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PSQH: Patient Safety & Quality Healthcare, May 25, 2017
Lawmakers have relaunched two bills aimed at lowering CMS restrictions on telemedicine coverage and test the efficacy of telehealth services in Medicare healthcare delivery reform models.
When it comes to healthcare and congress, finding bipartisan support on anything is a daunting task. That said, politicians from both sides are coming together in support of new bills aimed at improving and expanding telemedicine services in the United States.
The U.S. House of Representatives and Senate are considering both the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2017 and the Medicare Telehealth Parity Act (MTPA). The two bills are aimed at lowering CMS restrictions on telemedicine coverage and test the efficacy of telehealth services in Medicare healthcare delivery reform models. The Senate Finance Committee is also considering a bill called the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, which includes a section that would allow greater use of telehealth.
Both CONNECT and MTPA had failed to advance during previous sessions of Congress, and were re-launched by members of the newly formed bipartisan Congressional Telehealth Caucus on May 19. The four founding members of that caucus are Representatives Mike Thompson (D-Calif.), Gregg Harper (R-Mass.), Diane Black (R-Tenn.), and Peter Welch (D-Vt.)
“Telehealth saves lives and reduces costs; it’s a win-win for both patients and providers,” said Thompson in a press release. “We’ve all seen how technology has made us more connected in our daily lives. These same advances allow physicians to provide more patients with better healthcare—especially patients in rural, difficult-to-access, and underserved communities. Unfortunately, regulations haven’t kept pace with the times. These commonsense, bipartisan policies will allow us to make sure every American gets the best care and the best treatment—no matter where they live. The Caucus will give us a venue to collaborate with our interested colleagues to advance the delivery of care via telemedicine.”
“My many years as a nurse, especially my time spent working in long-term care, taught me that if Medicare is to provide real benefit to seniors while ensuring real efficiency for taxpayers, it must embrace the advances in technology and innovation that are already taking place across the health care sector,” said Black. “That is what telehealth is all about—promoting cost savings and quality care through the use of technology like remote patient monitoring services. Harnessing the power of telemedicine is a win for seniors, a win for providers, a win for taxpayers, and a win for rural Tennessee.”
If passed, the Medicare Telehealth Parity Act would:
• Allow for the provision of telehealth services in rural, underserved, and metropolitan areas, rather than just rural areas
• Expand the types of providers who can be reimbursed for telehealth services to include several kinds of allied health professionals
• Expand access to telestroke services
• Allow remote patient monitoring for patients with chronic conditions
• Allow a Medicare beneficiary’s home to serve as a site of care for remote dialysis, hospice care, outpatient mental health services, and home health services
If passed, the CONNECT for Health Act of 2017 would:
• Expand originating sites for telehealth care
• Create a Medicare remote patient monitoring benefit for certain high-risk, high-cost patients;
• Lift restrictions on the use of telehealth in ACOs and Medicare Advantage plans;
• Urge the Secretary of Health and Human Services to have CMMI evaluate the applicability of telehealth in demonstration projects;
• Authorize a study on the use of telehealth services after restrictions on coverage have been lifted.
• Save Medicare around $1.8 billion over the course of 10 years
It’s important to remember that even if these bills become law, providers will still have to be licensed in whatever state their patient is physically located.
For example, if you’re in New York and one of your patients is on vacation in California, you have to be licensed by the California medical board to treat him via telemedicine. And you still have to meet the standard of care required under California law. That won’t change under these proposed laws.
The conversation around tracking medical errors highlights a lack of safety cultures.
Why are medical errors the third leading cause of death?
It was a question asked frequently by the consumer press back in May 2016, in response to an article in BMJ (Makary & Daniel, 2016) that analyzed medical literature on such errors to better understand their contribution to deaths.
However, there’s a more pressing question that the article by John Hopkins researchers Martin Makary, professor, and Michael Daniel, research fellow, sought to address: Why aren’t we doing more research into strategies that can reduce medical errors?
Getting data on the problem
The goal of the BMJ analysis was to encourage strong research into and better reporting on preventing medical errors. Makary’s chief concern is that medical errors are not cited as a cause of death, which limits research into effective solutions.
As the John Hopkins researchers point out, causes of death are reported using codes from the International Classification of Diseases (ICD). Those causes not associated with an ICD code—namely, medical errors—are not captured. One result of this is that medical errors will never be listed on the Centers for Disease Control and Prevention’s annual list of the most common causes of death in the United States, which guides national research priorities for the year.
When ICD codes were first adopted nearly 70 years ago, medical mistakes weren’t broadly recognized as a cause of death. And in a culture where the emphasis is placed on assigning blame for problems rather than seeking solutions for improvement, there has been seemingly little interest in a broad, high-level investigation of strategies for reducing systemic medical errors and their impact on patient mortality. But by not capturing this data, healthcare organizations are losing out on a strong opportunity for improvement.
Makary and Daniel emphasize in their article that medical errors can’t solely be attributed to bad doctors. Most are the result of systemic problems stemming from challenges such as poorly coordinated care, fragmented insurance networks, or the lack or underuse of safety nets, as well as variation across physician practice patterns that lack accountability.
PSQH: Patient Safety & Quality Healthcare, May 16, 2017
Innovative military care delivery models can improve antibiotic stewardship. One example is the Cooperative High Reliability Organization, which is meant to predict critical task failures.
This article first appeared February 17, 2017 on PSHQ.
By Lt. Col. Jared A. Mort, MSN, MBA; Becky Alsup, BSN, RN; and Fabian Fregoli, MD
Overuse of antibiotics leads to drug-resistant microbes, placing patients at risk for more serious infections and sepsis, and placing more dependence on broad-spectrum antibiotics. This leads to a vicious cycle, as stronger antibiotics increase the risk of more drug-resistant microbes. Sepsis accounts for a high proportion of inpatient morbidity and mortality (Hall, Levant, & DeFrances, 2013), placing it among the top eight diagnoses that lead to inpatient death and costs. In addition, the incidence of sepsis has increased by 17% over the last decade, while other diagnoses have fallen by double digits.
Antibiotic stewardship can avoid preventable morbidity and mortality, and by extension, reduce healthcare costs. Recognizing this, the U.S. Army commissioned a new research arm to address the global threat of antibiotic overuse and preventable drug-resistant infections. In April 2016, Army scientists identified a dangerous strain of E. coli bacteria (MRSN 388634) in a patient that tested positive for resistance to colistin. The discovery gave new urgency to measures throughout the military and federal government on how to control its spread. The Army even created the Multidrug-Resistant Organism Repository and Surveillance Network (MRSN) in 2009 for biosurveillance (Sun, 2016).
In addition to discoveries in the laboratory, innovative military care delivery models can improve antibiotic stewardship. One example of innovation is the Cooperative High Reliability Organization (CHRO), a delivery model developed at Wright-Patterson (Wright-Patt) Air Force Base Medical Center (Barber, 2016) and based on the process improvement methodology called the Military Acuity Model, or MAM (Elnahal et al., 2015).
The purpose of a CHRO is to predict critical task failures (in this case, inappropriate antibiotic prescriptions) in a manner that is faster, more comprehensive, and requires fewer resources. MAM enables the CHRO to predict task failures in advance, to focus and force-multiply teams in high reliability organizations (HROs), making it possible to strive for a zero-defect culture. This care delivery improvement approach is complemented by the Fractal Model for Quality Management (Pronovost & Marteller, 2014), which helps create more easily replicable quality teams, to ensure simplicity and rapid scalability.
Aims for this study, which deployed CHRO in the Trinity Health System alongside Air Force project teams, focused on determining the advantages of:
Notifications that micro-target only predicted task failures, to in turn reduce the effort, interruptions, and other burdens placed on small footprint teams
Targeting patients “further upstream” before they become septic
Assessing the consequent reduction in restricted antibiotics, as well as other values offered by the new approach
Methods
The study population in the suburban Michigan medical setting consisted of approximately 800 patients over a four-month time period that had signs of infection, with alerting focused on 113 patient cases associated with three study cohorts.
The key “high value” tasks studied were the sepsis bundle, including lactic acid draw, blood culture draw, antibiotic administration, IV bolus administration, repeat lactic acid draw, and vasopressor tasks being completed within time limits. In the cohort identified to have tasks at risk of failure, the compliance for these high-value tasks essentially doubled from less than 40% on average to over 80% once the micro-targeting method was put in place beyond the weekdays’ day shift for the hospital. So, initially there was success in one key metric of the study.
The intervention in the CHRO was deployment of dynamic rather than static checklists to the emergency department (ED) charge nurses and sepsis team by predicting compliance. Organizing work in this way reduced task overload, focusing and force-multiplying teams. This enabled improved task shifting to minimize staff overloads (reducing failure to rescue) and under-loads (reducing opportunity costs).