What’s New in the NAHAM Joint Commission Survey Toolkit

Check out TJC Survey Toolkit and the What’s New section.  The Toolkit is accessible by NAHAM members with a valid username and password.  Go to NAHAM.org to sign in.  Look under “Government Relations” on the left-side banner.

2013 National Patient Safety Goals

The Joint Commission has revised its 2013 National Patient Safety Goals for Hospitals, effective January 1, 2013. 

The new goals for hospitals may be found here: http://www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_HAP.pdf, as well as through the link provided in the Toolkit section V, TJC Resource Link. 

In addition its 15 goals, including Goal 1 (Improve the accuracy of patient identification.), the 2013 also includes Universal Protocol for Preventing Wrong Site, Wrong Procedure (UP.01.01.01: Conduct a pre-procedure verification process.).  As a goal, among its principles are “wrong-person, wrong-site, and wrong procedure surgery can and must be prevented.” (Emphasis added by NAHAM News.)

New R3 Report focuses on patient flow

The Joint Commission released “R3 Report Issue 4” that provides the requirement, rationale and references for the updated Leadership standards that emphasize the importance of patient flow in hospitals, in particular the patient flow through the emergency department.  See Toolkit section V, TJC Resource Links.

The Joint Commission notes that “Although overcrowding and patient boarding in the emergency department have drawn widespread attention, the revised standards make clear that the flow of patients must be managed systematically throughout the entire hospital.” (Emphasis added by NAHAM News.)

The R3 Report addresses three key points: 1) The use of data and metrics to better manage patient flow as a hospital-wide concern; 2) The safe provision of care for patients when boarding occurs; and 3) Mitigating risks experienced by patients with psychiatric emergencies who are boarded in the emergency department. 

New “Speak Up” video focuses on managing pain

Hopefully NAHAM News readers are familiar with The Joint Commission’s Speak Up series.  The most recent release is "Speak Up: About Your Pain," a 60-second animated video intended to illustrate the reasons why it is important for patients to speak up about their pain.  As with other videos and material offered through the Speak Up series, it is also intended to provide easy-to-understand examples for the general public.

"Speak Up: About Your Pain" explains that proper pain management can help patients feel better and heal faster, and encourages everyone to: 1) Make sure their pain is assessed by a health care provider; 2) Describe the pain they are experiencing to their caregivers; 3) Take appropriate steps to alleviate pain instead of trying to "tough it out;" 4) Ask their doctor or other caregiver about an alternative pain treatment if medication causes side effects; and 5) Inquire about other methods for treating their pain, such as physical therapy, acupuncture or massage therapy. 

The new video may be found here: http://www.jointcommission.org/multimedia/speak_up_about_your_pain_english/, as well as through the link provided in the Toolkit section V, TJC Resource Links.

Readers should check out the entire series. “Speak Up: About Your Pain” is the eighth installment of the Speak Up video series. Previous videos emphasize the importance of speaking up and asking questions about: health care, preventing infection, taking and managing medication safely, preparing for a doctor’s office appointment, reducing the risk of falling, and understanding patient rights. There is also a video produced for children that encourages them to speak up about their own health care. 

About TJC Speak Up Series

The Speak Up campaign urges all patients to take a role in preventing health care errors by becoming active, involved and informed participants on the health care team:

Speak up if you have questions or concerns. If you still don’t understand, ask again. It’s your body and you have a right to know.

Pay attention to the care you get. Always make sure you’re getting the right treatments and medicines by the right health care professionals. Don’t assume anything.

Educate yourself about your illness. Learn about the medical tests you get, and your treatment plan.

Ask a trusted family member or friend to be your advocate (advisor or supporter).

Know what medicines you take and why you take them. Medicine errors are the most common health care mistakes.

Use a hospital, clinic, surgery center, or other type of health care organization that has been carefully checked out. For example, The Joint Commission visits hospitals to see if they are meeting The Joint Commission’s quality standards.

Participate in all decisions about your treatment. You are the center of the health care team.

Find more information about the Speak Up program and free downloadable files of all the Speak Up videos, brochures and posters (including Spanish language versions) on The Joint Commission website: http://www.jointcommission.org/speakup.aspx. 

New HIPAA Rules Take Effect

This week marked the effective date for some new privacy and security rules that were released by the Department of Health and Human Services (HHS) in January. The rules, mostly amendments to the 1996 HIPAA law, took effect on Tuesday, but most have a 180 day compliance window built in.

According to Modern Healthcare, the new rules expand HIPAA privacy and security coverage, and direct liability for violations to business associates of HIPAA “covered entities.” Those contractors might include vendors of remote-hosted EHRs, office-based physicians, or firms providing hospitals with clinical and financial data analytics. In addition to healthcare providers, HIPAA covered entities include claims clearinghouses and insurance plans. 

Another major change under the rule involves the policies and technologies needed to comply with a patient consent management provision. Under powers given to HHS under the American Recovery and Reinvestment Act, a patient who pays out-of-pocket for treatment can ask a provider not to share a record of that treatment with the patient's health insurance plan. Providers must comply with that request, presenting a challenge to EHR systems and staff training.

To tackle this issue, several private sector developers as well as the Veterans Affairs Department and other federal agencies, and others have come up with a new software system. This system is capable of tagging entire patient records or pieces of them to block their exchange pursuant to this new rule as well as other federal and state privacy laws. 

Cutting Medicaid Costs through Reduced ER Visits

Faced with rising Medicaid costs, most states are trying to come up with ways to save money. About a dozen states have proposed plans that would refuse to pay emergency room costs for patients whose problems could have been solved with a doctor office visit.

Proponents are basing their proposal on a widely held belief that people without private health insurance use public emergency rooms for minor or routine complaints. The supporters believe that this policy would encourage those individuals to get, and be treated by a primary care doctor where the care may be better and the price tag is cheaper.

The obvious problem that arises, however, is in figuring out how patients will know what is an emergency verses what can be treated with an office visit. As an NPR Shots article points out, people come to the ER with symptoms, not diagnoses. Opponents say that enacting a policy like this can discourage people from using the emergency room in cases where they should be there. Chest pains, for example, can be a heart attack or indigestion, but patients need to be in the ER if it is the former.

Under the Affordable Care Act, Medicare and private insurers are required to pay for emergency room visits that a “prudent layperson” would consider necessary; like the chest pains visit that turns out to be indigestion. Medicaid recipients, however, are not afforded the same protection.

One study cited in the article looked at the discharge records for 35,000 people that visited the emergency room in 2009. When researcher separated out the people that had primary care treatable problems, they were found to only make up six percent of all the records in their study. Additionally, the six percent of primary care treatable patients presented with the same symptoms as 89 percent of people that went to an ER.

Washington passed a plan to cut ER payments that was later overturned by the governor. Without state Medicaid programs paying, the cost for these ER visits would be passed on to the hospitals. 

Continuing Resolution to Fund the Government Passed

The Senate passed a Continuing Resolution (CR) yesterday to keep the federal government running through the end of the fiscal year. While the bill was passed a few days later then expected, it was passed in time to avoid the government shutdown that would happen when the current continuing resolution to fund the government expires on March 27^th. The House of Representatives passed the Senate’s bill this morning with bipartisan support.

The CR included concessions from both Republicans and Democrats. Both parties seemed to be more willing to make concessions in the short term so they can focus on a full budget resolution for the next fiscal year. According to the Washington Post, House Republicans compromised for bill that locks in the sequester cuts for the rest of the year even though they were holding out for further entitlement reform, and Democrats who wanted to reverse the sequester agreed to leave it in place for now.

Politico reports that the CR includes detailed appropriations for two-thirds of this year’s discretionary spending, as opposed to broad language. Funds were added back to some programs, but further cuts were made to other programs to balance out. The measure gave back $21 million of the $51 million that was cut from the Food Inspection Service in hopes that mean inspection interruptions would be minimized. On the other side, however, the Federal Aviation Administration will still have to cut rural air traffic controllers as ordered under the original sequestration measures.

Since the House and Senate have very different plans when it comes to social safety net and health care programs, non-defense entitlement programs were not changed in the CR. This leaves in place the sequestration cuts effecting the Department of Health and Human Services that went into effect on March 1^st.

The bill will now head to President Obama’s desk, where his signature is expected. With the government funded for the next six months, the House and Senate will begin talks into creating a 2014 budget that can be passed by both houses of Congress. The House and Senate have both released budget proposals, but both are currently too partisan to pass the other house and be signed into law. 

Differing Hospital Ratings

Hospitals all over the country often compete to be listed as a “top hospital”, or to be named to the “hospital honor roll.” Evaluations of hospitals are proliferating, giving patients unprecedented insight into data that they can use when choosing where to go for care. The lists are put out by non-profits and professional organizations alike, both on a state and national level, and can lead to more recognition, more patients, and more money.

According to Kaiser Health News, though, these ratings can sometimes provide as much confusion as clarity. Each organization uses their own methodology to rank facilities, sometimes resulting in wildly different conclusions. St. Mary Mercy Linovia Hospital in Michigan, for example, was given an “A” by The Leapfrog Group, a respected nonprofit that promotes patient safety. The company Healthgrades named it one of America's best 50 hospitals. But the Joint Commission and U.S. News and World Report omitted St. Mary from their best hospital lists due to high readmission rates and what they deemed to be excessive tests.

The process of ranking hospitals is still in its infancy and the quality of the data is rudimentary. Some agencies are also shifting their criteria as the Affordable Care Act changes the focus from procedural based rating to quality based ratings. This could lead the ranking systems to get more confusing before they equal out.

For a fee, most ratings can be used in hospital promotional materials. Others can be viewed online, which is important in an age where the internet is the first research step. While the debate over the ratings scales will continue, most hospitals still aspire to be on the various lists. 

Healthcare Costs Under Fire in Budget Battles

The budget battle is underway in Washington, and healthcare programs seem to be in the cross hairs. Republicans in the House and Democrats in the Senate have come out with budget proposals that differ dramatically. House Budget Committee Chair and former Vice-Presidential Candidate Rep. Paul Ryan (R-WI) announced his budget at a press conference on Tuesday. His plan would balance the federal budget by 2023, largely by reducing spending. Certain provisions proposed in the plan, however, have Washington insiders calling it a non-starter.

The Ryan plan, similar to the budget that he released last year, would deal a huge blow to healthcare programs in general, and specifically calls for the repeal of the Affordable Care Act. According to Politico, defunding the ACA alone accounts for almost half of the $2.72 trillion in healthcare spending cuts outlined in the plan. The Ryan plan also calls for Medicaid to be changed into block grants, and for Medicare to introduce a voucher system while raising the eligibility age for those who are currently under 55. The budget all together recommends $3.93 trillion in spending cuts on top of the sequestration cuts, which would stay in place.

Democrats responded to the Ryan budget proposal by releasing their budget on Wednesday. The proposal, announce in Committee by Senate Budget Committee Chair Patty Murray (D-WA), includes a sharp contrast of only $275 billion in healthcare spending cuts. Of that, $265 billion would come from Medicare and $10 million would come from Medicaid. The specific ways that the cuts would be implemented was unclear. The bill proposes a total of $1.85 billion in deficit reduction over 10 years through a combination of spending cuts and increased revenue. That is in addition to the $2.4 trillion in deficit reduction called for in current law. Read more about the Murray proposal in this Politico article.

Both of these proposals would have to pass both houses of Congress, which is highly unlikely in their current forms.  These budgets are through to be the starting points for each side of the aisle, from which they can work to a compromise. If a budget is passed, would be effective for the next fiscal year. The Senate is currently debating a continuing resolution, already passed by the House, that would fund the government from of March 27th through the end of the fiscal year.

Health Insurance Marketplace Draft Application Released

The Department of Health and Human Services (HHS) came out this week with a draft insurance application, showing what applying for benefits under the Affordable Care Act exchanges may look like. The application runs 15 pages for a family of three, extinguishing some hopes that signing up for a plan could be as simple as online shopping.

According to a CNBC/AP article, the online application outline is not much shorter, running at least 21 steps. Some of the steps have multiple questions included. The information will then be reviewed by at least three major federal agencies, including the IRS, to verify an applicant’s identity, citizenship, and income. The IRS is supposed to process online financial application in real time because the ACA is means-tested, meaning that lower income people get the most generous help to pay premiums.  Middle class applicants will be eligible for tax credits to help pay premiums to private companies, while low income applicants may be eligible for social programs like Medicaid.

The draft applications in paper and online form were posted by HHS seeking feedback from consumer and industry groups. HHS estimates that the online application will take about 30 minutes to complete, and the paper version will take about 45 minutes. Some groups are concerned that at that length, the form may overwhelm uninsured people, leading them to simply give up. Giving up will be an issue next year when carrying health insurance becomes mandatory.

HHS estimates it will receive more than 4.3 million applications for financial assistance in 2014, with online applications accounting for about 80 percent of them. Because families can apply together, the government estimates 16 million people will be served.

Auditors Urge Security for EHR Networks

Government auditors stressed the need for hospital network security in the New England Journal of Medicine last month. The auditors claimed that hacking into patient electronic health records (EHRs) can be as easy as tapping into the system using a laptop in the hospital parking lot. To prove it, they did exactly that.

Security breaches like the one demonstrated by the auditors have resulted in 300,000 Medicare beneficiary numbers being compromise. This has ramifications for all of us, not just the individual whom the number belongs to. According to MedPage Today and the New England Journal of Medicine, breaches in patient information can enable insurance fraudsters to defraud private insurers as well as Medicare and Medicaid. Taxpayer money is then drained away from services, resulting in waste and higher costs for beneficiaries. Additionally, patients can suffer harm if hackers change information in the patient’s EHR. Mislabeling a medical condition can lead to improper treatment, and changing the frequency that a prescription can be filled can leave patients without critical medicine.

Auditors and their colleagues from the Office of the Inspector General (OIG) at the Department of Health and Human Services (HHS) recommend that best practices for security be employed both in and out of hospitals. They recommend measures like password protection, firewalls, antivirus software, private consultation rooms, controlled prescription pads, paper shredding, biometrics, and secured copy machines.

The same security practices should be employed when healthcare workers access records from home laptops or home computers. These networks are often less secure, and scammers can obtain information to use when calling hospitals or practices pretending to be referring physicians, pharmacies, friends, or family.

The Office of the National Coordinator for Health Information Technology (ONC) recommends best practices for mobile devices here. 

CDC Cuts Mean Slow Response

The Centers for Disease Control and Prevention (CDC) is facing a funding cut of close to nine percent as a result of the budget cuts known as sequestration. The cuts total $350 million from its $6 billion budget over seven months.

These reduction could means that diseases would be detected more slowly and spread more widely before public health officials could begin efforts to contain them. This is even more relevant coming off of a flu season in which NAHAM News tracked it spread using CDC reports. According to a CQ HealthBeat article, CDC Director Thomas Frieden said that a new outbreak of influenza, such as the H1N1 epidemic that spread a few years ago from Mexico to the U.S. and other nations, wouldn’t be detected as quickly and countermeasures wouldn’t be started as promptly.

There would also be 2,000 fewer disease control specialists, which Director Frieden defined as “disease detectives and others in state and local governments — finding and stopping food-borne disease outbreaks, meningitis, pneumonia, flu, HIV, other critical health problems.” Additionally, recent progress in helping hospitals lessen the degree of infection acquired in their facilities would be slowed at a time when “superbugs” are in the news. 

CMS and ONC Renew Push for EHR Implementation

The heads of the Center for Medicare and Medicaid Studies (CMS) and the federal health information technology office stated this week that they will renew their efforts to implement electronic health records in hospitals and provider offices throughout the country. To do this, they are soliciting ideas for incentive programs and ways to improve the implementation process, according to a CQ report.

On Wednesday, Farzad Mostashari, the National Coordinator for Health Information Technology (ONC), announced a “request for information” to invite comments on how to speed up information exchanges. The request specifies that implementing the information exchanges is crucial to reforming the healthcare system, and CMS Acting Administrator Marilyn Tavenner said that they must be a routine part of care delivery.

The request for information is designed to solicit ideas for incentive programs that will reward providers for implementing the systems to lower costs and improve quality of care. The information exchanges are expected to speed the pace of sharing lab results, medical imaging, prescription drug use summaries, and other clinical data. This will avoid wasteful duplication of tests and treatments, and ward off medical errors. 

The goal of this new push is to have 50 percent of doctors’ offices using electronic health records by the end of 2013, and 80 percent of eligible hospitals receiving “meaningful use” incentive payments by that time. 

Effort to Create a Single EHR System between DOD and VA Scrapped

Last month, the Department of Defense and the Department of Veterans Affairs scrapped a much touted project to build a shared electronic health record system. The initiative, which was announced in May, was supposed to create a single virtual lifetime electronic record, or VLER, that could be accessed for DOD service members and veterans at any VA facility.

On February 5^th, VA Secretary Eric Shinseki and (then) Secretary of Defense Leon Panetta announced that they were discontinuing the program. Instead of creating a single new system for military EHRs, the agency heads decided that it would be faster and cheaper to integrate existing systems. According to representatives of the agencies, doing this would allow “quick wins” to improve healthcare.

According to the Washington Post, representatives from the agencies testified at a House Committee on Veterans Affairs hearing late last month, telling the committee that the single system plan was not feasible. Even though the first milestone was not set to come until 2014, the Director of Information Management and Technology Resources for the Government Accountability Office (GOA) told the Committee that “longstanding institutional differences” between the agencies could stand in the way of creating the system.

Members of both political parties joined veterans groups in expressing their dismay over the discontinuation of the program. According to the American Legion, over the past four years about a billion dollars has been spent working on the new system. The Defense Department continues to insist that they are still focused on achieving an integrated EHR for veterans.