Thursday, December 27, 2012

Ensuring Patient ID Online

Although patient identification has long been an issue within the hospital community, a new push in the conversion to electronic health records (EHRs) has added new challenges and solutions. Some organizations, like the Department of Defense (DoD) are already verifying the identity of their patients and other authorized users of their online system, MyHealtheVet. The DoD, however, has the luxury of a Veterans Administration database that includes all military personnel that would be accessing the system.

What health systems without pre-existing user databases should do is still up in the air. Privacy and security experts have not yet decided which methods of ensuring patient identity online are most effective and easiest to use. No matter the conclusion, however, most agree that it will still be necessary to verify patient credentials like a driver’s license, passport, or biometric identifier before allowing that patient to access their records online. 

Some states are implementing programs allowing access to partial records. Indiana’s State Department of Health, for example, has an online vaccination portal which allows parents to verify their children and view online immunization records. A parent must be registered by their child’s healthcare provider, and all access requests are monitored by a separate system.

Other businesses, such as identity card company Gemalto, are suggesting the use of SmartCards for patients. These cards, similar to the federal government’s Common Access or “CAC” cards, will contain a chip with biometric information about the user.

A federal policy committee has provided three guidelines that should be followed when thinking about enabling online access. The access should require a username and password at the minimum, with the option for additional security if the user chooses. The protection should not be so difficult that it discourages patients from participating, and providers should look to the Office of the National Coordinator for Health Information Technology (ONC) for guidance on identification methods. While this guidance has not yet been provided, a team within the National Institute of Standards and Technology has directed the agency to work with the ONC in setting up best practices.

You may find the original article from the Government Health IT website here

Hospitals Get Creative to Limit Medicare Readmissions

Since October, Medicare has been calculating the number of Medicare patients readmitted to hospitals within 30 days of their discharge. This data is kept for the new Value Based Purchasing Program, a part of health care reform (HCR) that penalizes hospitals with high rates of readmission by withholding a part of their reimbursement money.

The program has begun to change the payment structure of Medicaid away from government payments to hospitals per procedure, and towards payments for the overall wellness of the patients. These changes are a welcomed change by many patients, and even by some health care professionals who believe that this is the way hospitals will be paid in the future.

As a result, some hospitals have been employing new techniques to ensure that patients are able to care for themselves at home. According to an article in the Waco (TX) Tribune, some hospitals in Texas will have a nurse call the patient at home to follow up on their recovery and ask if there is anything the patient needs. Others will automatically schedule a follow up appointment with the patient’s doctor. Still others may send health care professionals to the patient’s home to ensure a smooth transition.

Many hospitals employ a discharge questionnaire that asks questions such as “will there be a friend or family member to assist you at home,” “Are you able to get to the pharmacy,” and “do you understand any changes in medication?” While these questionnaires have been in place for a while in many hospitals, some have tweaked the questions in an effort to prevent readmissions.

The program, combined with the resulting changes in hospital procedure, mark a significant change in hospital culture. This change will be important over time, as penalties for readmissions only escalate in the coming years. 

Thursday, December 20, 2012

CDC Predicts a Bad Flu Season

The Centers for Disease Control and Prevention (CDC) warned the public earlier this month to be prepared for a bad year of the flu. The CDC found that this year’s flu season got underway in late November, the earliest start since 2003. The CDC also warns that the strain being seen this year tends to be more severe than in the past.

Normally, a spike in flu like symptoms is not expected until late December, but the CDC reported that the season kicked off the week of November 24th. During that week, about 2.2% of doctor visits were for flu-like symptoms.

The flu is expected to be especially bad in the south, where five states are seeing outbreaks. These states include Tennessee, Mississippi, Alabama, Louisiana, and Texas. Meanwhile, Georgia and Missouri are reporting moderate levels of this year’s strain.

The best tool against infection is still vaccination. The vaccine that is available this year is well equipped to handle the flu, according to the CDC, and officials there believe the vaccine will be effective. So far, 123 million doses of the vaccine have been distributed, and 112 million of those have been administered.

This year, unlike past years, there is not expected to be any shortage of vaccines, so everyone should be able to get a vaccine if they want one. The CDC especially recommends vaccinating vulnerable groups including children, pregnant women, and healthcare workers.

You can view the Denver Post article here, and the CDC report here

OIG Report finds that More Oversight is Needed in EHR Incentive Program

More oversight is needed for the new Medicare Electronic Health Record (EHR) program, according to a report from the Health and Human Services’ (HHS) Office of the Inspector General (OIG).

The program started in 2011 under Center for Medicare and Medicaid (CMS) studies and disbursed about $1.7 billion in its first year. CMS estimates that they will pay a total of $6.6 billion in incentive payments throughout the life of the program, which goes through 2016. More information on the program can be found here.

The report found that, while cursory checks were done to ensure eligibility in the program, the program mostly operates by applicants self-reporting. The model can work, but there was not enough verification done to ensure that the self-reported data was correct. The report stated that CMS “does not verify that… percentage-based measures [reported] reflect the actual number of patients for a given measure, or that professionals and hospitals possess certified EHR technology.”

Specifically, CMS has not yet done any post-payment audits, and they do not have a system in place to assess a potential recipient before a payment is made. Part of the issue may be the limited information that is included in reports that are collected by the Office of the National Coordinator for Health Information Technology (ONC) and shared with CMS.

As a result, the OIG report suggested that CMS set up a pre-payment verification system, where they obtain supporting documentation from applicants, and that they provide guidance and specific examples of what would represent acceptable supporting documents from applicants.

The CMS Acting Administrator Marilyn Tavenner responded to the report, saying that pre-payment audits were not necessary. She contends that these audits would only slow down the process and delay incentive payments, but she agreed with the need for CMS to provide more guidance on documentation.

The report also suggested that ONC improve their reporting and certification programs for EHR technology so they can verify information that CMS is getting from applicants.

You can find the full OIG report here, and the Modern Healthcare article on the report here

More States Opt for Federal Health Exchanges than Expected

An important state health insurance exchange (HIX) deadline has come and gone, and it seems that more states will be opting for the federal option than experts originally thought.

In line with implementation of the exchanges under the Affordable Care Act, states had three options to choose between. There was the state-based exchange, in which a state would run its own HIX, the federal-exchange which ceded control of the HIX to the federal government, and a partnership option where the state and federal governments work together.

The Department of Health and Human Services (HHS) set a deadline of December 14th for states to report their decision.  States that opted to run their own exchanges were also required to submit blueprints of the HIX plans for approval. This deadline was moved from November at the request of the Republican Governors Association. NAHAM News previously reported the shift on November 16th (States Given More Time to Work on Health Exchanges).

The deadline has come and gone, with 18 states and the District of Columbia opting for their own exchanges. An additional 7 states have indicated that they will partner with the federal government, and the remaining 25 states default to the federal exchange. These partnership numbers may change slightly, however, because states that are not running their own exchanges have until by February 15, 2013 to partner with HHS.

State run exchanges will be put in place by California, Colorado, Connecticut, District of Columbia, Hawaii, Idaho, Kentucky, Maryland, Massachusetts, Minnesota, Mississippi, Nevada, New Mexico, New York, Oregon, Rhode Island, Utah, Vermont, and Washington.

Partnership exchanges will be put in place by Arkansas, Delaware, Illinois, Iowa, Michigan, North Carolina, and West Virginia.

These numbers are interesting for a number of reasons. First of all, many of the states that defaulted to the federal system have Republican governors who emphasize the importance of the state government. Some of those governors have supported their decision to default to the federal option by calling a state HIX, “state run in name only.”

Secondly, most experts expected the number of states that opted for the federal option to be much lower.  Mostly, only small states were supposed to default to the federal system. While states can switch to their own health exchanges in future years, the logistics of the first year are going to be a challenge for HHS.

See the Kaiser Family Foundation map of States decisions here. This article was written with research from and NPR article, and a Healthcare IT News article

Joint Commission Releases 2013 Survey

The Joint Commission has released its 2013 Survey Activity Guide for Health Care Organizations.

You may find it here, and it is also posted on NAHAM’s Joint Commission Toolkit, available to NAHAM members online.

The Joint Commission’s 2013 Survey Activity Guide (released December 18, 2012) has replaced the 2012 guide. The guide provides detailed information to help an organization prepare for an accreditation on-site survey. Included is a description of each activity that takes place during an accreditation on-site survey including logistical needs, session objectives, suggested participants and an overview of the session.
Also available online to NAHAM members is an archived webinar that introduces the toolkit and discusses Joint Commission surveys, the toolkit, Tracer Methodology, and other special considerations for your next Joint Commission Survey.  The webinar is presented by Michael Sciarabba, CHAM, Director of Patient Access Services, Advocate Illinois Masonic Medical Center and the chair of the NAHAM Policy Development/Government Relations Committee and Brenda Sauer, RN, MA CHAM, Director, New York Presbyterian Hospital and NAHAM’s current Vice President.

EHRs May turn Small Errors into Big Ones

A new review of electronic health records (EHRs) by the Pennsylvania Patient Safety Authority found that mistakes made in EHRs can be farther reaching than errors using traditional paper records.

The study examined over 3,000 incidents over the course of 8 years that stemmed from EHR errors. In about 80% of the cases, the results were errors with medication, and many of the rest involved incorrect or unnecessary lab tests. In the medication errors, about half of the patients were prescribed the wrong medication, and another quarter were under medicated.

So why are mistakes traveling farther? Electronic systems are becoming increasingly networked to things like the hospital pharmacy or other health information exchanges. This means that an error that may have previously been caught before it was replicated may now cascade to other systems before being caught. The scale and amplification of mistakes has increased.

The article, published here, also points out that in the short run, more mistakes are being made. One cause of this could be the lack of training that users of the systems have received. Federal programs that incentivize the implementation of electronic systems, and deadlines that came with the 2009 stimulus funds may have caused a quick rollout of systems to staff members who did not yet know how to use them. Additionally, some facilities may be using EHRs in addition to paper records, producing incomplete information entered into the system.

In some systems, information that is typed into the wrong box is not recognized. In others, system glitches can cause issues, like random medication orders appearing in some patients records.

Most experts believe, however, that these are temporary setbacks. As time progresses, EHR systems will become smarter, and staffs will become accustomed to using them. Long term, most still agree that EHRs serve as an investment that will yield future gains. 

Thursday, December 6, 2012

Public Hospitals Seek Patient Input for new Approach

A growing number of public hospitals are engaging their patients in a conversation on how to improve service. New committees and boards have been set up across the country, with membership comprised of patients or patients’ families. These committees seek the voice and the view of the patient as it relates to how care is delivered within the hospital.  The timing for this is not by accident.

Patient input and satisfaction have come back into the spotlight due to incentive programs recently put in place by the federal government. The Affordable Care Act carried with it both stick and carrot approaches to encourage hospitals and other patient care facilities to place patient care first.

The new Medicare Value Based Purchasing Program serves as the stick. The program focuses on the whole of patient care, including patient readmissions, shifting away from the traditional fee for service reimbursement model. Hospitals can lose from one to three percent of federal reimbursements for high readmission numbers. NAHAM News previously reported on this program here (Medicare’s new Value Based Purchasing program: Enough to inspire hospital change?)

The carrot, on the other hand, comes in the form of an Electronic Health Record (EHR) incentive program that rewards hospitals for utilizing the new technology. The program is still in its first stage, focusing on raw implementation of EHR systems, but the second stage will focus on meaningful use of the records. The program mandates that EHR technology must provide patients with an online means to view, download, and transmit selected data. More information on the EHR Incentive Program can be found here.

The Gordon and Berry Moore Foundation is also providing a carrot with their Patient Care Program. The program works towards eliminating patient harm with a two pronged approach. They emphasize meaningful patient and family engagement, and a reengineering of hospital processes. In turn, they believe that healthcare will become more cost effective and be more respectful to the patients and families they serve. To work toward the goal, they are planning to give out $500 million in grants to hospitals willing to alter their patient care model.

Ideas that come from these patient committees or boards can provide simple and effective ideas for hospitals. A hospital in northern California had a logical policy that all emergency patients had to be funneled through the emergency room. This included psychiatric patients who would be forced to have psychiatric episodes in the general ER. It was not until the hospital listened to advocacy from the mother of a mental health patient that the policy was changed to allow direct access to the psychiatric emergency department. This simple shift restored a sense of dignity and respect to an entire group of patients.

Another hospital in Oakland, California was shocked to hear about issues that patients experience when working with multiple hospital units. In this instance, physician rounds at 2pm meant that a nurse wouldn’t order a prescription until 2:30, which left little time for a patient to fill it in the discharge pharmacy before it closed at 3pm. This may delay a discharge and prevent another patient from getting an inpatient bed.
Still, other hospitals are requiring staff to attend patient care events that include patient panels and best practice discussions.

You can find the original article from here, but it requires a free subscription.

Changing Health Technology Challenges Traditional Privacy Laws

An improvement in health technology and the use of electronic health records (EHRs) is often touted as a movement that will improve communication between physician and patient. EHRs have enabled patients to access their records online, doctors to easily access patient history remotely, and hospitals to improve patient care.

Some new devices, however, have been testing the gray area left by patient privacy and patient access laws. Under the spotlight in a recent Wall Street Journal article were new implantable defibrillators. These devices serve a dual purpose, while they can correct an irregular heartbeat in patients, new models also collect information about the patient’s heart beat for the maker of the defibrillator. This information is collected and stored onboard the implant, while wireless monitors in the patient’shome download the information and send it to the parent company for the device. The information is provided to doctors and hospitals, but not patients directly. Medical device companies are also contemplating selling the collected information to health systems or insurers so they can use it to predict diseases and lower costs.

These types of records are not covered under the 1996 federal Health Insurance Portability and Accountability Act (HIPPA), because that law only gives patients the right to access information held by hospitals and doctors. The law, which some now claim is outdated, does not cover information collected by medical device companies. In fact, one company claims that federal laws prohibit giving the data collected back to the patient, since the customers of medical device companies are doctors and hospitals.

Another privacy concern involves new smartphone health apps that have also risen in use.  These apps have been praised for allowing users to do anything from collect their medical images to manage their incontinence. However, since the programs do not require FDA approval or doctor supervision, they are also not subject to HIPPA privacy or disclosure requirements.

Device and app companies contend that even if they voluntarily gave information directly to patients, the patient would likely not understand it. Implantable defibrillators collect raw data about heart rhythms, other devices or apps may report raw data to suggest a change in medication. Data of this type are typically not understood by those who have not had medical training.

This fact does not deter some patients who feel that they are within their rights to request information that is collected form their devices. Especially since as of now they are required to pay a copay and see their doctor if they want the information.

Regardless of your stance on the issues, the advice seems consistent. Be aware of what you are agreeing to when downloading smartphone apps, and work with your doctor of obtain and interpret medical device data.  

Changes to Medicare Looming

It is extremely likely that changes to Medicare are coming. The fiscal cliff is looming, the national debt is climbing, and spending on health entitlement programs such as Medicare, Medicaid, and Social Security are only foretasted to increase in the coming years.

With that in mind, many stakeholders and policymakers have different ideas on what to do with the programs, more especially Medicaid.

An idea that keeps surfacing from both sides of the political aisle is to raise the retirement and Medicare eligibility age from 65 to 67. Republican Senators Lindsey Graham (R-SC) and Bob Corker (R-TN) have both suggested the idea, and President Obama reportedly put the retirement age on the table in fiscal negotiations with Speaker of the House John Boehner (R-OH) last year.

The draw of raising the retirement age would be an immediate reduction in federal spending on Medicare, to the tune of 5% per year. A consequence, however, would likely be increased total spending on health care by consumers, according to a Kaiser Family Foundation (KFF) report.

Raising the retirement age would take 65 and 66 year olds, who are usually the healthiest in the Medicare participant pool, out of that pool. This would raise the risk, and therefore the premiums, for participants who are 67 and older in the program. In turn, the 65 and 66 year olds would be placed into the pool of citizens that can purchase insurance through the health insurance exchanges (HIX). When grouped with 18-64 year olds, these 65 and 66 year olds tend to be “sicker”, so their presence would also raise rates in the HIX pools.

The study from KFF found that federal government savings would be more than offset by costs to states, individuals, and employers with increased premiums.

Another part of Medicaid being considered are the reimbursement rates that doctors receive for the work done on patients. An NPR article explains that, if we go over the fiscal cliff, reimbursement rates would be cut by 30%. This number is the accumulation of annual 4% cuts in reimbursements that have been delayed for several years.

This means that, in an example given by the article, a doctor that treats a Medicare patient with an exam and a cardiogram would see their fees drop from $160 to about $120.

Find the full NPR article here