The Agency for Healthcare Research and Quality has awarded a 20-month, $1.8 million contract to the Health Research & Educational Trust to develop new ways to encourage hospitals to implement AHRQ safety and quality products and tools.
During the 20-month project, HRET will work with American Hospital Association affiliates, state hospital associations, quality improvement organizations, and an advisory panel of experts to provide free assistance to hospitals, health systems, and policy makers. The project begins June 1.
The Institute of Medicine estimates that in 1999 and 2000 as many as 98,000 people died each year in the U.S. as the result of medical errors. AHRQ says it has developed resources and strategies to improve quality and safety, but that broader use is needed to maximize their impact.
Founded in 1944, HRET is a private, not-for-profit organization affiliated with the AHA and involved in research, education, and demonstration programs addressing health management and policy issues.
The Robert Wood Johnson Foundation and the New Jersey Chamber of Commerce Foundation today unveiled a five-year, $22 million initiative to bolster the Garden State's nursing workforce.
The "New Jersey Nurse Initiative" targets grants, scholarships, and funding to increase faculty at nursing schools across the state. A central component will be a Faculty Preparation Program that funds 46 Robert Wood Johnson Foundation New Jersey Nursing Scholars who will study to become faculty and commit to teaching for three years after they complete their studies.
"There is a real danger that the short-term easing of the nursing shortage caused by the recession will create the false impression that we've found a solution to the more serious nursing shortage that lies ahead," says Risa Lavizzo-Mourey, MD, president and CEO of the Robert Wood Johnson Foundation. "We have not. Layoffs and older nurses staying in or returning to the workforce postpone, but do not fix, the problem."
The initiative was unveiled today during a hearing before the New Jersey Senate's Health, Human Services and Senior Citizens Committee.
A report issued today by the New Jersey Collaborating Center for Nursing at Rutgers finds that the average registered nurse in New Jersey is a 50-year-old woman who works more than 10 hours a day. More than half of the state’s RNs—54.4%—are between the ages of 46 and 60. Nearly one-third of the state's nursing workforce will reach retirement age in the next decade.
Joan Verplanck, president of the New Jersey Chamber of Commerce, says addressing the nursing shortage makes good business sense. "The annual cost to U.S. businesses of poor healthcare quality per covered employee is $1,900," she says. "Each year, inadequate care costs businesses as many as 45 million avoidable sick days—the equivalent of 180,000 full-time employees calling in sick every day for a full year. This costs the nation’s employers more than $7 billion a year in lost productivity."
The New Jersey Collaborating Center for Nursing reports that there are 567 full-time nurse faculty in the state. Their average age is 55, and 74 of them are expected to retire within five years. More than half the state’s nursing schools already limit student capacity due to limited faculty.
The nursing initiative will also create a single on-line application for prospective students by 2010 that will send their application to every nursing school in the state, as part of a national initiative headed by the American Association of Colleges of Nursing.
The initiative has set up a Web site— for anyone interested in nursing in New Jersey. It includes searchable listings of nursing programs filtered by degree, county and institution.
The Office of the National Coordinator has until December 31 to release a final set of EHR standards and certification criteria on which vendors can base their products and claim compliance with requirements outlined in the American Recovery and Reinvestment Act.
The timeline means there could potentially be several more months of unknowns related to what incentive prerequisites will entail. What will the certification of a qualified EHR look like? What will the parameters of meaningful use include? What will be required of vendors and providers to adapt to those changes?
If we all had a crystal ball, perhaps we could forecast the future. But there is no crystal ball. And right now, the industry must simply wait for additional guidance.
Even the Certification Commission for Healthcare Information Technology (CCHIT)—the organization that has been certifying EHR vendors since 2006—isn't privy to what the ONC will decide, says Sue Reber, marketing director for CCHIT. Though the commission will publish its final 2009-2010 certification criteria on Friday, Reber acknowledges there may be more changes to come.
"We are trying to remain as flexible as possible so we can react quickly to those decisions," she says. "Hopefully with the work of the HIT standards committee, we'll see some guidance later this summer, and then we’ll be able to adjust the criteria."
CCHIT will delay the launch of its 2009-2010 certification program until it has at least reviewed the draft standards and certification criteria that are due to HHS by August 26, according to ONC operating plan released May 18. CCHIT has not established a final implementation date for its new criteria and testing though Reber speculates it will be “later this year.” CCHIT typically launches its new certification programs on July 1.
But that shouldn't stop physicians from considering a certified EHR product, Reber says. That's because most current CCHIT certification criteria already include many of the "qualified electronic health record" capabilities required by ARRA, such as physician order entry, clinical decision support, and the ability to capture quality information and exchange electronic health information, Reber says. However, once HHS publishes specific standards and certification criteria—as well as the parameters for meaningful use—CCHIT will adjust the criteria to reflect those requirements, she adds.
One important change for 2009-2010 is that CCHIT's Certification Handbook, which includes the policies of the commission’s certification programs, is undergoing significant revisions to take into account the expanded applicability of EHR certification under ARRA, Reber says. As a result, the commission will not publish it until later this summer.
For example, the commission is researching a process for a more extensive verification of successful implementation and usability of commercial products.
It has also formed a subcommittee to research usability measurement, though many of the details have not yet been established, Reber says.
The commission will also pilot a program to inspect and certify EHR technologies-in-use that will accommodate a greater variety of development and deployment models. This includes looking at lower cost ways to certify open source, best-of-breed, or a variety of other self-developed or modular approaches to EHR implementation, Reber says. "We may not certify these as commercial products, but for the purposes of ARRA qualification, we may certify them as products used onsite in single environments," she adds.
CCHIT’s 2009-2010 criteria pertain to EHRs used in the following settings:
Ambulatory (office-based)
Inpatient (hospital-based)
Emergency department
There are also newly developed stand-alone criteria for e-prescribing and updated criteria for ambulatory add-on options in child health and cardiovascular medicine. Each set of criteria will include a simplified user’s guide to help providers and others understand how the current criteria map to requirements already outlined in ARRA, Reber says.
Will using InterQual, Milliman, MCAP or other screening criteria help keep RACs off your back?
Perhaps, but you should be aware that these decision-support products are merely screening criteria—and over reliance on them without adequate physician consultation could spell trouble for hospitals financially, says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc. "They screen for the most likely inpatient and outpatient admissions, but cannot take into account every medical circumstance."
"For example, there are a percentage of patients, who will fail inpatient criteria due to factors not considered in the InterQual criteria that upon physician's review will nevertheless be appropriate for inpatient admission," she adds.
For this reason, each permanent RAC is required to have a medical director who will help develop evidence for individual claim determinations and act as a resource for all reviewers making such individual claim determinations. Additionally, the provider has the opportunity to request that the medical director participate in discussions regarding individual claim denials.
This is an important change from the RAC demonstration program, which didn't require RACs to have a medical director on staff. "The addition of a medical director means that there will be a physician available to review cases that do not meet screening criteria, but still may be appropriate for inpatient admission. Previously these cases were just denied without further review and the hospital had to do costly appeals to demonstrate the medical necessity of the cases," says Hoy.
So which screening criteria should hospitals use? CMS doesn't require hospitals to use a particular screening tool, such as InterQual. And use of an older version or a different set of criteria than the set being used by the reviewing agency is not inherently a problem. However, because outside entities, such as RACs, Medicare Administrative Contractors, and Quality Improvement Organizations, will be reviewing cases, many hospitals choose to use the same version used by their contractors, says Hoy.
Typically, RACs, MACs, and most hospitals use the screening criteria version that would match the year applicable to the case. Outdated versions may not reflect advances in care and may cause inappropriate screening decisions.
For example, current screening criteria may indicate that based on the severity of their signs, symptoms, other factors a patient should be an outpatient for a particular procedure. However, there may have been recent advances in how the procedure is performed and criteria from prior years may reflect the same signs and symptoms as indicating inpatient admission for the procedure. Failure to use current year criteria may cause an inpatient admission that was not medically necessary because of advances in the performance of the procedure, explains Hoy.
Best practice to prepare for RACs is to know the screening criteria your RAC will be using and ensure your staff are trained in its use. Additionally, a good utilization review process, with the involvement of a medical director to review those borderline cases, will ensure appropriate placement for all cases, including cases that don't easily fit the criteria you are using, says Hoy.
Finally, don't forget that if you suspect only screening criteria were applied to a case and believe there was a good reason for the inpatient admission, providers should avail themselves of the RAC medical director as allowed under the RAC program guidelines, she says.
The recession is taking a toll on American employees' health and consequently motivating them to make behavioral changes—for better or for worse—and to better control their own healthcare costs, according to a new survey released Wednesday by the Washington-based National Business Group on Health.
"These data confirm that the widespread economic anxiety is cascading onto individual workers' health and well-being," said NBGH President Helen Darling in a statement. However, this environment also is presenting "teachable moments" that can produce new views on promoting a culture of health, such as by making healthier food choices and increased exercise.
NBGH commissioned this survey to find out how the recession is affecting American workers and to provide a picture about those areas where businesses can work more closely with their employees to help support them.
Among the key findings are that the recession is taking a toll on employees' physical and mental health. Approximately 27% reported forgoing healthcare treatment to save money on copayments or coinsurance costs. Also, 20% said they skipped taking their prescription drug medication dosage as prescribed by their physicians. Many workers, particularly older workers (44% of those aged 45-64), reported that their mental health has been negatively affected by the economy.
The employees surveyed also said they were more sensitive to the cost of healthcare, with 72% saying they have become more aware of the total cost of healthcare services in the past year and 56% saying they were more aware of what they pay for health insurance. Nearly all employees reported reviewing their health plan options during their last annual enrollment period and about a quarter changed health plans as a result.
Health improvement also appears to be becoming more of a priority than a year ago. More than half of the survey respondents (52%) report that living a healthy lifestyle was more of a priority than it was a year ago. Also, 34% reported exercising more, and 46% said they are eating healthier. Forty-four percent reported that they were eating out less at fast food restaurants.
NBGH represents 300 large employers, including 60 of the Fortune 100, and provides health benefits to more than 55 million American workers, dependents, and retirees. The survey of 1,500 workers employed at large employers (2,000 or more employees) was conducted by Fidelity Investments in March 2009. Workers in the survey are between the ages of 22 and 69 and are provided benefits through an employer-sponsored or union-sponsored health plan.
One could certainly argue that the image of the CEO has suffered with the implosion of the economy. The nation's business leaders have seen their hard-won reputations tarnished by the misdeeds of a few reckless executives. But can a CEO really make or break a corporation? This article published in The Atlantic tries to answer the question.
UnitedHealth Group, one of the nation's largest insurers, said in a working paper released Wednesday that if many of its currently used cost-saving programs and methods were adapted by Medicare over the next decade, roughly $540 billion could be saved by the federal program.
The new UnitedHealth paper provides "building blocks" that Medicare could build on to save money and promote quality, according to UnitedHealth Executive Vice President Simon Stevens, who heads the company's new Center for Health Reform.
The paper lists 15 suggestions for lowering the growth of health costs. "We do think that this is going to produce better health results" and generate savings, Simon said at a Washington briefing. The paper has been forwarded to congressional and White House officials.
The report comes just two weeks after an agreement among several health industry groups, including America's Health Insurance Plans, American Medical Association and American Hospital Association, to find ways to reduce cost growth in the health sector by $2 trillion over 10 years. The move had been seen by some as a way to head off a push by Congressional Democrats to create public plans that would compete against private insurers.
Among the cost-saving proposals cited by UnitedHealth are:
$165.5 billion by providing skilled nurse practitioners at nursing homes to manage illnesses, coordinate primary care, and prevent avoidable hospitalizations.
$55.1 billion for transitional case management programs that provides a bridge between hospital inpatient admission and discharge.
$24.8 billion for disease management programs using predictive modeling to identify high-risk patients.
$23.8 for a physician compensation program that rewards medical groups for providing high quality and cost-effective care for patients. (The program focuses on primary care physicians, but can include specialists.)
$57.3 million by prospectively reviewing claims before they are made.
Anticipating questions that some would see their measures as rationing, UnitedHealth officials said that much of the current healthcare system is fragmented and has knowledge gaps--and it could therefore benefit by reducing unnecessary care.
This is "really a far cry from the 'R' word that’s often bandied about, said Lewis Sandy, MD, UnitedHealth’s senior vice president for clinical advancement, in reference to rationing.
I am probably more optimistic than most healthcare professionals about the value of evidence-based medicine. To me, it is a tool that can be used or misused to achieve certain goals. Misuse doesn't mean the tool should be tossed out—it just needs to be policed.
As the former medical director for several health plans and for a large hospital, I used EBM to develop medical policies and make decisions about benefit coverage. Program participants felt that EBM made the decision-making process rational, objective, and based on facts, rather than on personal anecdotes, expert opinion or “that's the way we've always done it” methodology. Misuse generally occurs when there is profit or prestige involved. If the evaluation and funding for medical research (the basis for EBM) were moved to a more regulated environment, I believe the instances of misuse would decrease and be easier to spot.
The new administration has made healthcare a major focus and supports the idea of evidence-based medicine. Congress has approved President Obama's proposal to spend $1 billion to support comparative effectiveness research. The goal is to identify which medical products and procedures are most effective—and ultimately improve healthcare and decrease unnecessary spending.
The use of comparative effectiveness research risks cost-based restrictions. However, we may be headed for that now, but without clinical and value outcomes added to the mix. It's disturbing to watch when peer-reviewed research is sullied by undisclosed financial ties, whether they influenced the research or not. This appears to create a fraudulent base for clinical decision making.
Another danger for evidence-based medicine is the “R” word: Rationing. This issue is always raised as a red flag when EBM or comparative effectiveness is discussed, but the argument is a red herring. Rationing happens around the world because every country, except the United States, has confronted the reality that unlimited demand cannot be balanced with limited resources. Those countries have decided how to allocate their limited resources to best serve their citizens and the result is the “queue system,” or the wait for a limited resource.
Congress has also taken steps to help ensure that care cannot be rationed. In fact, the American Recovery and Reinvestment Act of 2009 stipulates that comparative effectiveness research cannot be used to “mandate coverage, reimbursement or other policies for any public or private payer.”
Evidence-based medicine doesn't cause rationing—rationing is the result of government policy decisions. Instead, EBM is a tool used to decide how much of a resource is needed and how patients are going to access it, based on medical need and value received. Linking rationing with EBM is a political trick used by those who don't want to be held accountable for the reality of limited resources and the necessity of telling someone no.
In this country, we routinely tolerate de facto rationing every day by limiting access to medical services based on ability to pay—a form of social justice that most other countries find incomprehensible. Just try getting access to a liver transplant is this country if you are self-employed, can't get health insurance, but make too much money to get on Medicaid. It can't be done.
The one danger of using EBM is the failure to realize that most of the things we do in medicine are not supported by good, solid medical evidence. The key policy behind EBM is a commitment to allowing practitioners to continue their current practices until EBM supports a change. We can't simply declare that we're going to stop doing things because they don't have an EBM basis because that would wipe out most of what we do. I think that key declaration of principle would take away most of the anxiety for most practitioners, but mostly on a generational basis. You can't do much about folks who are:
Simply opposed to change
Too far into their careers to deal with change
Have a financial stake in resisting/opposing change
My experience with setting and administering medical policy for several million enrollee-years tells me that approximately 20% to 25% of the annual healthcare dollar is wasted on redundant, low-value, useless or even harmful healthcare services. A well-organized, refereed approach to EBM would help with this problem, but it would be a long-term effort. The current administration is correct in stating that we can probably cover all of the 47 million uninsured Americans with the savings achieved by EBM, but they are far too optimistic about how long it will take to achieve that goal.
Applying evidence-based medicine or comparative effectiveness to medical policy need not be a foreign concept. My current employer helps hospitals improve their financial and clinical performance and does that quite well. That doesn't mean we contract for the cheapest items, but instead we choose items that provides the greatest value at the lowest cost. We also look at appropriate utilization and whether there are opportunities for clinical improvement. That is what EBM is all about.
That logic can prevail if applied more broadly. I'm only one physician, and many of my colleagues share my viewpoint. Nevertheless, healthcare won't get better unless doctors engage in serious discussions about how to change it.
Mark Hochstetler is vice president of clinical affairs at VHA Inc. He can be reached at mhochste@vha.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
I've heard lots of people lately decrying the lack of "innovators" among healthcare leadership. It's always hard to label a large group of people—no matter their position—as innovators, competent operators, or even nitwits, but healthcare CEOs as a group have not fared well when compared with innovators in other industries, where the reward for innovation is inarguably higher than it is in such a highly regulated industry as healthcare.
Let's leave out innovations in devices and drugs for a moment. The rewards there are still uncertain, but they're certainly potentially lucrative. It's rare to see hospital CEOs step up to the plate on matters of national policy involving patient care, payment mechanisms, and limiting waste, unless their well-being is threatened from an outside force like government reform or payer initiatives like pay for performance. Some of that head-down attitude is understandable. Running a hospital well has to be one of the toughest jobs out there. It's like running an industrial conglomerate without the huge profit margins those companies often enjoy. There's often little time to think outside the box when you feel like the box is getting smaller and smaller every day.
Hospital leaders have lots of good ideas to reform the system, but getting them past the entrenched bureaucracy that determines healthcare payment is often difficult and requires a lot more time and effort than they have at their disposal. As a result, most of the innovations I've seen in that arena have come from outside the acute care hospital sector.
So even if you agree that hospitals are often led by people who are more efficient operators than innovators, those people have strived mightily to achieve their position, and have achieved some measure of success in getting there. Getting to be a hospital CEO requires smarts and political skill, but not necessarily innovative ideas. With some good evidence, many people see healthcare CEOs as good operators with the hands they're dealt, but not really good at shuffling the deck to obtain a better hand.
But there's one problem with all this talk about lack of innovation at hospitals.
The whole argument starts from a presupposition that we need innovators at the helm of this nation's hospitals to help fix their myriad problems.
Do you agree? I'm not sure I do.
Innovations are often expensive. Maybe we're better off with people who are good at executing, but who are not necessarily idea people. With drastic healthcare reform proposals on the horizon, are we better off with a majority of operators versus innovators? It's possible we are. The industry is already the most regulated on the planet, and I include financial services in that assessment, even with recent unprecedented government intervention in that sector. As government works to further regulate healthcare, are innovators really what is needed? I'm not sure, but there are good arguments either way. With further regulation, I'm coming down on the side of the efficient operators.
So bring on the operators. People who can effectively navigate through bureaucratic hoops and chart a path to profitability without sacrificing patient care. Those are the people healthcare is going to need in the immediate future, where the line between surviving and thriving might live on the razor's edge.
Innovators need not apply.
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As physician practices move away from paper-based record keeping and into the era of electronic medical records, the caliber of staff needed to coordinate, manage, and protect patient information grows exponentially. Clerical staff, once well-qualified to manage paper charts, may not make the grade where new technology is concerned.
For example, practices that receive stimulus dollars under the Health Information Technology for Economic and Clinical Health (HITECH) Act will be under closer scrutiny for HIPAA security and privacy compliance. Providers that implement an EHR that then results in HIPAA violations can face fines as hefty as $50,000 per occurrence?quickly negating the $44,000 per physician incentive. Security and privacy of health information within the EHR is of paramount importance.
With all of these challenges, how can physician practices successfully make the transition to electronic records? The answer for many practices is to hire a credentialed Health Information Management (HIM) professional.
Who are HIM Professionals?
Formerly known as medical record technicians or administrators, these allied health professionals provide tremendous value to physician practices in such areas as HIPAA compliance, record management, coding, reimbursement, clinical documentation, and more. HIM professionals bring a wealth of knowledge, training, and expertise to the areas that are critical to the overall financial health of a physician's practice. And because they possess a unique combination of clinical knowledge and business acumen, they are highly effective in translating the clinician's process of diagnosis and treatment into dollars and cents.
Accredited by the American Health Information Management Association (AHIMA), HIM professionals are a vital layer of protection for all chart-management concerns. They are the keeper of the keys, so to speak, and provide a tremendous return on the investment in their services.
Managing and Protecting Charts
For over 70% of physician practices, loose documents, untimely filing, and misplaced records can be the downfall of their businesses. Some practices have records dating back to the 1950s, which can be a nightmare when cleaning out in preparation for EMR. The HIM professional knows state and federal guidelines for all aspects of record management?storing, archiving, retrieving and purging. If pulled into court, the practice must have well-organized, accurate, and accessible records (paper or electronic) that comply with state and federal regulations to back a case. HIM professionals can help.
Migrating to an HER
HIM professionals also provide valuable support for EHR initiatives in physician practices in three critical areas: demonstrating a return on investment, training and support, and migration of clinical documentation and legal records to an electronic environment.
HIM can help the entire practice become informed about the various aspects of EHR. "We can show providers how to save time, reduce operating costs, increase revenue, and sustain quality of care," says Catherine Stemple, RHIT, Office Manager of Barbour County Family Medicine, Philippi, WV. The benefits are contingent upon the internal efficiencies of the practice and the ability to make informed decisions that will ensure successful implementation. That's a key area where the HIM professional can add value to the practice.
Finally, HIM professionals are astute at creating policies and procedures to protect patient information. Though electronic records are more secure in many ways, there are new risks for privacy and security breaches. The American Recovery and Reinvestment Act (ARRA) includes guidance related to "breach notification," how providers must notify stakeholders in the event of a privacy breach, and security of personal health information (PHI). The Act includes specific definitions for a "breach" and lays out the various notifications that must be made to the individual and the media.<
For breaches involving more than 500 entities or individuals, the Secretary of Health and Human Services (HHS) must also be notified. Again, HIM professionals can help ensure compliance with these new guidelines by establishing policies about what is and what is not acceptable with appropriate sanctions in place for non-compliance.
Case In Point: St. John's Clinic
At St. John's Clinic in Springfield, Missouri, the EHR is fast becoming a reality, making its way to 170 clinics on a rolling schedule that started in April 2008 and is slated for full implementation in Summer 2009. St. John's is a physician-led and professionally managed multi-specialty group practice encompassing more than 500 physicians and 140 mid-level and allied health practitioners in southwest Missouri and northern Arkansas. The HIM department manages HIM for all clinics, oversees a staff of 25 transcriptionists, manages supervision and training, participates in creating policy and procedures and coordinating privacy and HIPAA security.
One of the first steps in migration to the EHR was to centralize patient charts and address the problem of missing charts. HIM implemented a Procedure Checklist system for each clinic to keep track of charts and conducted training for managers and staff. From there, they created a system for purging old records and deciding which information to upload or integrate into the new EHR. This required cleaning out and organizing a centralized warehouse containing 600,000 records along with annual purging of thousands more charts from each clinic. HIM knows exactly where records are for medical and legal purposes.
Documentation Requirements and Reimbursement
The bottom line for physicians is reimbursement. Providers often don't realize the critical link between proper documentation and appropriate reimbursement, as well as the liability involved. Many, if not most, practices tend to under-code. And coding mistakes can result in fines and administrative consequences imposed by regulatory agencies for failure to comply.
HIM professionals are the experts on clinical coding and documentation—they know the elements required to determine what goes on the bill to capture all charges. That's why physicians need trained HIM professionals in charge of coding, clinical documentation improvement, and developing best practices for capturing the data required to ensure proper reimbursement.
Finally, HIM professionals are trained in the appeals process, which involves researching the patient record to determine the validity of a denial and following through with an appeal if necessary. Increased revenue is largely contingent upon reduced denials. Sound HIM clinical documentation practices can ensure a complete and accurate record before it is submitted, resulting in optimal reimbursement.
The Bottom Line
HIM professionals are in a unique position to help physicians better manage their patient information in a paper world and successfully migrate to electronic medical records. They are natural leaders with the ability to anticipate problems in practice before they occur and take proactive measures to seek solutions. With a broad range of skills required to see the big picture—scheduling, office visit, precertification, documentation, coding, payment—they can identify areas that need improvement and determine the best approach for achieving desired outcomes.
"In physician practice, everyone has to wear a lot of hats," says Phyllis Schuck, CIO at Pinehurst Surgical, a multi-specialty surgical practice comprised of nine specialty centers and 54 providers located in Pinehurst, North Carolina. "In addition to managing vast volumes of medical records, our HIM manager plays a key role in defining the designated record set for litigation (legal record), conducting HIPAA training, and serving on a clinical leadership committee whose goal is to involve clinicians in identifying problems and working together to find the best solutions."
Deborah Robb is a physician management consultant at HealthPort, and Whitney Gregg is manager of Health Information Management at St. John's Clinic in Springfield, MO.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
