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June 3, 2019 

Submitted via 

Ms. Seema Verma
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244 

RE: CMS–9115–P; Medicare and Medicaid Programs;  Patient  Protection  and  Affordable Care Act; Interoperability and Patient Access for Medicare Advantage Organization and Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans in the Federally Facilitated Exchanges and Health Care Providers 

Dear Administrator Verma, 

We write to express strong support for CMS’ proposal to require hospitals participating in Medicare and Medicaid to send event notifications – also known as admission/discharge/transfer or ADT feeds – to community practitioners. These notifications are critical to improving patient safety through better care transitions and are key to enabling value-based care at scale. 

Although our organizations play different roles in the health care system, we are united in a common commitment to realizing the promise of health care data through increased information sharing. We believe that advancing regulations that lead hospitals to share information with community practitioners is a transformative step toward greater data liquidity that will enable better decision-making, reduce waste, and improve outcomes for patients. The benefits of such notifications are evident in states and localities where this information is shared today, and CMS’ proposal will ensure that they are experienced by all patients regardless of where they live. 

Below we put forth several recommendations designed to further strengthen and refine CMS’ approach based on our real-world experience. 

1.       Hospitals are able to send ADT notifications today without any new standards or use of certified EHRs to collect data. 

While there are many hospitals that have chosen not to share ADT feed alerts with community providers for competitive or other reasons, states such as Connecticut, Iowa, Wisconsin, Florida, Tennessee, Maryland and New York have already taken steps to encourage hospitals to share ADT feeds with community providers. In other localities, many hospitals are sharing alerts with accountable care organizations (ACOs) and other providers, on their own or through intermediaries. 

We stress that hospitals are able to share ADT notifications today using their existing systems, and by working with a health information exchange (HIE) or health information network (HIN), contracting with a vendor that can send the alerts on their behalf, or building their own interfaces. As evidenced by the widescale adoption of this use case today, new standards efforts are not needed for the successful, immediate implementation of the proposed requirements. In numerous conversations with HIEs, other intermediaries and providers, we were unable to find a single example where a hospital was unable to send an ADT notification today due to lack of standards. For the future, further development of ADT messaging standards could be useful to support inclusion of new data elements and/or types of notifications. 

2.       CMS should strike language limiting proposed requirements to hospitals with EHR systems, recognizing that many facilities use other types of systems to send notifications. 

While CMS proposed to limit the new requirements to hospitals that currently possess an EHR system with the capacity to generate the basic information needed for the notification, it is not necessary to use an EHR to gather the required information or send the notification. In fact, many hospitals use administrative IT systems for this purpose. We encourage CMS to strike this language and instead allow hospitals the flexibility to choose how to comply with the new requirement. 

3.       Event notifications should be shared for patients who present in the ED regardless of whether they are subsequently admitted as an inpatient, and the minimum information included in the notification should be expanded to include discharge disposition. 

We strongly encourage CMS to expand the patient population to whom this requirement applies to include patients who present in the ED and are subsequently discharged without being admitted, as well as those patients who are admitted in observational status. Planning for a safe care transition begins when a patient presents in the ED regardless of whether they are admitted to the facility. In addition, notifying the community practitioner when a patient visits the ED enables them to intervene immediately which can improve outcomes for the patient and result in better coordination that reduces costs and prevents waste. 

We also recommend that CMS expand the minimum information in the notification to include the discharge disposition data field. This information is critical for community providers because it gives insight into the outpatient care recommended to the patient and better enables the provider to follow-up with the patient on their hospital visit and coordinate any additional care. 

4.       CMS should consider other policy options for replacing and/or augmenting what constitutes “reasonable certainty” with respect to receipt of notifications. 

We appreciate the need for CMS to establish parameters around a hospital’s responsibility for sharing information with community practitioner. While we agree that an exception may be needed when technical issues beyond a hospital’s control prevent successful receipt and use of a notification, we are concerned that the “reasonable certainty” standard may not be specific enough to ensure the requirement has the intended effect on information sharing.

Accordingly, we recommend that CMS consider other policy options for replacing and/or augmenting the “reasonable certainty” standard included in the proposed regulation. For example, we encourage CMS to deem a hospital compliant if they send the required information to an intermediary for distribution to their provider networks if the intermediary is covered by the prohibition on information blocking. A hospital would be compliant with the new requirement if they: 1) attest that they are not information blocking through the Promoting Interoperability Program; and 2) generate a notification and share it with the intermediary, but it is not ultimately sent because there is no subscribing provider. 

This is an important clarification that ensures hospitals receive credit if they are unable to comply through no fault of their own. It also reinforces that hospitals have discretion in determining the technological mechanism through which they will share notifications; we urge CMS to further clarify this point in the final rule. 

5.       CMS should implement a feedback mechanism for community providers to report issues receiving ADT notifications. 

We encourage CMS to consider creating a feedback mechanism for community providers that have the ability to receive notifications yet get incomplete, unreasonably delayed, or no data at all to log or report these issues. 


Advancing regulatory levers to promote Medicare and Medicaid-participating hospitals to share ADT feeds has the potential to significantly improve care for patients across the country. CMS’ proposed rule is a significant first step on the path to greater information sharing and interoperability. We encourage CMS to implement this new requirement expeditiously (e.g., within months) given that there are no technical barriers to doing so.


American Academy of Home Care Medicine
Audacious InquiryBeth Israel Deaconess Care Organization
Biden Cancer Initiative
Blue Shield of California
Caregiver Action Network
Community Care Collaborative of Pennsylvania and New Jersey
Elation Health
Florida Association of ACOs
Greater Houston Healthconnect
Iora Health
Keystone ACO
Lahey Clinical Performance ACO
Lahey Clinical Performance Network
MaineHealth Accountable Care Organization
Manifest Medex
Mental Health America
Missouri Health Connection
National Association of Accountable Care Organizations
National Council for Behavioral Health
ational Partnership for Women & Families
NEQCA Accountable Care, Inc.
Network ACO OneHealth Nebraska
Partnership to Empower Physician-Led Care
Patient-Centered Primary Care Collaborative
Rhode Island Quality Institute
RGV ACO Health Providers, LLC
Saint Francis Healthcare Partners
The Health Collaborative