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Finding the causes of EHR failure

Despite the many promises to the otherwise, electronic health records (EHR) haven’t simplified physicians’ lives. Instead, the average physician today spends twice as much time working with EHRs than interacting with patients.

One study by the Office of the National Coordinator for Health Information Technology (ONC) found that 14% of physicians have experienced a potential medication error due to their EHR in the past month. Another 14% said that the excessive amount of alerts had caused them to overlook something important.

To solve this problem, the Johns Hopkins Armstrong Institute for Patient Safety and Quality and the Pew Charitable Trusts held a summit with 70 EHR systems experts from across the medical field. The group discussed the best possible solutions of preventing EHR medical errors, improve care quality, and improve workflow. The group published a fact sheet on their findings this month, outlining three major problems and their solutions.

“By raising the bar on testing for usability, measuring performance, and opening up ways to share learning on problems and solutions stakeholders can make progress on EHR usability and safety and help clinicians deliver safe, patient-centered, high-quality care,” they write.

Problem: Inadequate testing requirements
Sometimes EHR vendors fail to conduct rigorous enough testing on their products before they are released. Whereas a small bug, glitch, or unexpected change would be a minor annoyance in other fields, improper testing of systems can result in patient harm.
Solution: Create minimum requirements for EHR testing
Currently, only summative testing (which is done after the EHR’s design process) is mandated by the ONC. The summit agreed that additional requirements be made for both formative testing (while the system is being developed) and post-implantation testing (after it’s been installed.)

Problem: insufficient measures of HER safety and usability
The group pointed to a lack of a universally accepted metrics of EHR performance as a major issue. Without them, there’s no way to set quality benchmarks or see if an issue is specific to one system or popping up everywhere.
Solution: Create and disseminate recommendations to the healthcare field
The National Quality Forum has come up with a list of recommended measures for hospitals, vendors, and patient safety organizations to use when improving EHR safety and usability.

Problem: Poor communication of EHR failures between facilities
Between fear of infringing on EHR vendor intellectual property clauses, and a lack of clear communication system, facilities are often unable or unwilling to discuss problems they’ve had with their EHRs. This results in hospitals having to reinvent the wheel every time there’s an issue, even if the same problem was already solved in a different facility.
Solution: Create an organization to examine and manage all EHR-related issues
This step is recommended by the ONC and the Institute of Medicine. The organization would be able to share providers’ experiences without violating copyright gag orders.

Study: Quality isn’t affected by physician employment

A new study published in the Annals of Internal Medicine found that between 2003 and 2012, the number of hospitals hiring physicians jumped up by 13%. Despite this, the authors caution that the glut in physicians will have little impact on care quality.

Forty-two percent of hospitals were employing physicians in 2012, the majority of which were teaching hospitals, nonprofits, and larger facilities. The study’s authors then looked at key quality metrics between 803 hospitals that switched to the employment model vs. 2,085 hospitals that didn’t. They wanted to see if there was a noticeable difference in length of stay, patient satisfaction, mortality, and 30-day readmissions when hospitals changed their employment style. What the researchers found was that hiring physicians had almost no impact on any of these metrics. Mortality rates, for example, were only 0.1% better in hospitals that switched compared to those that didn’t. The only exception was for pneumonia (secret and public) which saw a 0.6% improvement in switched hospitals.

“Our study, which used contemporary national data, suggests that a fundamental improvement in care delivery will require more than mere changes in hospital-physician integration, and if physician employment is a key ingredient, it must be linked to other key goals, such as hospital prioritization of quality, to be successful,” the authors wrote.
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CMS: Hospital readmission rate drop nationwide

Between 2010 and 2015, hospital readmission rates have dropped an average of 8% nationally, with 100,000 unnecessary patient readmissions avoided in 2015 alone. CMS reported the news on its blog, stating that 49 states and the District of Columbia have seen reductions in avoidable 30-day readmissions of Medicare patients over the past five years.

Readmissions reduction has been a major goal for CMS, with an estimated $17 billion in Medicare spending spent annually on avoidable hospital readmissions.  The agency also announced that it would be increasing its fines for high readmission rates in fiscal 2017. While hospitals may look to this new data as a sign of hope, a study in The New England Journal of Medicine  cautions that the continuing the drop may not be possible.

“Presumably, hospitals made substantial changes during the study period but could not sustain such a high rate of reductions in the long term,” the authors wrote. [more]

Joint Commission revises ‘notification of organization changes’

The Joint Commission has updated its “notification of organization changes” policy for accredited facilities.

Previously, organizations had 30 days to notify The Joint Commission that a significant change had been made. The updated policy now requires organizations alert the accreditor the moment the changes are confirmed (i.e., once leadership has decided to move ahead with a change and has created a timeline for completion).

The updated regulations go into effect on October 1. The changes apply to all Joint Commission-accredited programs. Click here to read the revised policy. 

Surgeons rail against reporting every 10 minutes to CMS

A proposed CMS change to the 2017 Medicare Physician Fee Schedule will require surgeons document and report data every 10 minutes for new billing codes (G-codes). The penalty for not submitting this data is 5% of a facility’s Medicare reimbursement.

CMS’ plans to phase out 10-day and 90-day global surgery packages over the next two years. Instead, the fee schedule would have a zero-day package, with all preoperative and postoperative care bundled together on the day of the surgery. Surgeons would receive a lump sum for their work and bill CMS on a piecemeal basis for care provided before and after the day of surgery.

Surgeons and medical groups have loudly decried the move, calling it impractical, untested, and a huge waste of time and money. In one survey of 7,000 surgeons, 37% said the new codes will cost them between $25,000 and $100,000 per surgeon.  Fifteen percent said it would cost them over $100,000 in hiring scribes to keep up with documentation, updating electronic health records, and having less time for patients.

Respondents also claimed that if the standards go into effect:
•    85.9% will have to modify EHR and billing systems
•    88.8% of physicians and 75.7% of staff will lose time tracking and processing global surgery information into EHR and billing systems
•    82.8% will have to develop new tracking and collecting methods for global surgery data
•    46.4% will need to buy more technology (such as handheld devices or stopwatches) to document time spent providing global surgery services

So far, the American College of Surgeons (ACS), the American Association of Orthopaedic Surgeons, the American Association of Neurological Surgeons (AANS), the Congress of Neurological Surgeons (CNS), the American Medical Association, and several others have filed protests with CMS.

“The claims-based data collection mandate is so burdensome that most physicians will not be able to comply by January 1, 2017, which will result in CMS being unable to collect accurate and usable data, particularly in light of the unfinished final rule at the time of this writing,” the AANS and CNS wrote in a letter to CMS.
For more, read the full article at HealthLeaders Media.

HFAP releases 2017 CAH, ASC prepublication manuals

HFAP this week released its prepublication manual for critical access hospital (CAH), and ambulatory surgical center (ASC) surveys. The manuals have been updated to include requirements of the 2012 Life Safety Code® (LSC), which was recently adopted by CMS.  The CMS adoption of the 2012 LSC went into effect in July, and the new requirements will go into effect for HFAP facilities on November 1, 2016.

The changes to the accreditation requirements for CAHs are in Chapters 3, Chapter 14, and Chapter 17. They also include a CAH Facility Demographic Report and a HFAP-CMS Crosswalk.

The changes for ASCs are in Chapter 5, and include a ASC Facility Demographic Report.

10 ways to prevent drug diversion

Preventing the theft of controlled substances at hospitals continues to be an issue even with increased security measures. Failed drug diversion programs in hospitals have led to record fines levied against facilities. The Mayo Clinic experienced a highly publicized case of drug diversion back in 2008, where a nurse was caught stealing fentanyl from patients about to have a catheter inserted. The incident prompted the Mayo Clinic to take proactive steps toward drug diversion, such as:

1.    Having a zero tolerance policy for theft of any drugs from anywhere
This includes workers who fail to properly witness a coworker disposing a drug that is not ultimately given to the patient. Workers should be given pre-employment drug screening and receive education on the dangers of drug addiction and misuse.

2.    Work with law enforcement agencies
This includes local police and U.S. Drug Enforcement Administration (DEA). Officials from these agencies can process search warrants of employees’ homes and cars to help prove a case. This also lets other facilities know whether a prospective job hire has been caught trying to steal drugs before.

3.    Employ a 24-hour diversion hotline for workers to report suspicious behavior
Place advertisements for the hotline around the facility and make sure that those working on the hotline are qualified.

[more]

CMS finalizes new emergency preparedness rule

CMS announced yesterday that it had finalized new emergency response requirements for healthcare providers participating in the Medicare or Medicaid system. The new rule comes as a response to a string of disasters, natural and mad-made, including the recent flooding in Louisiana. The rule requires that healthcare providers meet the following four standards:CMS Logo

  1. Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier.
  2. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment.
  3. Communication plan: Develop and maintain a communication plan that complies with both Federal and State law. Patient care must be well-coordinated within the facility, across health care providers, and with State and local public health departments and emergency systems.
  4. Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.

“As people with medical needs are cared for in increasingly diverse settings, disaster preparedness is not only a responsibility of hospitals, but of many other providers and suppliers of healthcare services. Whether it’s trauma care or long-term nursing care or a home health service, patients’ needs for health care don’t stop when disasters strike; in fact, their needs often increase in the immediate aftermath of a disaster,” said Dr. Nicole Lurie, Health and Human Services assistant secretary for preparedness and response, in a press release. “All parts of the healthcare system must be able to keep providing care through a disaster, both to save lives and to ensure that people can continue to function in their usual setting. Disasters tend to stress the entire health care system, and that’s not good for anyone.”

 

Study: Readmissions sometimes improve patient health

Are readmissions always bad? A new study by John Hopkins Medicine published in The Journal of Hospital Medicine says the answer is not as clear cut as once believed. Researchers looked at three years and 4,500 acute-care facilities worth of readmission and mortality data, finding that hospitals with high readmission rates tended to have lower mortality rates as well.

The study focused on the six conditions that CMS penalizes hospitals for in its readmissions reduction program: heart attack, pneumonia, heart failure, stroke, chronic obstructive pulmonary disease (COPD), and coronary artery bypass. In particular, high readmission rates seemed to correlate with better mortality rates for COPD, heart failure, and stroke.

“But using readmission rates as a measure of hospital quality is inherently problematic,” study author Daniel J. Brotman, MD, said in a press release. “High readmission rates could stem from the legitimate need to care for chronically ill patients in high-intensity settings.”

This especially applies to cases of medically fragile patients who may need that follow up care to stay alive, he said. Readmission rates are currently used in CMS’s hospital star ratings system and the agency financially penalizes hospitals that have high readmission rates.

Brotman said it’s “particularly problematic” that the star rating system applies equal weight to readmissions and mortality, saying that it unfairly skews the data against hospitals. While some readmissions are the result of preventable issues such as bad handoffs, he added, there are times when readmission results from serious disease and patient frailty.

“It’s possible that global efforts to keep patients out of the hospital might, in some instances, place patients at risk by delaying necessary acute care,” said Brotman.

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2017 reporting requirements for ORYX

The Joint Commission released it’s 2017 reporting requirements for ORYX. Changes in include deletion of the measure set reporting requirement.

ORYX is a performance measurement and improvement initiative, for which facilities are  required to collect and submit data on six sets of core measures.

Click here to see the full document.