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How Hospitals Comply with the ADT CoP Requirement: Part I

Hospitals have to demonstrate compliance with a CMS requirement for ADT event notifications.

With the publishing of the Interoperability and Patient Access final rule, CMS requires as the deadline for all hospitals, including behavioral health and critical access hospitals, to comply with a requirement to send admission, discharge, and transfer (ADT) event notifications to all providers primarily responsible for a patient's care.

The goal of the ADT real-time notifications requirement has the potential to improve transitions of care, enhance patient outcomes, decrease care costs, and improve patient and provider satisfaction by supporting improve care coordination, closing care gaps, and reducing readmissions.


Following the announcement of the final rule on March 9, 2020, the federal agency finalized that this condition of participation (CoP) applies to all hospitals with an EHR or electronic administrative system "conformant" with the HL7 2.5.1 content exchange standard. Hospitals must show reasonable effort to send information to a patient's primary care physician, other specialty providers identified by the patient, and applicable post-acute providers who need to receive information for coordination of care.

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, 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:

  1. The patient's established primary care practitioner
  2. The patient's established primary care practice group or entity; or
  3. 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 in compliance. 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 an 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.

By its own estimates, CMS contends that a majority of hospitals are able to meet the mandate; however, the situation is bleak for those that haven't 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. That 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 be in compliance.


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 as a result 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 hospitals 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.


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 their 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 through the use of ADT event notifications? In our next article, we will explore how going above and beyond compliance can achieve the spirit of this CoP and positively impact care quality and outcomes.

*Editor's note: Portions of this article have been updated to conform with the CMS compliance date.

See the other articles in this series on the ADT Notification Requirement:

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