FutureFocus March 27, 2019: EHR Incentives for PAC Providers: What Will CMS Recommend?

Lisa Remington

In this FutureFocus is important discussions about the future adoption of EHRs across post-acute sectors. A new RFI has been issued by CMS to ask for stakeholder feedback about the best ways to incentivize EHR adoption in post-acute. We have pulled out from the RFI important communications about proposed patient information hospital’s would be required to provide to post-acute providers at admission and discharge.

Lisa Remington, President, Remington Health Strategy Group

By: Lisa Remington, President, Remington Health Strategy Group, Publisher, The Remington Report

The post-acute sector was overlooked when federal incentives were offered for EHR adoption. Providers in the post-acute setting weren’t eligible for the Medicare and Medicaid EHR Incentive Programs. To date, the federal government has spent more than $35 billion under the Medicare and Medicaid EHR Incentive Programs to encourage EHR adoption in the acute-care setting.

“We are asking for comments on how CMS can ensure that post-acute care providers adopt health technology, allowing for a more seamless flow of data,” said CMS Administrator Seema Verma.

CMS released a request for information (RFI)  this month asking healthcare industry stakeholders to offer input about the best ways to incentivize EHR adoption and use among providers in the PAC setting.

Why Is It Important for PAC Providers To Use EHRs?

“PAC facilities are critical in the care of patients’ post-hospital discharge, and can be a determining step in the health progress for those patients,” stated CMS in the RFI.

“Interoperable health IT can improve the ability of these facilities to coordinate and provide care; however, long-term care and PAC providers, such as nursing homes, home health agencies, long-term care providers, and others, were not eligible for the EHR Incentive Programs under the HITECH Act,” the federal agency clarified.

CMS says: “we believe patients should have the ability to move from health plan to health plan, provider to provider, and have both their clinical and administrative information travel with them throughout their journey. When a patient receives care from a new provider, a complete record of their health information should be readily available to that care provider, regardless of where or by who care was previously provided. When a patient is discharged from a hospital to a post-acute care (PAC) setting there should be no question as to how, when, or where their data will be exchanged. Likewise, when an enrollee changes health plans or ages into Medicare, the enrollee should be able to have their claims history and encounter data follow so that information is not lost."

Lack of Adoption/Use of Certified Health IT

Among Post-Acute Care (PAC) Providers PAC facilities are critical in the care of patients’ post-hospital discharge, and can be a determining step in the health progress for those patients. Interoperable health IT can improve the ability of these facilities to coordinate and provide care; however, long-term care and PAC providers, such as nursing homes, home health agencies (HHAs), long-term care providers, and others, were not eligible for the EHR Incentive Programs under the HITECH Act.

Based on the information we have, we understand that this was a contributing factor to these providers not adopting CEHRT at the same rate as eligible hospitals and physicians, who were able to adopt CEHRT using the financial incentives provided under the programs. While a majority of skilled nursing facilities (SNFs) used an EHR in 2016 (64 percent), there is considerable work to be done to increase adoption and the exchange of data in this provider population. In that same year, only three out of 10 SNFs electronically exchanged (that is, sent or received) key clinical health information, and only 7 percent had the ability to electronically send, receive, find, and integrate patient health information.

In 2017, the Office of the National Coordinator for Health Information (ONC) survey found that more HHAs (78 percent) adopted EHRs than SNFs (66 percent), but integration of received information continued to lag behind for both HHAs (36 percent) and SNFs (18 percent). While both ONC surveys focused on SNFs, it is important to note the large provider overlap between SNFs and other nursing facilities. In 2014, 14,409 out of 15,640 (92 percent) of nursing homes were certified for both Medicare and Medicaid.

Standardized Patient Assessment Data: Post-Acute

Long-term hospitals, inpatient rehabilitation facilities (IRFs), SNFs, and HHAs are required to submit to CMS standardized patient assessment data described in section 1899B(b)(1) of the Act (as added by section 2(a) of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) (Pub. L. 113–185, enacted October 6, 2014)). We have defined the term ‘‘standardized patient assessment data’’ (or ‘‘standardized resident assessment data’’ for purposes of SNFs) as patient or resident assessment questions and response options that are identical in all four PAC assessment instruments, and to which identical standards and definitions apply.

Section 1899B(b)(1)(B) of the Act states that the categories for which standardized patient or resident assessment data must be submitted include, at a minimum, functional status; cognitive function; medical conditions and co-morbidities; special services, treatments and interventions; and impairments. Section 1899B(b)(1)(A) of the Act requires that such data must be submitted through the applicable reporting provision that applies to each PAC provider type using the PAC assessment instrument that applies to the PAC provider. Section 1899B(a)(1)(B) of the Act additionally requires that these data be standardized and interoperable so as to allow for their exchange among health care providers, including PAC providers, to ensure coordinated care and improved Medicare beneficiary outcomes as these patients transition throughout the care continuum. To enable the interoperable exchange of such information, we have adopted certain patient assessment data elements as standardized patient or resident assessment data and mapped them to appropriate health IT standards which can support the exchange of this information. For more information, we refer the reader to the CMS website at https://del.cms.gov/DELWeb/pubHome.

CMS issued a request for information (RFI) which is designed to reduce information blocking and streamline health data exchange to fulfill the aims of the 21st Century Cures Act. 

The Remington Report Pulled From The Proposed Rule Important Information For PAC Providers

“We are proposing that the hospital must demonstrate that its system sends notifications that must include the minimum patient health information (which must be patient name, treating practitioner name, sending institution name, and, if not prohibited by other applicable law, patient diagnosis).

The hospital would also need to demonstrate that the system 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, to licensed and qualified practitioners, other patient care team members, and PAC services providers and suppliers that: (1) Receive the notification for treatment, care coordination, or quality improvement purposes; (2) have an established care relationship with the patient relevant to his or her care; and (3) for whom the hospital has a reasonable certainty of receipt of notifications.

Similarly, we are also proposing that the hospital would need to demonstrate the transmission of these notifications either directly, or through an intermediary that facilitates the exchange of health information, and either immediately prior to or at the time of the patient’s discharge or transfer from the hospital, to licensed and qualified practitioners, other patient care team members, and PAC services providers and suppliers that: (1) Receive the notification for treatment, care coordination, or quality improvement purposes; (2) have an established care relationship with the patient relevant to his or her care; and (3) for whom the hospital has a reasonable certainty of receipt of notifications. We believe this proposal will allow for a diverse set of strategies that hospitals might use when implementing patient event notifications.

Through these provisions, we are seeking to allow for different ways that a hospital might identify those practitioners, other patient care team members, and PAC services providers and suppliers that are most relevant to both the pre-admission and post-discharge care of a patient. We are proposing that hospitals should send notifications to those practitioners or providers that have an established care relationship with the patient relevant to his or her care.

We recognize that hospitals and their partners may identify appropriate recipients through various methods. For instance, hospitals might identify appropriate practitioners by requesting this information from patients or caregivers upon arrival, or by obtaining information about care team members from the patient’s record. We expect hospitals might develop or optimize processes to capture information about established care relationships directly, or work with an intermediary that maintains information about care relationships.

In other cases, hospitals may, directly or through an intermediary, identify appropriate notification recipients through the analysis of care patterns or other attribution methods that seek to determine the provider most likely to be able to effectively coordinate care post-discharge for a specific patient. The hospital or intermediary might also develop processes to allow a provider to specifically request notifications for a given patient for whom they are responsible for care coordination as confirmed through conversations with the patient.”