not expect an ADT event notification to be sent. Instead, a hospital must be able to demonstrate that it “has made a reasonable effort to ensure that” the system sends the notifications to any of the following that need to receive notification of the patient’s status for treatment, care coordination or quality improvement purposes to all applicable post-acute care services providers and suppliers and:
- The patient’s established primary care practitioner;
- The patient’s established primary care practice group or entity; or
- Other practitioners, or other practice group or entity, identified by the patient as the practitioner, or practice group or entity, primarily responsible for his or her care.
CMS will develop new policies and procedures for surveyors to determine if a hospital is complying. CMS will examine 10% or 30-plus inpatient records. If out of compliance, hospitals will have 10 days to submit a plan of correction or risk CMS denial of payment or other sanctions.
According to industry analysis of hospital reimbursement, nearly half of hospital revenue is tied to Medicare and Medicaid. Therefore, the ADT requirement carries significant weight for a hospital found to be in non-compliance by an accreditation agency or state survey.
CMS contends that most hospitals can meet the mandate; however, the situation is bleak for those that have not made the necessary investments to maintain or upgrade their health IT systems.
The federal agency projects that 71 percent of hospitals were routinely sending ADT event notifications by 2018, even if the process was done manually. This means that 29 percent, nearly 1,400 hospitals, “will incur costs associated with updating or configuring their respective EHR systems for electronic patient event notifications.” CMS anticipates that approximately 394 CAHs – hospitals already operating on razor-thin margins – find themselves in the hot seat to make the technical changes necessary to comply by May 2021.
UNDERSTANDING TECHNICAL REQUIREMENTS
For a rule that requires technical capabilities, it is short on specifics for standards and implementation, which provides an unclear path for hospitals to achieve compliance with the ADT requirement.
What then is known about the technical infrastructure CMS anticipates Medicare and Medicaid hospitals to have?
The final rule makes frequent mention of the HL7 Messaging Standard Version 2.5.1 – that EHR or other systems are to be assessed by their similarity to a widely used messaging standard used by certified EHR technology. CMS does note that HL7 messages are often sent using common forms of transport. CMS is encouraging the use of the most updated HL7 messaging, FHIR Release 4, or Direct Messages as a prime example.
Direct Messaging is commonly used to send messages from one provider to another. Health information exchanges and networks also rely on Direct Messaging to exchange this information over the past decade, with some even claiming that their subscribers have already achieved compliance because of being connected. Direct Trust, the governing body for Direct Messaging, has created a workgroup to develop a standard for Direct Messaging protocols to deliver the ADT requirement.
The federal agency claims that “virtually all EHR systems (as well as older legacy electronic administrative systems, such as electronic patient registrations systems, and which we are including in this final rule) generate information to support the basic messages commonly used for electronic patient event notifications.”
Many vendors, including hospital EHRs, are making this process easier by automating the event notification. This type of workflow will not depend on the administrative staff to spend time sending ADT messages for all patients that encounter an event at the hospital.
BEST PRACTICES FOR HOSPITALS
Considering estimates about the ability of hospitals to comply with the ADT CoP, assumptions about EHR capabilities could easily lead to non-compliance.
Here are the steps hospitals must take to avoid falling short of this CoP and running the risk of losing reimbursement from Medicare and Medicaid:
- Identify established care relationships for patients
- Match patient care events to ADT event notification recipients
- Create ADT event notifications in real-time adherent to privacy and notification requirements
- Deliver ADT event notifications to recipients
- Maintain a log of ADT event notifications
The onus is on hospitals to work with health IT partners – EHR developers, HIEs and HINs, and other data exchange service providers – to ensure that their systems are properly configured and functional and their procedures clearly demonstrate they have acted in good faith.
But is baseline compliance sufficient to the task of truly transforming care coordination using ADT event notification? The EMR was a fundamental step in creating transparent health care as an operational document repository. ADT notification to the primary physician is a great idea if there is a primary physician to receive that notification.
Mark Watts is the enterprise imaging director at Fountain Hills Medical Center.