The Trump administration's final rules promoting interoperability contain a little-scrutinized provision hospitals worry could boot them off Medicare at a time of great financial and administrative stress.
The final CMS rule, one of a set published Monday aimed at breaking down barriers between data transferred in the healthcare system, finalized a regulation requiring hospitals to send basic electronic messages to other providers communicating key changes in a patient's status — or potentially get cut off of reimbursement.
Compliance with the admissions, discharge and transfer, or ADT provision, is tied to Medicare's Conditions of Participation. In a nutshell, if a hospital isn't able to send those notifications in six months, its entire Medicare payment could be at risk.
"It's a severe penalty," Shahid Zaman, principal policy analyst at America's Essential Hospitals, told Healthcare Dive. "Six months is not sufficient time to allow vendors and providers to come up to speed with these requirements."
But EHR vendors and the government say the technological capability is already there, and patient advocates and value-based care experts say the notifications, which help providers coordinate care, are long overdue. And some top hospital executives have no problem with the new standards being hitched to Medicare dollars.
"The whole world is being selfish. Get over it! Why else would anybody comply?," Shafiq Rab, CIO of Rush University Medical Center in Chicago, told Healthcare Dive, noting Rush has been sending ADT notifications for two years.
But that hasn't stopped hospitals, especially rural facilities and those serving low-income patients, from wringing their hands over the new directive.
Controversial from the start
Hospitals and health systems opposed this facet of the almost 500-page rule since its proposal one year ago. CMS received more than 600 public comments on it alone, including providers slamming the provision for adding more administrative burden onto hospitals and doctors, both for upkeep and to get into compliance in six months.
Under the regulation, now final, once a patient registers in the emergency room or is admitted to inpatient services, or just before their discharge or transfer to another location, the hospital must send a notification to all post-acute care services providers, primary care doctors or other groups the patient (or his or her record) says is primarily responsible for his or her medical care.
The Trump administration says the provision will help improve post-discharge transitions, reducing the chance a patient faces complications down the line. That's backed up by research: ADT notifications are correlated with a reduction in later re-admissions, according to research published in the Journal of the American Medical Informatics Association in 2017.
The provision won't be enforced until September, which should give all providers — including small and rural hospitals — "adequate and additional time" to come into compliance, CMS says.
But that's "not ideal" for providers, Mari Savickis, vice president of public policy for the College of Health Information Management Executives, told Healthcare Dive. Though the final rule offers more clarity about the ADT provision, including that third-party health information exchanges could help providers administer it, much is still up in the air.
Hospitals take the most umbrage at CMS' decision to tie compliance to Medicare CoP, federal regulations healthcare facilities have to comply with in order to receive funding from Medicare and Medicaid.
That puts hospitals' participation in Medicare at risk — an outsized punishment for failure to implement the notifications, providers say.
Though the Trump administration says the framework is already there (some states, like Maryland, already require hospitals to transmit notifications), hospitals, especially small, rural or disproportionate share facilities that serve high numbers of uninsured or low-income patients, worry they don't have the bandwidth to implement ADT.
Despite mounting volumes, hospital margins continue to be stressed.
AEH member hospitals have an average margin of 1.5% compared to 7% for other hospitals. "Given that, and given the limited resources, essential hospitals have resource limitations. This is adding burden. This is going to require hospitals to change their workflows, train their staff, update their internal processes," Zaman said.
"There needs to be extra time and some sort of additional guidance," he added.
Additionally, hospitals also worry marrying compliance to the CoP could result in executives sending more information than necessary to the government to make sure they're in lockstep with the rule, increasing administrative burden and regulatory overhead.
It will also be difficult to get information from patients on appropriate providers to send ADT notifications to, and maintain those lists, providers say.
Hospitals would rather CMS tie certification to ADT to other avenues, like the Promoting Interoperability Program, which gives incentive payments to hospitals for developing and updating certified EHR systems. Marrying compliance to PIP would be a carrot, as opposed to the stick of Medicare CoP.
"I understand there's a burden piece to [ADT]," Lucia Savage, a former ONC privacy expert who currently works at Omada Health, told Healthcare Dive. "But if you don't have a requirement like the ADT requirement, then you don't get a good handoff" between sites of care.
The ADT notifications are meant to cover gaps in the medical system, pinging the appropriate provider as a patient bounces through the healthcare system. It could lower costs down the line, and will help doctors in value-based payment arrangements succeed, according to Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, which supports the provision.
CMS "disagrees that the CoPs are an inappropriate vehicle for this purpose," the rule reads.
According to the agency, the ability to send patient notifications is a "fundamental" part of hospital EHR systems for patient safety, and should weigh on whether a facility belongs in Medicare or not.
Additionally CoP is weighed as a whole, meaning a hospital noncompliance with one standard is considered in tandem with whether or not a hospital met other standards, along with the severity of the noncompliance and if it poses a risk to patient safety.
The provision would also only apply to hospitals, psychiatric facilities and critical access hospitals using EHRs with the ability to generate information for electronic patient event notifications. And "virtually all" EHR systems already generate those basic messages to communicate key changes in a patient's status, sending basic personal or demographic information, along with the name of the hospital and, in some cases, diagnosis, CMS says.
"Maybe I should say it’s a burden. But it’s not," Rab said.
A CMS spokesperson told Healthcare Dive the government believes the majority of Medicare-participating hospitals will be able to use their existing processes to satisfy the conditions, and should lean into the provision in order to prioritize patient care coordination.
"There's a group of providers that will really take this ball and run down the field with it, because they want more information to manage a population," Savage said. "There's another group of providers that will just see this as another notification to respond to, giving them alert fatigue."