Spotlight on Information Transfer PRO-PM

The Information Transfer PRO-PM

In order to evaluate the effectiveness of how facilities communicate discharge instructions to patients, the CMS Information Transfer PRO-PM targets outpatient surgeries for survey collection. This measure emphasizes the importance of clear, patient-centered communication during a pivotal point in the care journey.

Why Is It Important?

Research shows 3 key items related to discharge instructions:

• Patients who receive well-communicated discharge instructions have lower readmission rates and fewer follow-up calls to their providers 
• Patients receive better discharge instructions when they have surgery in an inpatient setting compared to those who have outpatient surgery
• Clear discharge instructions and improved patient outcomes are linked

With outpatient surgeries on the rise it’s essential to assess how well outpatient providers are meeting this need. 

What is the Information Transfer PRO-PM? 

The Information Transfer PRO-PM tool focuses on capturing patients’ perceptions of how effectively discharge information was communicated and understood, giving them a voice in the process.

The survey consists of nine questions that cover three key areas: medications, applicability, and daily activities. It’s sent to patients 2 to 7 days after their procedure. The survey evaluates the entire process, from surgery scheduling to discharge, including pre-op visits, post-op packets, phone calls, or conversations with staff. 

Who is Eligible?

Any patient 18 years or older who had a surgery or procedure at an outpatient facility is eligible. They must be discharged alive and have a stay of less than 2 midnights, calculated by subtracting the discharge date from the admission date and dividing by 24.

Data Sources

The data for this analysis is calculated based on patient-reported outcome  data collected by hospitals, either directly or through vendors who distribute the surveys to patients. Patients are given a 65-day window to respond to the survey, providing ample time for thoughtful and comprehensive feedback. 

To ensure the data’s reliability and representativeness, a minimum random sample of 300 completed surveys is required. In cases where hospitals are unable to collect the minimum number of surveys, they are required to submit data on all completed surveys available, and must have 100 for it to be scored. This approach ensures that even smaller hospitals or those with lower patient volumes contribute valuable data to the overall analysis. [Slide 27 Entitled Data Source from CMS presentation]

Measure Specifications

The survey uses a continuous variable scoring methodology where a higher score indicates better quality.

• Denominator: Total number of patients who completed the survey. Those who are sent the survey but do not respond are removed from the denominator. For each patient in the denominator, individual scores are calculated. The individual score is calculated for each respondent by summing the items to which they responded positively with “Yes” or “Very Clear” and then dividing this sum by the total number of items that respondents found applicable to their procedure or surgery. Applicable items are determined by subtracting the sum of items marked as “Does not apply” from the total number of items, which is 9 for this instrument. 
• Numerator: This is calculated by summing all individual scores from eligible respondents. Specifically, it involves adding up the items to which the respondent gave a positive response of “Yes” or “Very Clear” and then dividing this sum by the number of items the respondent deemed applicable (determined by subtracting the number of items for which the respondent said “Does not apply” from the total possible of 9 items surveyed). The facility’s measure score is the arithmetic mean of all individual scores calculated by dividing the numerator by the denominator.  [Slide 28 Entitled Measure Specifications from CMS presentation]

The 9 Question Survey | PRO-PM Submission Documents

Key Dates & Data Submission

Voluntary reporting starts CY 2026 | Mandatory reporting CY2027 | Payment Determinations CY 2029

Hospitals are required to use the Hospital Quality Reporting (HQR) system for the submission of any Patient-Reported Outcome Performance Measures (PRO-PM). They have the flexibility to either submit PRO-PM data directly to the Centers for Medicare & Medicaid Services (CMS) or utilize a third-party vendor. The HQR system supports multiple file formats and also offers a manual data entry option, making it versatile and user-friendly.

The reporting period for each measure spans from January 1 to December 31, two years prior to the applicable payment determination year. This timeline ensures that the data reflects a full calendar year of patient outcomes and hospital performance.

Hospitals must submit their data annually via the HQR system, with the submission window opening on January 1 and closing on May 15 of the following year. [Slide 29 Entitled Data Reporting and Submission from CMS presentation]

Final Thoughts on Information Transfer PRO-PM

The data is clear- well communicated discharge instructions lead to better patient outcomes. It is also well understood that patients who have surgery in the inpatient setting receive better discharge instructions than those who have surgery in the outpatient setting. If passed, the Information Transfer PRO-PM could provide facilities with the qualitative data necessary to understand the gaps in discharge education, and subsequently create systems and processes that improve the quality of care.