Total patient visits to physician offices were down 7.3% in July from the July 2009—the fourth consecutive month to post negative growth in physician visits, according to researchers with the North American offices of Deutsche Bank Securities. Overall, primary care visits were down by 5.7% for the month.

July appeared even weaker than June (with a 4.1% decline in visits) and the previous second quarter, with a 4.6% decrease in visits.

From a regional perspective, for total market growth for physician-patient visits, the West looked particularly weak in July (with an 8.5% decline) and in the 2nd quarter (with a 9.5% decline). In the South, total market growth for visits was down 7.9% in the South; down 5.1% in the East; and 6.9% in the Midwest.

As a result of these trends, volumes for major outpatient service provider chains—such as labs, ambulatory surgical centers, and imaging—may continue to be "constrained" into the third quarter, with a possible continued downward slide if these trends continue, the researchers said.

They added that these volumes may be down because a strong relationship exists between physician office visits and diagnostic test orders (through labs and radiology).

In addition, physician office visits tend to be an important leading indicator for elective outpatient surgery volumes. The ambulatory surgical centers may be impacted as well with not only soft demand but over-capacity to create a "very difficult fundamental environment" over the near-term, they said.

The Certification Commission for Health Information Technology of Chicago and the Drummond Group, Inc. of Austin, TX, have been named by the Office of the National Coordinator for Health Information Technology as the first technology review bodies authorized to test and certify electronic health record systems.

With the announcement of the testing and certification bodies, EHR vendors now can begin to have their products certified as meeting and supporting meaningful use criteria released in July by the Centers for Medicare & Medicaid Services. Applications for additional authorized testing and certification bodies are still under review.

Certification is "a crucial step because it ensures that certified EHR products will be available to support the achievement of the required meaningful use objectives, that these products will be aligned with one another on key standards, and that doctors and hospitals can invest with confidence in these certified systems," says David Blumenthal, MD, the national coordinator for health information technology.

Certification of EHRs is part of the initiative undertaken last  year under the Health Information Technology for Economic and Clinical Health (HITECH) Act, which created new incentive payment programs as part of the American Recovery and Reinvestment Act to help healthcare providers as they transition from paper?based medical records to EHRs.

"Multiple steps are underway to carry out the intent of Congress in supporting rapid and effective adoption of EHRs throughout our health care system, Dr. Blumenthal says.

 
CMS is working to create an online system for providers to register and attest for the EHR incentive programs, according to Blumenthal. The first incentive payments are targeted to be made in May 2011. Meanwhile, the ONC is also carrying out new programs of technical assistance and training—especially for smaller hospitals and physician practices.

We are gratified to be among the first organizations authorized to certify EHRs by ONC," says Karen M. Bell, MD, chair of CCHIT. CCHIT plans to launch its authorized certification program on Sept. 20 with a town hall-type webcast describing its application and testing process; CCHIT will take new health IT developer applications immediately after. The first group of certified complete EHRs and EHR modules are expected to be announced within weeks of that launch.

In addition to certification, CCHIT will continue to offer its CCHIT certified program for ambulatory and inpatient EHR products that exceed the ONC criteria and are designed for hospitals and physician practices that are "looking for assurance of more robust, integrated EHR products," the company says.

"We highly commend the work of ONC and their accreditation process which tested the details of our testing and certification process and our industry knowledge," says Rik Drummond, CEO of the Drummond Group.

"Having started new tests with other industries, we found this approval process to be the most demanding and the most thorough we have encountered," he added.

This summer, my family took a sidetrip to Weston, WV—home to what is now called the Trans-Allegheny Lunatic Asylum. This huge, now-empty stone building with the majestic clock tower was closed (as Weston State Hospital) in 1994—and opened for tours several years ago. But the stories it leaves behind can trigger a new perspective on a very modern issue: quality improvement initiatives and ethics.

Construction of the facility—which has been classified as the second largest hand-carved stone masonry building in the world (next to the Kremlin)—started in 1858. The design called for long and rambling wings that could provide therapeutic sunlight and air, in the midst of a bucolic environment for its patients—those identified with varying mental conditions or recuperating from illnesses such as tuberculosis.

But laced into that history of the hospital are stories of early 20th century treatments such as "hydrotherapy" with patients wrapped in sheets and suspended in ice water baths for hours or even days. Or, even darker yet, of transorbital lobotomies performed by medical professionals with ice pick-like instruments in the 1940s and 1950s.

These "treatments" are considered cruel and even barbaric by today's standards. But at the time, they were seen as providing "acceptable" outcomes—at least in the view of various medical professionals—that could improve the life of the patient.

While decades have passed since these treatments appeared and disappeared, an interesting question, though, continues to hover: are all medical organizations making sure that their quality initiatives are meeting ethical standards?

This issue is addressed in a brief "to advance the policy debate" compiled by the Commonwealth Fund. The authors note that over the last two decades, quality improvement initiatives have flourished among hospitals and healthcare systems. But, while enhancing the quality of healthcare is important—and often required by accrediting organizations and others—the process of improvement can raise ethical issues.

They note, for example, questions that were raised in 2001 about a project on end-stage renal disease that was funded by the Centers for Medicaid & Medicare Services. While CMS considered the project to be a quality improvement initiative, the Office for Human Research Protection (OHRP) determined it was human subject research and that it should have been reviewed by an institutional review boards (IRB) prior to implementation.

And, in 2007, an anonymous whistleblower accused the leaders of a project in Michigan (funded by the Agency for Healthcare Research and Quality) to reduce life?threatening infections in intensive care units—through the use of checklists—of not having received proper ethical review. Questions were raised about whether the project constituted research and if informed consent should have been obtained from all patients who were involved.

The authors found that "despite myriad proposals" regarding the ethical oversight of quality improvement, "surprisingly little empirical research" has been reported on the review and oversight of quality improvement initiatives.

To get a better understanding of where this issue is now, they carried out two surveys. One was conducted in collaboration with the Institute for Healthcare Improvement (IHI) in April 2009 of quality improvement practitioners that had participated in IHI's "100.000 Lives Campaign."

The majority of IHI respondents in the study self-identified as managers either in a quality improvement/safety department or other hospital department. Most of the respondents (83%) indicated that quality improvement initiatives conducted by their faculty and staff were subject to some type of review prior to implementation; most of those (85%) reported that the review is conducted most of the time or always.

A majority of respondents said that they also agreed that assessing established practices (67%), scientifically sound design (62%), transparency (62%), and the identification and minimization of potential conflicts (57%) were ethical considerations for quality improvement initiatives conducted at their institution.

The authors also sought out the opinions of hospital CEOs through a survey conducted last November. About 71% of the CEO respondents indicated that quality improvement initiatives conducted by faculty and staff affiliated with their organization always were reviewed by some entity within their organization prior to implementation; 26% said that quality improvement initiatives sometimes were reviewed prior to implementation.

A larger proportion of hospital CEO respondents (56%) reported that an oversight mechanism pays attention to ethical issues "well"—compared with the IHI group at 45%. And, nearly twice as many hospital CEOs (70%) as IHI quality improvement professionals (40%) indicated that QI initiatives at their institution are funded by internal sources.

Overall, this means that according to the authors' data, quality improvement initiatives are being routinely reviewed by a variety of internal mechanisms prior to implementation—although rarely through the institutional review board or any other independent body charged specifically with ethical oversight.

This is turn raises more questions about whether an independent review board could provide a more independent assessment of quality initiatives? Or, whether activities that pose little if any risks or burdens even require such a review?

As the authors note, those answers still aren't easy, and in fact, require more research—particularly on how existing review mechanisms for quality improvement initiatives are structured: This includes who reviews these activities, how they are reviewed, and whether such processes include an ethical assessment of the proposed QI intervention?

This research, they said, is essential to ensuring that quality of care is improved and patients' rights and interests protected. The long-lost voices of the residents former Weston State Hospital would probably agree.

The Congressional Budget Office (CBO), incorporating its latest August 2010 outlook report data on the budget, estimates that the effects of the healthcare reform legislation approved in March will reduce the projected deficit in 2020 by $28 billion, with an additional $2 billion projected as well from education provisions.

CBO Director Douglas Elmendorf, responding to a query by Sen. Mike Crapo (R-ID), a member of the Senate Finance Subcommittee on Health Care, noted that the Patient Protection and Affordable Care Act (PPACA) and the subsequent reconciliation law approved by Congress will produce $143 billion in net budgetary savings between 2010 and 2019. This figure includes $124 billion in net savings for the health and revenue provisions of both laws and $19 billion in net savings.

In answer to another question, CBO estimated that the cost of preventing Medicare payment reductions to physicians under the sustainable growth (SGR) formula would be $330 billion between 2010 and 2020. This would include the 2.2% increase approved by Congress in June (through November) and allowing for subsequent inflation updates.

CBO had previously estimated that the costs of freezing payment rates at the 2009 level for six months—during the second half of 2010—and allowing for an inflation update for 2011 through 2019 for physician payment rates would total $278 billion.