Author Archives

maithri

Congratulations, Doctor, On Your Federally-Subsidized “Hardship”

Mar 13, 2014• 32

By Dan Haley

At HIMSS 2014, the health information technology’s (HIT) largest annual confab, the bestest-best news we heard from a policy perspective, and maybe even an industry perspective, was the Centers for Medicare & Medicaid Services’ (CMS) dual announcement that there will be no further delays for either Meaningful Use Stage 2 (MU-2) or ICD-10.

Perhaps we should have immediately directed our gaze skyward in search of the second shoe preparing to drop.

As it turns out, CMS de facto back-doored an MU-2 delay by issuing broad “hardship” exemptions from scheduled MU-2 penalties. To wit: any provider whose health IT vendor is unprepared to meet MU-2 deadlines, established lo these many months ago, is eligible for a “hardship” exemption.

Few would disagree with the notion that it’s unproductive to criticize policy without offering constructive ideas to fix the underlying problems.

Here, the underlying problem is easy to define: it is in point of irrefutable fact fundamentally unfair to penalize care providers for their vendors’ failings—especially when the very government proposing to penalize them put its seal of approval on the vendors’ foreheads to begin with.

CMS’s move to exempt providers from those penalties is correctly motivated, but it seeks to ease the provider pain without addressing its cause.

Instead of issuing a blanket exemption for use of unprepared vendors, CMS should:

Waive penalties only for those providers who take steps to replace their inferior technologies with systems that can meet the demands of the 21^st century’s information economy;
Publish lists of health IT vendors whose systems are the basis for a hardship exemption, along with an accounting of how many of those 21 billion dollars have been paid to subsidize those vendors’ products; and
Immediately initiate a reevaluation of the MU certification of any vendor whose products form the basis for a hardship exemption.

This proposal might seem bold, but if we’re truly looking to advance health care through the application and use of EHR, then what I’ve outlined above simply represents necessary and sound public policy. Current practice rewards vendors whose products are falling short by perpetuating subsidies for those products.

The federal government should stop paying doctors to implement health IT that cannot meet the standards of the program under which the payments are issued. That’s just a no-brainer.

An EHR should not be a federally-subsidized “hardship.”

The ACO Hypothesis: What We’re Learning

Mar 12, 2014• 31

By Farzad Mostashari, MD & Ross White

Last month, the Center for Medicare and Medicaid Services (CMS) reported first-year results from the Medicare Shared Saving Accountable Care Organization Program (MSSP).

As noted in a previous post, shifting to an accountable care model is a long-term, multi-year transition that requires major overhauls to care delivery processes, technology systems, operations, and governance, as well as coordinating efforts with new partners and payers.

Participants in the MSSP program are also taking much more responsibility and risk when it comes to the effectiveness and quality of care delivered.

Given these complexities, it is no surprise that MSSP’s first year results (released January 30, 2014) were mixed. The good news? Of the 114 ACOs in the program, 54 of the ACOs saved money and 29 saved enough money to receive bonus payments.

The 54 ACOs that saved money produced shared net savings of $126 million, while Medicare will see $128 million in total trust fund savings.

At the time, CMS did not provide additional information about the ACOs with savings versus those without.

While a more complete understanding of their characteristics and actions will be necessary to understand what drives ACO success, the recent disclosure of the 29 ACOs that received bonus payments allows us to offer some preliminary interpretations.

Why You Should Care about the New Accreditation Agreement for Osteopaths

Mar 11, 2014• 3

By John Schumann, MD

More than a century of American medical history was turned on its ear last week by the announcement that the groups that accredit medical residencies will unify their standards. Don’t be too hard on yourself if you failed to understand the significance (or notice at all).

But this should be viewed as good news across the land. As someone who trains doctors from both ‘traditions,’ I certainly welcome a more level playing field.

First, a little background:

Osteopathic physicians (those with a D.O., or Doctor of Osteopathy degree) have a history dating back to the 1800s. They comprise slightly more than 10% of practicing doctors in the United States. Currently, there are 35 osteopathic medical schools, compared with 135 ‘allopathic’ institutions, the kind that confer the M.D. (Doctor of Medicine) degree.

Though historically the two educational paths varied in principles and practice, there aren’t many remaining differences. Both disciplines now use biomedical science as their core.

Originally, osteopathy relied on manipulation of bones and joints to diagnose and treat illness.

This tradition, known as Osteopathic Manipulative Treatment (OMT), lives on in the osteopathic curriculum, though it’s now mostly used as an adjunct for treatment of chronic musculoskeletal conditions. Today, most D.O.s leave OMT behind after they finish their training.

The OpenNotes Toolkit

Mar 10, 2014• 58

By Steve Downs

In writing about OpenNotes last summer, I argued that the practice of sharing clinicians’ notes with patients had moved beyond the question of whether it was a good idea (the landmark study published in Annals of Internal Medicine was pretty clear on that) to questions of how best to implement it.

As more organizations adopt the practice, it’s clear that we’re now in a phase of implementation, and experimentation with different approaches and learning. Tom Delbanco, MD, one of the project leads, often compares open notes to a drug — it does have some side effects and some contraindications for some people and some circumstances — and we all need to understand those nuances.

To make it easier for health care organizations to offer the service to their patients, the OpenNotes project team has just released a new toolkit.

The toolkit focuses on two challenges: helping organizations make the decision to implement open notes and helping organizations with all the steps involved in implementing open notes.

It includes a slide deck that lays out the results of the study and makes the case for implementation, a video profile of how a patient and her doctor have used the practice, profiles of the implementations at the pioneering sites, FAQs for clinicians and patients, and tips for clinicians on how to write open notes.

Please check it out and tell the OpenNotes team what you think: is it valuable? How could it be better?

The Open Notes Toolkit: Writing Fully Transparent Notes

Mar 10, 2014• 1

By Open Notes Staff

Since HIPAA entitles virtually all patients to obtain copies of their complete medical records at any time, it is always best to write notes with the assumption that patients may read them.

However, as electronic portals provide patients with easy access to their records, clinicians may feel new pressure to be more mindful about how they write their notes. They may alter their approach to or even omit sensitive information to avoid worrying patients unnecessarily. They may try to balance clinical and non-technical language to avoid confusing patients; they may feel they need more time to write notes that patients can read.

They may be concerned about how patients might choose to share their notes, including posting a clinician’s note on Facebook, medical forums, or other social media.

Most doctors in the OpenNotes study found that they generally didn’t need to change how they wrote their notes. Patients did not expect doctors to write notes aimed specifically at them and were grateful simply to have a window into their medical record.

However, a minority of doctors reported that they changed how they documented potentially sensitive topics. These included mental health, obesity, substance abuse, sexual history, elder, child or spousal abuse, driving privileges, or suspicions of life-threatening illness. These are not new dilemmas, but they gain urgency in an era of shared visit notes.

Recommendations

Unless you believe a conversation might harm your patient, a good rule of thumb is to write about things you discussed with your patients (and conversely, to talk about content you will write about). Many clinicians already follow this practice, and some choose to dictate notes with their patients present.

When documenting sensitive behavioral health issues, we recommend trying to describe behaviors descriptively, rather than labeling them or suggesting judgments. We also suggest highlighting the patient’s strengths and achievements alongside his/her clinical problems. This can help the patient gain a broader context within which to consider his or her illness and tackle difficult behavioral changes.

The Death of SGR Reform

Mar 9, 2014• 18

By Billy Wynne

Late last week, House Republican leaders declared their intention to bring H.R. 4015, the bipartisan, bicameral SGR repeal measure, to the floor for a vote.

Good news, you’d think, for doctors and the broader healthcare system, that we might finally be rid of the SGR’s broken machinations and perverse cycle of congressional intervention.

But House leaders added a footnote: the measure would be paid for by delaying the individual mandate, which CBO opined last week would save money through reduced enrollment in Exchanges and Medicaid. To cover the approximate $150 billion cost of the SGR measure, the mandate would probably need to be delayed by at least 10 years.

While sparing us a rehash of the individual mandate debate here, suffice it to say that the Obama Administration, the authors of the Affordable Care Act, and most healthcare insurers and providers consider it to be a linchpin of the health reform regime.

Without it, most agree, the consumer protections established by the ACA would precipitate spiraling premiums that would quickly destroy the market.

In other words, the House measure is DOA in the Democrat-controlled Senate and White House, which House leaders know all too well. In a move whose political deftness is hard to quibble with, they are coupling two very popular measures into a single package that they know the vast majority of Democrats can’t support.

Good politics? Probably. Good for enactment of SGR repeal? More like the opposite.

But don’t blame House leaders for the demise of SGR repeal. This move is a symptom, not a cause, of its end. As previously reported, the well-intentioned negotiators were having difficulty finding common ground on the so-called extenders package that would be included, and were miles apart on the offsets that would be used to fund it.

This train had already come off the tracks.

The Dangers Of Quality Improvement Overload

Mar 9, 2014• 9

By Brooks, Gorbenko, van de Ruit & Bosk

Quality improvement (QI) and patient safety initiatives are created with the laudable goal of saving lives and reducing “preventable harms” to patients.

As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.

We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.

National Quality Improvement Initiatives

Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals.

We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others.

To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change: “You cannot go from imperfect to perfect. It’s a slow process.”

While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change.

Frontline providers often bristle at expectations from those they believe have little understanding of the demands of their daily work.

Actually, High-Tech Imaging Can Be High-Value Medicine

Mar 6, 2014• 4

By Karan Chhabra

Lub-SHHRRR. Lub-SHHRRR. Lub-SHHRRR.

“Can you hear it?” she asked with a smile. The thin, pleasant lady seemed as struck by her murmur as I was. She was calm, perhaps amused by the clumsy second-year medical student listening to her heart.

“Yes, yes I can,” I replied, barely concealing my excitement. We had just learned about the heart sounds in class. This was my first time hearing anything abnormal on a patient, though it was impossible to miss—her heart was practically shouting at me.

Her mitral valve prolapse—a fairly common, benign condition—had progressed into acute mitral regurgitation. She came to the hospital short of breath because her faulty valve was letting blood back up into her lungs.

Though it was certainly frightening, surgery to fix the valve could wait a few weeks. But before doing anything, the surgical team wanted a picture of the blood vessels in her heart.

If the picture showed a blockage, the surgeons would have to perform two procedures: one to fix the blockage, and another to fix her valve. If her vessels were healthy, though, the surgeons could use a simpler approach focused just on her valve.

So she came to the interventional cardiologist who was teaching me for the day. Coronary angiograms are the interventionalists’ bread-and-butter procedure, done routinely to look for blockages and to guide stent placement. They involve snaking a catheter from the groin or arm through major blood vessels and up to the heart.

Under fluoroscopy (like a video X-ray), the cardiologists shoot contrast medium into the arteries, revealing the anatomy in exquisite detail.

The images are recorded electronically and accompanied by the cardiologist’s interpretation for anyone else who opens her medical record.

Though routine, these catheterizations aren’t trivial. Whenever you enter a blood vessel, you introduce the risk of bleeding and infection. Fluoroscopy is radiation, and contrast medium can damage the kidneys. And let’s not forget cost—reimbursing the interventional cardiologist, a radiology technician, and nursing staff costs Medicare almost $3,000 per case.

So I asked the cardiologist if such an invasive approach was really necessary.

The Medical Home’s Humpty Dumpty Defense

Mar 6, 2014• 22

By Michael L. Millenson

I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.

The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost and reduced utilization. This was an “important contribution,” said the PCPCC, because it showed “refinement” of the concept that was still necessary.

That was just the set up, though, to this challenge from Marci Nielsen, chief executive officer of the group. “It is fair,” said Nielsen, “to question whether these pilot practices (studied) had yet transformed to be true medical homes.”

Where might one find these true medical homes? The answer turns out to be as elusive as a white rabbit. Formal recognition as a medical home via accreditation “can help serve as an important roadmap for practices to transform.” However, accreditation as a PCMH “is not necessarily synonymous with being one.” Conversely, you can be a “true PCMH” without having received any recognition at all!

But maybe the true medical home does not yet exist, since, “the evidence base” for the model “is still being developed.”

In Through the Looking Glass, Humpty Dumpty scornfully informs Alice: “When I use a word, it means just what I choose it to mean – neither more nor less.” And so we learn that a true medical home means just what the PCPCC says it does.

It’s confusing. If the truly transformational medical home lies in the future, why does the PCPCC chide the JAMA researchers in this “otherwise well-conducted study” for failing to “reference the recent PCPCC annual report which analyzed 13 peer-reviewed and 7 industry studies and found cost savings and utilization reductions in over 60 percent of the evaluations”?

CDC: Together We Can Provide Safer Patient Care

Mar 4, 2014• 32

By Tom Frieden, MD

There are many stories of patients who suffer when we make errors prescribing antibiotics. 75-year-old Bob Totsch from Coshocton, Ohio, went in for heart bypass surgery with every expectation of a good outcome.

Instead, he developed a surgical site infection caused by MRSA. Given a variety of antibiotics, he developed the deadly diarrheal infection C. difficile, went into septic shock, and died.

A tragic story and, probably, a preventable death.

Today, we’ve published a report about the need to improve antibiotic prescribing in hospitals. Antibiotic resistance is one of the most urgent health threats facing us today. Antibiotics can save lives.

But when they’re not prescribed correctly, they put patients at risk for preventable allergic reactions, resistant infections, and deadly diarrhea. And they become less likely to work in the future.

About half of hospital patients receive an antibiotic during the course of their stay. But doctors in some hospitals prescribe three times more antibiotics than doctors in other hospitals, even though patients were receiving care in similar areas of each hospital.

Among 26 medical-surgical wards, there were 3-fold differences in prescribing rates of all antibiotics, including antibiotics that place patients at high risk for developing Clostridium difficile infections (CDI).

CDC has estimated that there are about 250,000 CDIs in hospitalized patients each year resulting in 14,000 deaths.