CMS Interoperability Compliance


On May 1, 2020, the Centers for Medicare & Medicaid Services (CMS) issued an Interoperability and Patient Access final rule applying to hospitals, psychiatric hospitals, and critical access hospitals under the federal provisions known as the Conditions of Participation with Medicare and Medicaid (CoPs). Though federal law, CoPs is the basis for both state licensure requirements and healthcare facility accreditation processes. In response to this final rule, the Joint Commission created new requirements, which were made effective on May 1, 2021.

For hospitals that use Joint Commission accreditation for deemed status purposes:

  1. The hospital demonstrates that its electronic medical records system (or other electronic administrative system) has a fully operational notification capacity and is used in accordance with applicable state and federal laws and regulations for the exchange of patient health information.
  2. The hospital demonstrates that its electronic medical records system (or other electronic administrative system) sends notifications that include at least the patient’s name, treating practitioner’s name, and sending institution’s name.
  3. In accordance with the patient’s expressed privacy preferences and applicable laws and regulations, the hospital’s electronic medical records system or other electronic administrative system (HIE) sends notifications directly, or through an intermediary that facilitates exchange of health information, at the time of the patient’s emergency department registration or inpatient admission.
  4. The hospital makes a reasonable effort to confirm that its electronic medical records system (or other electronic administrative system) sends the notifications to the following (as applicable) post-acute care services providers and suppliers who need to receive notification of the patient’s status for treatment, care coordination, or quality improvement purposes:

    • The patient’s established primary care practitioner
    • The patient’s established primary care practice group or entity
    • Other practitioners, or other practice groups or entities, identified by the patient as primarily responsible for his or her care.
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Inpatient Prospective Payment System

Recently, CMS posted policy changes for Fiscal Year 2022 rates as it relates to the Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals. The changes establish new requirements and revise existing requirements. Reporting begins October 2021. CMS has created a new interoperability measure that provides: Health Information Exchange (HIE) Bi-Directional Exchange measure as a yes/no attestation, to the HIE objective as an optional alternative to the two existing measures beginning with the EHR reporting period in CY 2022, October 1, 2021.

Centralis Health, a community health information exchange, provides IDNs, independent, rural hospitals, and critical access hospitals the ability to connect to the national eHealth Exchange, which satisfies the bidirectional health information exchange requirement for Inpatient Prospective Payment Services (IPPS).

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Merit-based Incentive Payment System (MIPS)

CMS established the Medicare and Medicaid EHR Incentive Programs in 2011 to encourage eligible clinicians, eligible hospitals, and critical access hospitals (CAHs) to adopt, implement, upgrade, and demonstrate meaningful use of EMRs. After the Medicare Access and CHIP Reauthorization Act of 2015 was signed into law, CMS introduced a separate Quality Payment Program (QPP) just for Medicare-eligible clinicians. These eligible clinicians who had previously participated in the EHR Incentive Programs (renamed the Promoting Interoperability Programs) now participate in the Merit-based Incentive Payment System (MIPS), which is one of two ways to participate in QPP.

Over the last several years, the MIPS interoperability requirements have become more stringent and will continue to do so, as described by CMS, in future years. For the performance year of 2021, in order to meet the Health Information Exchange Measure (known as PI_HIE5), MIPS-eligible clinicians or groups must attest that they engage in a bi-directional exchange with an HIE to support transitions of care. In working with their certified EHR vendor, the reporting requirements mandate that the MIPS-eligible clinician simply must attest YES or TRUE to the following:

  • I participate in an HIE to enable secure, bi-directional exchange to occur for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period in accordance with applicable law and policy.
  • The HIE that I participate in is capable of exchanging information across a broad network of unaffiliated exchange partners including those using disparate EHRs and does not engage in exclusionary behavior when determining exchange partners.
  • I use the functions of CEHRT (certified EHR) to support bi-directional exchange with an HIE.

Centralis Health enables you to meet the bi-directional exchange of information via the use of our interface with the national eHealth exchange.

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State Medicaid Programs

Nationally, states’ compliance with the CMS Interoperability and Patient Access final rule is aggressive, and CMS is committed to providing states with the necessary technical assistance to implement these advancements in improving patient access to their data and interoperability. Is your hospital and or physician practice preparing for the mandatory requirements?

CMS suggest that states should seriously consider leveraging existing state and federal investments in health information exchanges (HIEs) to implement these new requirements. For example, HIEs that might have received funding under the HITECH Act from their state Medicaid agency might be able to improve patient access to their data, and would, as such, potentially be demonstrating thoughtful re-use. A few key activities a state should undertake immediately are the following:

  • The CMS Interoperability and Patient Access final rule requires Medicaid managed care plans and CHIP managed care entities to develop the ability to share the United States Core Data for Interoperability (USCDI) as specified in 45 CFR 170.213 with the approval and at the direction of a current or former enrollee or the enrollee’s personal representative under the Payer-to-Payer Data Exchange policy. An assessment of the ability to create that data set and the completeness of that data set for all parties and the ability to send and receive such data by all parties would be appropriate as a first step in preparation for implementation.
  • For purposes of API development, common use of implementation guides ensures better interoperability and thus, state Medicaid agencies, Medicaid managed care plans, CHIP agencies, and CHIP managed care entities may wish to consider beginning an assessment on using the IGs identified by CMS that are available to help facilitate implementation of the API policies.
  • Consider what contract amendments might need to be put in place with managed care plans and entities and what advance planning documents might be necessary.
  • Develop a project plan in coordination with the appropriate CMS Medicaid Enterprise System (MES) State Officers. Such project plans might include tasks such as:

    • Requesting funding through the state’s budgetary process and/or submitting an Advance Planning Document (APD) to CMS to request enhanced FFP.
    • Amending a state’s information technology vendor contracts and/or procuring new contracts.
    • Revising current state data system designs, business processes, and related efforts, including assessing how to make their data accessible via APIs.
    • Evaluating necessary systems changes, which may require contract modifications and/or new procurements with information technology (IT) vendors.
    • Developing managed care plan contract amendments reflecting revised rates (as appropriate) and new federal requirements.
    • Providing amendments to managed care plans for review and signature.
    • Developing the required beneficiary education materials to assist individuals in protecting their health information, making informed choices about which third party applications they want to use, and informing them about how to submit complaints to relevant federal entities.
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COVID 19 ELR Mandatory Reporting

The U.S. Department of Health and Human Services issued instructions pursuant to the Coronavirus Aid, Relief, and Economic Security (CARES) Act on June 4, 2020, requiring all laboratories to report data for all COVID-19 testing completed by Health Level 7 (HL7) Lab Results Interface, for each individual tested, within 24 hours of results being known or determined, daily. On August 25, 2020, the Centers for Medicare & Medicaid Services issued an Interim Final Rule implementing the CARES Act requirement for daily laboratory reporting of COVID-19 test results to the Secretary of Health and Human Services, with a penalty of $1,000 for the first day of noncompliance and an additional $500 penalty for each subsequent day of noncompliance.

Immediately reporting COVID-19 test results contributes to the ability of the U.S. Department of Health to conduct meaningful epidemiological investigations to slow the spread of COVID-19 and drastically increasing the accuracy and meaningfulness of COVID-19 data reported daily based on the number of test results received.

Centralis Health has established several state interfaces for the mandatory COVID-19 lab reporting to comply with both the national standards and any unique state reporting requirements.