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How to Avoid Data Breaches, HIPAA Violations When Posting Patients’ Protected Health Information Online
Facebook, Twitter, Instagram, Snapchat, YouTube, blogs, webpages, Google+, LinkedIn. What do all of these social media outlets have in common? Each can get physicians in trouble under the Health Insurance Portability and Accountability Act (HIPAA), state privacy laws, and state medical laws, to name a few. It seems that all too often, news outlets are reporting data breaches generated in the medical community, many of which arise out of physicians’ use of social media, and most of which could have been avoided.
Physicians should be aware of the intersection of social media—both for personal and professional use—and HIPAA and state laws. Even an inadvertent, seemingly innocuous disclosure of a patient’s protected health information (PHI) through social media can be problematic.
PHI is defined under HIPAA, in part, as health information that (i) is created or received by a physician, (ii) relates to the health or condition of an individual, (iii) identifies the individual (or with respect to which there is a reasonable basis to believe the information can be used to identify the individual), and (iv) is transmitted by or maintained in electronic media, or transmitted or maintained in another form or medium. Under HIPAA, a physician may use and disclose PHI for “treatment, payment, or healthcare operations.” Generally, using or disclosing PHI through social media does not qualify as treatment, payment, or healthcare operations. If a physician were to use or disclose a patient’s PHI without permission, this would be a violation of HIPAA—and likely state law as well.
In order to use or disclose a patient’s PHI without obtaining the patient’s consent, a physician must de-identify the information so that the information does not identify the patient and there is no reasonable basis to believe that the information can be used to identify the patient. One option under HIPAA is to retain an expert to determine “that the risk is very small that the information could be used, alone or in combination with other reasonably available information, by an anticipated recipient to identify an individual who is the subject of the information.” Alternatively, and more commonly, a physician seeking to use or disclose patient PHI can remove the following identifiers from the PHI:
- Names;
- Geographic information;
- Dates (e.g. birth date, admission date, discharge date, date of death);
- Telephone numbers;
- Fax numbers;
- E-mail addresses;
- Social Security numbers;
- Medical record numbers;
- Health plan beneficiary numbers;
- Account numbers;
- Certificate/license numbers;
- Vehicle identifiers and serial numbers, including license plate numbers;
- Device identifiers and serial numbers;
- URLs;
- IP address numbers;
- Biometric identifiers (e.g. finger and voice prints);
- Full-face photographic images and any comparable images; and
- Other unique identifying numbers, characteristics, or codes.
Identifier #18 is the most difficult to comply with in light of the significant amount of personal information available on the Internet, particularly through search engines like Google. Inputting even a small amount of information into a search engine will generate relevant “hits” that make it increasingly difficult to comply with the de-identification standards under HIPAA. Even if the first 17 identifiers are carefully removed, the broadness of #18 can turn a seemingly harmless post on social media into a patient privacy violation.
Do not let the following examples be you:
Example 1: An ED physician in Rhode Island was fired, lost her hospital medical staff privileges, and was reprimanded by the Rhode Island Board of Medical Licensure and Discipline for posting information about a trauma patient on her personal Facebook page. According to the Rhode Island Board of Medical Licensure and Discipline, “[She] did not use patient names and had no intention to reveal any confidential patient information. However, because of the nature of one person’s injury … the patient was identified by unauthorized third parties. As soon as it was brought to [her] attention that this had occurred, [she] deleted her Facebook account.” Despite the physician leaving out all information she thought might make the patient identifiable, she apparently did not omit enough.
Example 2: An OB-GYN in St. Louis took to Facebook to complain about her frustration with a patient: “So I have a patient who has chosen to either no-show or be late (sometimes hours) for all of her prenatal visits, ultrasounds, and NSTs. She is now 3 hours late for her induction. May I show up late to her delivery?” Another physician then commented on this post: “If it’s elective, it’d be canceled!” The OB-GYN at issue then responded: “Here is the explanation why I have put up with it/not cancelled induction: prior stillbirth.”
Although the OB-GYN did not reveal the patient’s name, controversy erupted after someone posted a screenshot of the post and response comments to the hospital’s Facebook page. The hospital issued a statement indicating that its privacy compliance staff did not find the posting to be a breach of privacy, but the hospital added it would use this opportunity to educate its staff about the appropriate use of social media. Many believe this physician got off too easy.
The penalties for patient privacy violations (or even alleged patient privacy violations) are multifaceted. Not only can the federal government impose civil and criminal sanctions under HIPAA on the physician and his/her affiliated parties (e.g. physician’s employer), but states can also impose penalties. State-imposed penalties for patient privacy violations vary from state to state. Additionally, the patient may sue the violating physician and his/her affiliated parties for privacy violations. Although HIPAA does not afford patients the right to bring a private cause of action against a physician, state law often does grant patients such a right. Also, state medical boards often have the right to impose penalties, monetary and non-monetary, on a physician for privacy violations. These can include suspension or termination of medical licensure.
Recent reports indicate that people who “like,” “share,” “re-tweet,” or comment on inappropriate social media posts are also getting reprimanded. Finally, the reputational harm associated with an inappropriate post on social media is immeasurable, especially in light of the availability of information on the Internet. Unfortunately, when the physicians described above enter their names in a search engine, they do not see their professional accomplishments and prestigious educations; instead, their top hits are news articles reporting on their inappropriate posts.
Post with caution.
Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].
Facebook, Twitter, Instagram, Snapchat, YouTube, blogs, webpages, Google+, LinkedIn. What do all of these social media outlets have in common? Each can get physicians in trouble under the Health Insurance Portability and Accountability Act (HIPAA), state privacy laws, and state medical laws, to name a few. It seems that all too often, news outlets are reporting data breaches generated in the medical community, many of which arise out of physicians’ use of social media, and most of which could have been avoided.
Physicians should be aware of the intersection of social media—both for personal and professional use—and HIPAA and state laws. Even an inadvertent, seemingly innocuous disclosure of a patient’s protected health information (PHI) through social media can be problematic.
PHI is defined under HIPAA, in part, as health information that (i) is created or received by a physician, (ii) relates to the health or condition of an individual, (iii) identifies the individual (or with respect to which there is a reasonable basis to believe the information can be used to identify the individual), and (iv) is transmitted by or maintained in electronic media, or transmitted or maintained in another form or medium. Under HIPAA, a physician may use and disclose PHI for “treatment, payment, or healthcare operations.” Generally, using or disclosing PHI through social media does not qualify as treatment, payment, or healthcare operations. If a physician were to use or disclose a patient’s PHI without permission, this would be a violation of HIPAA—and likely state law as well.
In order to use or disclose a patient’s PHI without obtaining the patient’s consent, a physician must de-identify the information so that the information does not identify the patient and there is no reasonable basis to believe that the information can be used to identify the patient. One option under HIPAA is to retain an expert to determine “that the risk is very small that the information could be used, alone or in combination with other reasonably available information, by an anticipated recipient to identify an individual who is the subject of the information.” Alternatively, and more commonly, a physician seeking to use or disclose patient PHI can remove the following identifiers from the PHI:
- Names;
- Geographic information;
- Dates (e.g. birth date, admission date, discharge date, date of death);
- Telephone numbers;
- Fax numbers;
- E-mail addresses;
- Social Security numbers;
- Medical record numbers;
- Health plan beneficiary numbers;
- Account numbers;
- Certificate/license numbers;
- Vehicle identifiers and serial numbers, including license plate numbers;
- Device identifiers and serial numbers;
- URLs;
- IP address numbers;
- Biometric identifiers (e.g. finger and voice prints);
- Full-face photographic images and any comparable images; and
- Other unique identifying numbers, characteristics, or codes.
Identifier #18 is the most difficult to comply with in light of the significant amount of personal information available on the Internet, particularly through search engines like Google. Inputting even a small amount of information into a search engine will generate relevant “hits” that make it increasingly difficult to comply with the de-identification standards under HIPAA. Even if the first 17 identifiers are carefully removed, the broadness of #18 can turn a seemingly harmless post on social media into a patient privacy violation.
Do not let the following examples be you:
Example 1: An ED physician in Rhode Island was fired, lost her hospital medical staff privileges, and was reprimanded by the Rhode Island Board of Medical Licensure and Discipline for posting information about a trauma patient on her personal Facebook page. According to the Rhode Island Board of Medical Licensure and Discipline, “[She] did not use patient names and had no intention to reveal any confidential patient information. However, because of the nature of one person’s injury … the patient was identified by unauthorized third parties. As soon as it was brought to [her] attention that this had occurred, [she] deleted her Facebook account.” Despite the physician leaving out all information she thought might make the patient identifiable, she apparently did not omit enough.
Example 2: An OB-GYN in St. Louis took to Facebook to complain about her frustration with a patient: “So I have a patient who has chosen to either no-show or be late (sometimes hours) for all of her prenatal visits, ultrasounds, and NSTs. She is now 3 hours late for her induction. May I show up late to her delivery?” Another physician then commented on this post: “If it’s elective, it’d be canceled!” The OB-GYN at issue then responded: “Here is the explanation why I have put up with it/not cancelled induction: prior stillbirth.”
Although the OB-GYN did not reveal the patient’s name, controversy erupted after someone posted a screenshot of the post and response comments to the hospital’s Facebook page. The hospital issued a statement indicating that its privacy compliance staff did not find the posting to be a breach of privacy, but the hospital added it would use this opportunity to educate its staff about the appropriate use of social media. Many believe this physician got off too easy.
The penalties for patient privacy violations (or even alleged patient privacy violations) are multifaceted. Not only can the federal government impose civil and criminal sanctions under HIPAA on the physician and his/her affiliated parties (e.g. physician’s employer), but states can also impose penalties. State-imposed penalties for patient privacy violations vary from state to state. Additionally, the patient may sue the violating physician and his/her affiliated parties for privacy violations. Although HIPAA does not afford patients the right to bring a private cause of action against a physician, state law often does grant patients such a right. Also, state medical boards often have the right to impose penalties, monetary and non-monetary, on a physician for privacy violations. These can include suspension or termination of medical licensure.
Recent reports indicate that people who “like,” “share,” “re-tweet,” or comment on inappropriate social media posts are also getting reprimanded. Finally, the reputational harm associated with an inappropriate post on social media is immeasurable, especially in light of the availability of information on the Internet. Unfortunately, when the physicians described above enter their names in a search engine, they do not see their professional accomplishments and prestigious educations; instead, their top hits are news articles reporting on their inappropriate posts.
Post with caution.
Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].
Facebook, Twitter, Instagram, Snapchat, YouTube, blogs, webpages, Google+, LinkedIn. What do all of these social media outlets have in common? Each can get physicians in trouble under the Health Insurance Portability and Accountability Act (HIPAA), state privacy laws, and state medical laws, to name a few. It seems that all too often, news outlets are reporting data breaches generated in the medical community, many of which arise out of physicians’ use of social media, and most of which could have been avoided.
Physicians should be aware of the intersection of social media—both for personal and professional use—and HIPAA and state laws. Even an inadvertent, seemingly innocuous disclosure of a patient’s protected health information (PHI) through social media can be problematic.
PHI is defined under HIPAA, in part, as health information that (i) is created or received by a physician, (ii) relates to the health or condition of an individual, (iii) identifies the individual (or with respect to which there is a reasonable basis to believe the information can be used to identify the individual), and (iv) is transmitted by or maintained in electronic media, or transmitted or maintained in another form or medium. Under HIPAA, a physician may use and disclose PHI for “treatment, payment, or healthcare operations.” Generally, using or disclosing PHI through social media does not qualify as treatment, payment, or healthcare operations. If a physician were to use or disclose a patient’s PHI without permission, this would be a violation of HIPAA—and likely state law as well.
In order to use or disclose a patient’s PHI without obtaining the patient’s consent, a physician must de-identify the information so that the information does not identify the patient and there is no reasonable basis to believe that the information can be used to identify the patient. One option under HIPAA is to retain an expert to determine “that the risk is very small that the information could be used, alone or in combination with other reasonably available information, by an anticipated recipient to identify an individual who is the subject of the information.” Alternatively, and more commonly, a physician seeking to use or disclose patient PHI can remove the following identifiers from the PHI:
- Names;
- Geographic information;
- Dates (e.g. birth date, admission date, discharge date, date of death);
- Telephone numbers;
- Fax numbers;
- E-mail addresses;
- Social Security numbers;
- Medical record numbers;
- Health plan beneficiary numbers;
- Account numbers;
- Certificate/license numbers;
- Vehicle identifiers and serial numbers, including license plate numbers;
- Device identifiers and serial numbers;
- URLs;
- IP address numbers;
- Biometric identifiers (e.g. finger and voice prints);
- Full-face photographic images and any comparable images; and
- Other unique identifying numbers, characteristics, or codes.
Identifier #18 is the most difficult to comply with in light of the significant amount of personal information available on the Internet, particularly through search engines like Google. Inputting even a small amount of information into a search engine will generate relevant “hits” that make it increasingly difficult to comply with the de-identification standards under HIPAA. Even if the first 17 identifiers are carefully removed, the broadness of #18 can turn a seemingly harmless post on social media into a patient privacy violation.
Do not let the following examples be you:
Example 1: An ED physician in Rhode Island was fired, lost her hospital medical staff privileges, and was reprimanded by the Rhode Island Board of Medical Licensure and Discipline for posting information about a trauma patient on her personal Facebook page. According to the Rhode Island Board of Medical Licensure and Discipline, “[She] did not use patient names and had no intention to reveal any confidential patient information. However, because of the nature of one person’s injury … the patient was identified by unauthorized third parties. As soon as it was brought to [her] attention that this had occurred, [she] deleted her Facebook account.” Despite the physician leaving out all information she thought might make the patient identifiable, she apparently did not omit enough.
Example 2: An OB-GYN in St. Louis took to Facebook to complain about her frustration with a patient: “So I have a patient who has chosen to either no-show or be late (sometimes hours) for all of her prenatal visits, ultrasounds, and NSTs. She is now 3 hours late for her induction. May I show up late to her delivery?” Another physician then commented on this post: “If it’s elective, it’d be canceled!” The OB-GYN at issue then responded: “Here is the explanation why I have put up with it/not cancelled induction: prior stillbirth.”
Although the OB-GYN did not reveal the patient’s name, controversy erupted after someone posted a screenshot of the post and response comments to the hospital’s Facebook page. The hospital issued a statement indicating that its privacy compliance staff did not find the posting to be a breach of privacy, but the hospital added it would use this opportunity to educate its staff about the appropriate use of social media. Many believe this physician got off too easy.
The penalties for patient privacy violations (or even alleged patient privacy violations) are multifaceted. Not only can the federal government impose civil and criminal sanctions under HIPAA on the physician and his/her affiliated parties (e.g. physician’s employer), but states can also impose penalties. State-imposed penalties for patient privacy violations vary from state to state. Additionally, the patient may sue the violating physician and his/her affiliated parties for privacy violations. Although HIPAA does not afford patients the right to bring a private cause of action against a physician, state law often does grant patients such a right. Also, state medical boards often have the right to impose penalties, monetary and non-monetary, on a physician for privacy violations. These can include suspension or termination of medical licensure.
Recent reports indicate that people who “like,” “share,” “re-tweet,” or comment on inappropriate social media posts are also getting reprimanded. Finally, the reputational harm associated with an inappropriate post on social media is immeasurable, especially in light of the availability of information on the Internet. Unfortunately, when the physicians described above enter their names in a search engine, they do not see their professional accomplishments and prestigious educations; instead, their top hits are news articles reporting on their inappropriate posts.
Post with caution.
Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].
10 Choosing Wisely Recommendations by Specialists for Hospitalists
When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.
In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.
1 American Gastroenterological Association (AGA)
Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.
“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”
An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.1
“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.
According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”
2 American College of Rheumatology (ACR)
Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”
Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.
“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.
Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”
3 American College of Physicians (ACP)
Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.
Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.
Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.
Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.
—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic
4 American Geriatrics Society (AGS)
Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.2 In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).
The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.
“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”
If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.
“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”
5 American Society of Echocardiography (ASE)
Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.
Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.
“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”
If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.
“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.
6 American Society of Nephrology (ASN)
Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.
Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.
PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.
Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.3 In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.4 The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).7
A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.
—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member
7 The Society of Thoracic Surgeons (STS)
Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.
By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.
“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”
Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.
LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
9 American Academy of Pediatrics (AAP)
Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9
“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.
Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.
This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.
—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.
10 American College of Obstetricians and Gynecologists (ACOB)
Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.
Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.
This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.
“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.
Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”
Karen Appold is a freelance writer in Pennsylvania.
References
- U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
- Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
- Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
- Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
- Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
- Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
- El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
- Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
- Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.
When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.
In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.
1 American Gastroenterological Association (AGA)
Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.
“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”
An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.1
“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.
According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”
2 American College of Rheumatology (ACR)
Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”
Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.
“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.
Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”
3 American College of Physicians (ACP)
Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.
Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.
Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.
Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.
—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic
4 American Geriatrics Society (AGS)
Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.2 In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).
The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.
“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”
If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.
“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”
5 American Society of Echocardiography (ASE)
Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.
Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.
“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”
If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.
“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.
6 American Society of Nephrology (ASN)
Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.
Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.
PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.
Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.3 In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.4 The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).7
A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.
—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member
7 The Society of Thoracic Surgeons (STS)
Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.
By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.
“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”
Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.
LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
9 American Academy of Pediatrics (AAP)
Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9
“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.
Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.
This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.
—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.
10 American College of Obstetricians and Gynecologists (ACOB)
Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.
Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.
This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.
“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.
Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”
Karen Appold is a freelance writer in Pennsylvania.
References
- U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
- Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
- Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
- Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
- Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
- Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
- El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
- Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
- Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.
When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.
In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.
1 American Gastroenterological Association (AGA)
Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.
“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”
An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.1
“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.
According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”
2 American College of Rheumatology (ACR)
Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”
Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.
“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.
Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”
3 American College of Physicians (ACP)
Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.
Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.
Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.
Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.
—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic
4 American Geriatrics Society (AGS)
Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.2 In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).
The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.
“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”
If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.
“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”
5 American Society of Echocardiography (ASE)
Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.
Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.
“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”
If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.
“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.
6 American Society of Nephrology (ASN)
Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.
Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.
PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.
Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.3 In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.4 The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).7
A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.
—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member
7 The Society of Thoracic Surgeons (STS)
Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.
By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.
“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”
Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.
LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
9 American Academy of Pediatrics (AAP)
Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9
“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.
Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.
This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.
—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.
10 American College of Obstetricians and Gynecologists (ACOB)
Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.
Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.
This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.
“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.
Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”
Karen Appold is a freelance writer in Pennsylvania.
References
- U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
- Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
- Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
- Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
- Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
- Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
- El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
- Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
- Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.
Open Payments registration now underway
On June 1, physicians and teaching hospitals began registering with the Centers for Medicare & Medicaid Services to review their data under the Open Payments program.
Under Open Payments – previously – CMS officials publish information on the financial relationship between physicians and drug and device manufacturers. In September, CMS plans to release information on payments and gifts made to individual physicians and teaching hospitals during the last five months of 2013. The payments may include compensations for meals and travel, consulting payments, or research grants.
The data release will be based on information collected and reported by the drug and device industry. However, physicians and teaching hospitals will have a chance to review and dispute their data before September.
Starting June 1, physicians and teaching hospitals were able to register on the CMS Enterprise Portal. In July, physicians and teaching hospitals must register again in the Open Payments system. Once registered in both systems, providers will be notified if data is submitted about them.
While there is no deadline for registration in either the Enterprise Portal or the Open Payment system, physicians and teaching hospitals will have only 45 days to review their data once it becomes available.
Data can be disputed during the 45-day period; however, if disputed data is not corrected by the drug or device manufacturer, it will be publicly listed as disputed.
Physicians aren’t required to review their data, but both CMS and the American Medical Association are encouraging them to do so.
The Open Payments program "will impact many physicians with a current medical license and it is important that they are properly registered to review and ensure the accuracy of the data reported by manufacturers and group purchasing organizations before the world sees it," Dr. Ardis Hoven, AMA president, said in a statement. "To avert one of the problems that came to light as a result of the Medicare claims data release earlier this year, we strongly urge physicians to make sure their information in the national provider identifier (NPI) database is current."
The AMA is asking CMS to give physicians more time to review and dispute their data.
The AMA has also released an online toolkit to help physicians stay on top of the Open Payments deadlines.
On Twitter @maryellenny
*Updated 6/2/2014
On June 1, physicians and teaching hospitals began registering with the Centers for Medicare & Medicaid Services to review their data under the Open Payments program.
Under Open Payments – previously – CMS officials publish information on the financial relationship between physicians and drug and device manufacturers. In September, CMS plans to release information on payments and gifts made to individual physicians and teaching hospitals during the last five months of 2013. The payments may include compensations for meals and travel, consulting payments, or research grants.
The data release will be based on information collected and reported by the drug and device industry. However, physicians and teaching hospitals will have a chance to review and dispute their data before September.
Starting June 1, physicians and teaching hospitals were able to register on the CMS Enterprise Portal. In July, physicians and teaching hospitals must register again in the Open Payments system. Once registered in both systems, providers will be notified if data is submitted about them.
While there is no deadline for registration in either the Enterprise Portal or the Open Payment system, physicians and teaching hospitals will have only 45 days to review their data once it becomes available.
Data can be disputed during the 45-day period; however, if disputed data is not corrected by the drug or device manufacturer, it will be publicly listed as disputed.
Physicians aren’t required to review their data, but both CMS and the American Medical Association are encouraging them to do so.
The Open Payments program "will impact many physicians with a current medical license and it is important that they are properly registered to review and ensure the accuracy of the data reported by manufacturers and group purchasing organizations before the world sees it," Dr. Ardis Hoven, AMA president, said in a statement. "To avert one of the problems that came to light as a result of the Medicare claims data release earlier this year, we strongly urge physicians to make sure their information in the national provider identifier (NPI) database is current."
The AMA is asking CMS to give physicians more time to review and dispute their data.
The AMA has also released an online toolkit to help physicians stay on top of the Open Payments deadlines.
On Twitter @maryellenny
*Updated 6/2/2014
On June 1, physicians and teaching hospitals began registering with the Centers for Medicare & Medicaid Services to review their data under the Open Payments program.
Under Open Payments – previously – CMS officials publish information on the financial relationship between physicians and drug and device manufacturers. In September, CMS plans to release information on payments and gifts made to individual physicians and teaching hospitals during the last five months of 2013. The payments may include compensations for meals and travel, consulting payments, or research grants.
The data release will be based on information collected and reported by the drug and device industry. However, physicians and teaching hospitals will have a chance to review and dispute their data before September.
Starting June 1, physicians and teaching hospitals were able to register on the CMS Enterprise Portal. In July, physicians and teaching hospitals must register again in the Open Payments system. Once registered in both systems, providers will be notified if data is submitted about them.
While there is no deadline for registration in either the Enterprise Portal or the Open Payment system, physicians and teaching hospitals will have only 45 days to review their data once it becomes available.
Data can be disputed during the 45-day period; however, if disputed data is not corrected by the drug or device manufacturer, it will be publicly listed as disputed.
Physicians aren’t required to review their data, but both CMS and the American Medical Association are encouraging them to do so.
The Open Payments program "will impact many physicians with a current medical license and it is important that they are properly registered to review and ensure the accuracy of the data reported by manufacturers and group purchasing organizations before the world sees it," Dr. Ardis Hoven, AMA president, said in a statement. "To avert one of the problems that came to light as a result of the Medicare claims data release earlier this year, we strongly urge physicians to make sure their information in the national provider identifier (NPI) database is current."
The AMA is asking CMS to give physicians more time to review and dispute their data.
The AMA has also released an online toolkit to help physicians stay on top of the Open Payments deadlines.
On Twitter @maryellenny
*Updated 6/2/2014
Feds award $110 million for innovative care models
The Department of Health & Human Services says it is giving some $110 million to health care organizations that have come up with innovative ways to deliver high-quality care at lower cost.
The federal grants will last for 3 years and are part of the Health Care Innovation Awards program created by the Affordable Care Act and administered by the innovation center at the Centers for Medicare & Medicaid Services.
Last May, the department announced that it was seeking applicants for as much as $1 billion in federal money for the projects.
In addition to the $110 million awarded to 12 health care organizations, the agency is making $730 million available to states seeking to "design and test improvements to their public and private health care payment and delivery systems," according to a Health & Human Services (HHS) department press release. That money has not yet been awarded.
The 12 current recipients of the Health Care Innovation Awards, profiled here, are the Altarum Institute; American College of Cardiology Foundation; Association of American Medical Colleges; Avera Health; Children’s Home Society of Florida; Clifford W. Beers Guidance Clinic; Four Seasons Compassion for Life; Icahn School of Medicine at Mount Sinai; New York City Health and Hospitals Corporation; North Shore LIJ Health System; Regents of the University of California, San Francisco; and Regents of the University of Michigan.
Additional recipients will be announced in the coming months.
Projects funded include ways to provide better care for dementia patients, to improve coordination between specialists and primary care physicians, and to ensure that children in Medicaid and the Children’s Health Insurance Program get more rapid attention to dental problems.
The American College of Cardiology Foundation received one of the biggest grants – $15.8 million – for its project, called SMARTCare. The project will use a combination of clinical decision support, shared decision-making, patient engagement, and provider feedback tools designed to improve care for stable ischemic heart disease. Among the goals: a reduction of imaging procedures not meeting appropriate use criteria; a reduction in the percentage of percutaneous coronary interventions not meeting appropriate use criteria while achieving high levels of patient engagement and lower rates of complications; and an increase in the percentage of stable ischemic heart disease patients with optimal risk factor modification.
The ACC will test SMARTCare at five sites in Wisconsin and five sites in Florida. It was developed by cardiologists who belong to those states’ ACC chapters, along with other physicians at health systems and in primary care, payers and insurers, employer health coalitions, patient advisers, and payment reform advisers.
The SMARTCare goals are big, "but we have the right people at the table to make them a reality," said Dr. Thomas Lewandowski, SMARTCare project director and immediate past governor of the ACC’s Wisconsin Chapter, in a statement.
"We believe involving patients in an evidence-based decision-making process is the best way to improve outcomes while providing the highest value for the health care dollar," said ACC President Patrick T. O’Gara, in the statement. "This grant will give us an opportunity to demonstrate how data from clinical registries can be leveraged to enhance physician/patient communication," he said.
The biggest award, about $18 million, went to the New York City Health and Hospitals Corporation, to test out an Emergency Department Care Management model. Six hospitals will expand upon a pilot program that uses multidisciplinary teams to assess ED patients; create a care plan to avoid unnecessary hospitalization; and provide ongoing support after discharge, including medication management, education, and linkages with primary care providers.
The agency says there was great interest in the latest round of awards, but it could not say how many organizations had applied. For the first round, in which awards were given out in 2012, there were 3,000 applicants, and 107 winners.
The Center for Medicare & Medicaid Innovation (CMMI) has the authority to expand any program nationally if it looks like it is producing savings.
HHS also is making $730 million available under the State Innovation Models Initiative to states that apply for the funds.
"As a former governor, I understand the real sense of urgency states and local communities feel to improve the health of their populations while also reducing health care costs, and it’s critical that the many elements of health care in each state – including Medicaid, public health, and workforce training – work together," said HHS Secretary Kathleen Sebelius in a statement. "To help, HHS will continue to encourage and assist them in their efforts to transform health care."
The states can apply for either a Model Test award to assist in implementation or a Model Design award to develop or enhance a comprehensive State Health Care Innovation Plan. Up to 12 states will be chosen for Model Test awards, and up to 15 will be chosen for Model Design awards.
HHS said that current examples of state-led health innovations include development of advanced primary care networks supported by statewide health information technology systems, and models that coordinate care seamlessly across providers.
[email protected]
On Twitter @aliciaault
The Department of Health & Human Services says it is giving some $110 million to health care organizations that have come up with innovative ways to deliver high-quality care at lower cost.
The federal grants will last for 3 years and are part of the Health Care Innovation Awards program created by the Affordable Care Act and administered by the innovation center at the Centers for Medicare & Medicaid Services.
Last May, the department announced that it was seeking applicants for as much as $1 billion in federal money for the projects.
In addition to the $110 million awarded to 12 health care organizations, the agency is making $730 million available to states seeking to "design and test improvements to their public and private health care payment and delivery systems," according to a Health & Human Services (HHS) department press release. That money has not yet been awarded.
The 12 current recipients of the Health Care Innovation Awards, profiled here, are the Altarum Institute; American College of Cardiology Foundation; Association of American Medical Colleges; Avera Health; Children’s Home Society of Florida; Clifford W. Beers Guidance Clinic; Four Seasons Compassion for Life; Icahn School of Medicine at Mount Sinai; New York City Health and Hospitals Corporation; North Shore LIJ Health System; Regents of the University of California, San Francisco; and Regents of the University of Michigan.
Additional recipients will be announced in the coming months.
Projects funded include ways to provide better care for dementia patients, to improve coordination between specialists and primary care physicians, and to ensure that children in Medicaid and the Children’s Health Insurance Program get more rapid attention to dental problems.
The American College of Cardiology Foundation received one of the biggest grants – $15.8 million – for its project, called SMARTCare. The project will use a combination of clinical decision support, shared decision-making, patient engagement, and provider feedback tools designed to improve care for stable ischemic heart disease. Among the goals: a reduction of imaging procedures not meeting appropriate use criteria; a reduction in the percentage of percutaneous coronary interventions not meeting appropriate use criteria while achieving high levels of patient engagement and lower rates of complications; and an increase in the percentage of stable ischemic heart disease patients with optimal risk factor modification.
The ACC will test SMARTCare at five sites in Wisconsin and five sites in Florida. It was developed by cardiologists who belong to those states’ ACC chapters, along with other physicians at health systems and in primary care, payers and insurers, employer health coalitions, patient advisers, and payment reform advisers.
The SMARTCare goals are big, "but we have the right people at the table to make them a reality," said Dr. Thomas Lewandowski, SMARTCare project director and immediate past governor of the ACC’s Wisconsin Chapter, in a statement.
"We believe involving patients in an evidence-based decision-making process is the best way to improve outcomes while providing the highest value for the health care dollar," said ACC President Patrick T. O’Gara, in the statement. "This grant will give us an opportunity to demonstrate how data from clinical registries can be leveraged to enhance physician/patient communication," he said.
The biggest award, about $18 million, went to the New York City Health and Hospitals Corporation, to test out an Emergency Department Care Management model. Six hospitals will expand upon a pilot program that uses multidisciplinary teams to assess ED patients; create a care plan to avoid unnecessary hospitalization; and provide ongoing support after discharge, including medication management, education, and linkages with primary care providers.
The agency says there was great interest in the latest round of awards, but it could not say how many organizations had applied. For the first round, in which awards were given out in 2012, there were 3,000 applicants, and 107 winners.
The Center for Medicare & Medicaid Innovation (CMMI) has the authority to expand any program nationally if it looks like it is producing savings.
HHS also is making $730 million available under the State Innovation Models Initiative to states that apply for the funds.
"As a former governor, I understand the real sense of urgency states and local communities feel to improve the health of their populations while also reducing health care costs, and it’s critical that the many elements of health care in each state – including Medicaid, public health, and workforce training – work together," said HHS Secretary Kathleen Sebelius in a statement. "To help, HHS will continue to encourage and assist them in their efforts to transform health care."
The states can apply for either a Model Test award to assist in implementation or a Model Design award to develop or enhance a comprehensive State Health Care Innovation Plan. Up to 12 states will be chosen for Model Test awards, and up to 15 will be chosen for Model Design awards.
HHS said that current examples of state-led health innovations include development of advanced primary care networks supported by statewide health information technology systems, and models that coordinate care seamlessly across providers.
[email protected]
On Twitter @aliciaault
The Department of Health & Human Services says it is giving some $110 million to health care organizations that have come up with innovative ways to deliver high-quality care at lower cost.
The federal grants will last for 3 years and are part of the Health Care Innovation Awards program created by the Affordable Care Act and administered by the innovation center at the Centers for Medicare & Medicaid Services.
Last May, the department announced that it was seeking applicants for as much as $1 billion in federal money for the projects.
In addition to the $110 million awarded to 12 health care organizations, the agency is making $730 million available to states seeking to "design and test improvements to their public and private health care payment and delivery systems," according to a Health & Human Services (HHS) department press release. That money has not yet been awarded.
The 12 current recipients of the Health Care Innovation Awards, profiled here, are the Altarum Institute; American College of Cardiology Foundation; Association of American Medical Colleges; Avera Health; Children’s Home Society of Florida; Clifford W. Beers Guidance Clinic; Four Seasons Compassion for Life; Icahn School of Medicine at Mount Sinai; New York City Health and Hospitals Corporation; North Shore LIJ Health System; Regents of the University of California, San Francisco; and Regents of the University of Michigan.
Additional recipients will be announced in the coming months.
Projects funded include ways to provide better care for dementia patients, to improve coordination between specialists and primary care physicians, and to ensure that children in Medicaid and the Children’s Health Insurance Program get more rapid attention to dental problems.
The American College of Cardiology Foundation received one of the biggest grants – $15.8 million – for its project, called SMARTCare. The project will use a combination of clinical decision support, shared decision-making, patient engagement, and provider feedback tools designed to improve care for stable ischemic heart disease. Among the goals: a reduction of imaging procedures not meeting appropriate use criteria; a reduction in the percentage of percutaneous coronary interventions not meeting appropriate use criteria while achieving high levels of patient engagement and lower rates of complications; and an increase in the percentage of stable ischemic heart disease patients with optimal risk factor modification.
The ACC will test SMARTCare at five sites in Wisconsin and five sites in Florida. It was developed by cardiologists who belong to those states’ ACC chapters, along with other physicians at health systems and in primary care, payers and insurers, employer health coalitions, patient advisers, and payment reform advisers.
The SMARTCare goals are big, "but we have the right people at the table to make them a reality," said Dr. Thomas Lewandowski, SMARTCare project director and immediate past governor of the ACC’s Wisconsin Chapter, in a statement.
"We believe involving patients in an evidence-based decision-making process is the best way to improve outcomes while providing the highest value for the health care dollar," said ACC President Patrick T. O’Gara, in the statement. "This grant will give us an opportunity to demonstrate how data from clinical registries can be leveraged to enhance physician/patient communication," he said.
The biggest award, about $18 million, went to the New York City Health and Hospitals Corporation, to test out an Emergency Department Care Management model. Six hospitals will expand upon a pilot program that uses multidisciplinary teams to assess ED patients; create a care plan to avoid unnecessary hospitalization; and provide ongoing support after discharge, including medication management, education, and linkages with primary care providers.
The agency says there was great interest in the latest round of awards, but it could not say how many organizations had applied. For the first round, in which awards were given out in 2012, there were 3,000 applicants, and 107 winners.
The Center for Medicare & Medicaid Innovation (CMMI) has the authority to expand any program nationally if it looks like it is producing savings.
HHS also is making $730 million available under the State Innovation Models Initiative to states that apply for the funds.
"As a former governor, I understand the real sense of urgency states and local communities feel to improve the health of their populations while also reducing health care costs, and it’s critical that the many elements of health care in each state – including Medicaid, public health, and workforce training – work together," said HHS Secretary Kathleen Sebelius in a statement. "To help, HHS will continue to encourage and assist them in their efforts to transform health care."
The states can apply for either a Model Test award to assist in implementation or a Model Design award to develop or enhance a comprehensive State Health Care Innovation Plan. Up to 12 states will be chosen for Model Test awards, and up to 15 will be chosen for Model Design awards.
HHS said that current examples of state-led health innovations include development of advanced primary care networks supported by statewide health information technology systems, and models that coordinate care seamlessly across providers.
[email protected]
On Twitter @aliciaault
CMS proposes to ease meaningful use technology requirements
Federal officials are proposing to give physicians some extra time to move to 2014 edition certified electronic health record technology and still qualify for incentives under the Medicare and Medicaid EHR Incentive Programs.
Under a proposed rule released on May 20, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology (ONC) would allow physicians, hospitals, and other eligible health care providers to continue using 2011 edition certified products or a combination of 2011 and 2014 edition certified products during the 2014 reporting period in the EHR Incentive Programs.
Though 2014 edition certified EHR products are currently available, there is a backlog of several months for the newer versions to be installed in hospitals and physician offices, according to CMS.
"Increasing the adoption of EHRs is key to improving the nation’s health care system and the steps we are taking today will give new options to those who, through no fault of their own, have been unable to get the new 2014 Edition technology, including those at high risk, such as smaller providers and rural hospitals," Dr. Karen DeSalvo, national coordinator for health information technology, said in a statement.
Physicians and hospitals would need to complete the switch to 2014 edition certified products in time for the Medicare and Medicaid programs’ 2015 reporting periods.
But there are some exceptions, the proposal states that to qualify for an incentive payment under Medicaid for adopting, implementing, or upgrading certified EHRs for 2014, the provider must use 2014 edition products only.
Physicians and hospitals may have to adjust their plans for attesting to EHR meaningful use depending on which edition of the certified technology they have available. For instance, the 2011 edition technology alone does not have the functionality required to meet the Stage 2 objectives and measures.
Providers who are scheduled to begin Stage 2 for the 2014 reporting period, but can’t fully implement the functions of their 2014 edition certified technology, have the option of attest to Stage 1 objective and measures for 2014. But they must attest that they are unable to fully implement their technology due to delays, according to the proposal.
The proposal also formalizes the government’s plan to extend some of the deadlines in the "meaningful use" program. In December, CMS announced in a blog post that it would extend reporting for Stage 2 of meaningful use through 2016 and would begin Stage 3 in 2017.
The change primarily affects physicians who began attesting to meaningful EHR use in 2011 and 2012. Those physicians were scheduled to advance to Stage 3 in 2016, after 2 years working on Stage 2. The change gives them an additional year before advancing to Stage 3.
While the proposed rule responds to concerns raised by physicians and vendors about the problems in implementing 2014 edition certified products, it does not address other critiques of the meaningful use program. The American Medical Association noted that the proposed changes are helpful, but they still leave intact an all-or-nothing approach to meaningful use requirements.
"Our chief concern remains unaddressed, and we worry that current requirements will slow the adoption of technology that will help coordinate care and improve quality, and that many physicians will drop out of the meaningful use program if the current all-or-nothing approach remains in place," Dr. Steven J. Stack, the AMA’s immediate past board chairman, said in a statement. "To date, approximately 20% of eligible professionals – mostly doctors – have dropped out of the program, and we expect this number to grow unless more changes are made."
The AMA recommends using a 75% pass rate as the standard for achieving meaningful use, and allowing physicians who meet 50% of meaningful use requirements to avoid financial penalties. CMS should also do a better job of aligning the Physician Quality Reporting System, the Value Based Modifier, and meaningful use requirements.
On Twitter @maryellenny
Federal officials are proposing to give physicians some extra time to move to 2014 edition certified electronic health record technology and still qualify for incentives under the Medicare and Medicaid EHR Incentive Programs.
Under a proposed rule released on May 20, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology (ONC) would allow physicians, hospitals, and other eligible health care providers to continue using 2011 edition certified products or a combination of 2011 and 2014 edition certified products during the 2014 reporting period in the EHR Incentive Programs.
Though 2014 edition certified EHR products are currently available, there is a backlog of several months for the newer versions to be installed in hospitals and physician offices, according to CMS.
"Increasing the adoption of EHRs is key to improving the nation’s health care system and the steps we are taking today will give new options to those who, through no fault of their own, have been unable to get the new 2014 Edition technology, including those at high risk, such as smaller providers and rural hospitals," Dr. Karen DeSalvo, national coordinator for health information technology, said in a statement.
Physicians and hospitals would need to complete the switch to 2014 edition certified products in time for the Medicare and Medicaid programs’ 2015 reporting periods.
But there are some exceptions, the proposal states that to qualify for an incentive payment under Medicaid for adopting, implementing, or upgrading certified EHRs for 2014, the provider must use 2014 edition products only.
Physicians and hospitals may have to adjust their plans for attesting to EHR meaningful use depending on which edition of the certified technology they have available. For instance, the 2011 edition technology alone does not have the functionality required to meet the Stage 2 objectives and measures.
Providers who are scheduled to begin Stage 2 for the 2014 reporting period, but can’t fully implement the functions of their 2014 edition certified technology, have the option of attest to Stage 1 objective and measures for 2014. But they must attest that they are unable to fully implement their technology due to delays, according to the proposal.
The proposal also formalizes the government’s plan to extend some of the deadlines in the "meaningful use" program. In December, CMS announced in a blog post that it would extend reporting for Stage 2 of meaningful use through 2016 and would begin Stage 3 in 2017.
The change primarily affects physicians who began attesting to meaningful EHR use in 2011 and 2012. Those physicians were scheduled to advance to Stage 3 in 2016, after 2 years working on Stage 2. The change gives them an additional year before advancing to Stage 3.
While the proposed rule responds to concerns raised by physicians and vendors about the problems in implementing 2014 edition certified products, it does not address other critiques of the meaningful use program. The American Medical Association noted that the proposed changes are helpful, but they still leave intact an all-or-nothing approach to meaningful use requirements.
"Our chief concern remains unaddressed, and we worry that current requirements will slow the adoption of technology that will help coordinate care and improve quality, and that many physicians will drop out of the meaningful use program if the current all-or-nothing approach remains in place," Dr. Steven J. Stack, the AMA’s immediate past board chairman, said in a statement. "To date, approximately 20% of eligible professionals – mostly doctors – have dropped out of the program, and we expect this number to grow unless more changes are made."
The AMA recommends using a 75% pass rate as the standard for achieving meaningful use, and allowing physicians who meet 50% of meaningful use requirements to avoid financial penalties. CMS should also do a better job of aligning the Physician Quality Reporting System, the Value Based Modifier, and meaningful use requirements.
On Twitter @maryellenny
Federal officials are proposing to give physicians some extra time to move to 2014 edition certified electronic health record technology and still qualify for incentives under the Medicare and Medicaid EHR Incentive Programs.
Under a proposed rule released on May 20, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology (ONC) would allow physicians, hospitals, and other eligible health care providers to continue using 2011 edition certified products or a combination of 2011 and 2014 edition certified products during the 2014 reporting period in the EHR Incentive Programs.
Though 2014 edition certified EHR products are currently available, there is a backlog of several months for the newer versions to be installed in hospitals and physician offices, according to CMS.
"Increasing the adoption of EHRs is key to improving the nation’s health care system and the steps we are taking today will give new options to those who, through no fault of their own, have been unable to get the new 2014 Edition technology, including those at high risk, such as smaller providers and rural hospitals," Dr. Karen DeSalvo, national coordinator for health information technology, said in a statement.
Physicians and hospitals would need to complete the switch to 2014 edition certified products in time for the Medicare and Medicaid programs’ 2015 reporting periods.
But there are some exceptions, the proposal states that to qualify for an incentive payment under Medicaid for adopting, implementing, or upgrading certified EHRs for 2014, the provider must use 2014 edition products only.
Physicians and hospitals may have to adjust their plans for attesting to EHR meaningful use depending on which edition of the certified technology they have available. For instance, the 2011 edition technology alone does not have the functionality required to meet the Stage 2 objectives and measures.
Providers who are scheduled to begin Stage 2 for the 2014 reporting period, but can’t fully implement the functions of their 2014 edition certified technology, have the option of attest to Stage 1 objective and measures for 2014. But they must attest that they are unable to fully implement their technology due to delays, according to the proposal.
The proposal also formalizes the government’s plan to extend some of the deadlines in the "meaningful use" program. In December, CMS announced in a blog post that it would extend reporting for Stage 2 of meaningful use through 2016 and would begin Stage 3 in 2017.
The change primarily affects physicians who began attesting to meaningful EHR use in 2011 and 2012. Those physicians were scheduled to advance to Stage 3 in 2016, after 2 years working on Stage 2. The change gives them an additional year before advancing to Stage 3.
While the proposed rule responds to concerns raised by physicians and vendors about the problems in implementing 2014 edition certified products, it does not address other critiques of the meaningful use program. The American Medical Association noted that the proposed changes are helpful, but they still leave intact an all-or-nothing approach to meaningful use requirements.
"Our chief concern remains unaddressed, and we worry that current requirements will slow the adoption of technology that will help coordinate care and improve quality, and that many physicians will drop out of the meaningful use program if the current all-or-nothing approach remains in place," Dr. Steven J. Stack, the AMA’s immediate past board chairman, said in a statement. "To date, approximately 20% of eligible professionals – mostly doctors – have dropped out of the program, and we expect this number to grow unless more changes are made."
The AMA recommends using a 75% pass rate as the standard for achieving meaningful use, and allowing physicians who meet 50% of meaningful use requirements to avoid financial penalties. CMS should also do a better job of aligning the Physician Quality Reporting System, the Value Based Modifier, and meaningful use requirements.
On Twitter @maryellenny
Medicare beefs up requirements for Part D prescribing
Physicians must enroll in Medicare or opt-out by June 1, 2015, in order to prescribe drugs covered by the Medicare Part D prescription drug program, according to new federal regulations.
The final rule, released on May 19, outlines changes to the Medicare Advantage and Part D prescription drug programs for 2015.
Officials at the Centers for Medicare & Medicaid Services said they moved forward with the plan to require physician enrollment after reports that unqualified individuals were prescribing Part D drugs, including some physicians with suspended licenses.
Under the rule, physicians and other prescribers must enroll in the Medicare program or have a valid opt-out affidavit on file with a Part A/Part B Medicare Administrative Contractor by June 1, 2015. CMS will not pay for drug claims that do not have a National Provider Identifier on the claim.
CMS had originally proposed that physicians and other prescribers enroll by Jan. 1, 2015, but decided to offer more time because the earlier date would not have given physicians or the agency adequate time to prepare.
The Affordable Care Act already requires physicians and other providers to enroll in Medicare if they order durable medical equipment, prosthetics, orthotics and supplies, or if they certify home health care for Medicare beneficiaries.
The final rule also aims to crack down on improper prescribing by threatening to kick physicians and other providers out of the Medicare program if they display a pattern of "abusive" prescribing or if their prescribing patterns pose a "threat to the health and safety of Medicare beneficiaries" or both.
The agency did not provide a definition of those terms, stating that it needed flexibility to implement the new policy.
But they outlined criteria that will be used when assessing prescribing patterns. Here are some of the questions that CMS will ask:
- Are there diagnoses to support the indications for which the drugs were prescribed?
- Was the patient deceased or out of state at the time of an alleged office visit?
- Has the physician prescribed controlled substances in excessive dosages linked to patient overdoses?
- Has the physician been subject to disciplinary actions by the state medical board?
- Has the physician been sued for malpractice related to their drug prescribing and been found liable or paid a settlement?
- Has a public insurance program restricted or revoked the physician's prescribing privileges?
CMS can also remove physicians from Medicare if the physician's Drug Enforcement Administration Certificate of Registration is suspended or revoked, or the state licensing body has been suspended or revoked their prescribing authority.
But CMS will revoke Medicare enrollment for prescribers only in "very limited and exceptional circumstances," agency officials wrote in the final rule. And, as a result, they wrote that they don't expect the new rule to have a chilling effect on prescribing activities or to impact access to medications.
Information on the Medicare enrollment process and the timeframes for processing applications is available on the CMS website.
[email protected]
On Twitter @maryellenny
Physicians must enroll in Medicare or opt-out by June 1, 2015, in order to prescribe drugs covered by the Medicare Part D prescription drug program, according to new federal regulations.
The final rule, released on May 19, outlines changes to the Medicare Advantage and Part D prescription drug programs for 2015.
Officials at the Centers for Medicare & Medicaid Services said they moved forward with the plan to require physician enrollment after reports that unqualified individuals were prescribing Part D drugs, including some physicians with suspended licenses.
Under the rule, physicians and other prescribers must enroll in the Medicare program or have a valid opt-out affidavit on file with a Part A/Part B Medicare Administrative Contractor by June 1, 2015. CMS will not pay for drug claims that do not have a National Provider Identifier on the claim.
CMS had originally proposed that physicians and other prescribers enroll by Jan. 1, 2015, but decided to offer more time because the earlier date would not have given physicians or the agency adequate time to prepare.
The Affordable Care Act already requires physicians and other providers to enroll in Medicare if they order durable medical equipment, prosthetics, orthotics and supplies, or if they certify home health care for Medicare beneficiaries.
The final rule also aims to crack down on improper prescribing by threatening to kick physicians and other providers out of the Medicare program if they display a pattern of "abusive" prescribing or if their prescribing patterns pose a "threat to the health and safety of Medicare beneficiaries" or both.
The agency did not provide a definition of those terms, stating that it needed flexibility to implement the new policy.
But they outlined criteria that will be used when assessing prescribing patterns. Here are some of the questions that CMS will ask:
- Are there diagnoses to support the indications for which the drugs were prescribed?
- Was the patient deceased or out of state at the time of an alleged office visit?
- Has the physician prescribed controlled substances in excessive dosages linked to patient overdoses?
- Has the physician been subject to disciplinary actions by the state medical board?
- Has the physician been sued for malpractice related to their drug prescribing and been found liable or paid a settlement?
- Has a public insurance program restricted or revoked the physician's prescribing privileges?
CMS can also remove physicians from Medicare if the physician's Drug Enforcement Administration Certificate of Registration is suspended or revoked, or the state licensing body has been suspended or revoked their prescribing authority.
But CMS will revoke Medicare enrollment for prescribers only in "very limited and exceptional circumstances," agency officials wrote in the final rule. And, as a result, they wrote that they don't expect the new rule to have a chilling effect on prescribing activities or to impact access to medications.
Information on the Medicare enrollment process and the timeframes for processing applications is available on the CMS website.
[email protected]
On Twitter @maryellenny
Physicians must enroll in Medicare or opt-out by June 1, 2015, in order to prescribe drugs covered by the Medicare Part D prescription drug program, according to new federal regulations.
The final rule, released on May 19, outlines changes to the Medicare Advantage and Part D prescription drug programs for 2015.
Officials at the Centers for Medicare & Medicaid Services said they moved forward with the plan to require physician enrollment after reports that unqualified individuals were prescribing Part D drugs, including some physicians with suspended licenses.
Under the rule, physicians and other prescribers must enroll in the Medicare program or have a valid opt-out affidavit on file with a Part A/Part B Medicare Administrative Contractor by June 1, 2015. CMS will not pay for drug claims that do not have a National Provider Identifier on the claim.
CMS had originally proposed that physicians and other prescribers enroll by Jan. 1, 2015, but decided to offer more time because the earlier date would not have given physicians or the agency adequate time to prepare.
The Affordable Care Act already requires physicians and other providers to enroll in Medicare if they order durable medical equipment, prosthetics, orthotics and supplies, or if they certify home health care for Medicare beneficiaries.
The final rule also aims to crack down on improper prescribing by threatening to kick physicians and other providers out of the Medicare program if they display a pattern of "abusive" prescribing or if their prescribing patterns pose a "threat to the health and safety of Medicare beneficiaries" or both.
The agency did not provide a definition of those terms, stating that it needed flexibility to implement the new policy.
But they outlined criteria that will be used when assessing prescribing patterns. Here are some of the questions that CMS will ask:
- Are there diagnoses to support the indications for which the drugs were prescribed?
- Was the patient deceased or out of state at the time of an alleged office visit?
- Has the physician prescribed controlled substances in excessive dosages linked to patient overdoses?
- Has the physician been subject to disciplinary actions by the state medical board?
- Has the physician been sued for malpractice related to their drug prescribing and been found liable or paid a settlement?
- Has a public insurance program restricted or revoked the physician's prescribing privileges?
CMS can also remove physicians from Medicare if the physician's Drug Enforcement Administration Certificate of Registration is suspended or revoked, or the state licensing body has been suspended or revoked their prescribing authority.
But CMS will revoke Medicare enrollment for prescribers only in "very limited and exceptional circumstances," agency officials wrote in the final rule. And, as a result, they wrote that they don't expect the new rule to have a chilling effect on prescribing activities or to impact access to medications.
Information on the Medicare enrollment process and the timeframes for processing applications is available on the CMS website.
[email protected]
On Twitter @maryellenny
Senate committee approves Burwell to head HHS
President Obama’s choice to be the new Secretary of the Department of Health & Human Services moved one step closer to that position with a Senate panel voting in favor of the nominee.
The Senate Finance Committee voted 21-3 May 21 to approve Sylvia Mathews Burwell as the new chief of HHS. She will replace Kathleen Sebelius, who has said she will step down when there is a new secretary in place.
"Ms. Burwell is highly qualified and well respected by Democrats and Republicans in government and in the private sector," said Sen. Ron Wyden (D-Ore.), chairman of the Finance Committee. "My view is that she will hit the ground running at the Department of Health & Human Services," he said.
At a Finance Committee hearing May 14, Ms. Burwell promised to be responsive to Congress, particularly in addressing issues related to the Affordable Care Act. She also said she was eager to work on a replacement for Medicare’s Sustainable Growth Rate factor.
Ms. Burwell is currently the director of the White House Office of Management and Budget.
Sen. Johnny Isakson (R-Ga.) said that at that earlier hearing, he found Ms. Burwell to be "forthright, and she was honest." He added, "I didn’t support the Affordable Care Act, but I believe with her in place, we’ll get answers to questions when they are asked, we’ll get accountability and honesty in the management of the department, and that’s a step in the right direction."
He said that he would vote for Ms. Burwell when the full Senate took up her nomination.
"I think we have a chance at having a really great administrator," said Sen. Orrin Hatch (R-Utah) of Ms. Burwell. "I very much support her."
Three Republican committee members voted against the nomination: Pat Roberts (Kan.), John Cornyn (Texas), and John Thune (S.D.).
The full Senate likely will vote on her nomination soon, possibly before the Senate recesses for a week beginning May 23.
On Twitter @aliciaault
President Obama’s choice to be the new Secretary of the Department of Health & Human Services moved one step closer to that position with a Senate panel voting in favor of the nominee.
The Senate Finance Committee voted 21-3 May 21 to approve Sylvia Mathews Burwell as the new chief of HHS. She will replace Kathleen Sebelius, who has said she will step down when there is a new secretary in place.
"Ms. Burwell is highly qualified and well respected by Democrats and Republicans in government and in the private sector," said Sen. Ron Wyden (D-Ore.), chairman of the Finance Committee. "My view is that she will hit the ground running at the Department of Health & Human Services," he said.
At a Finance Committee hearing May 14, Ms. Burwell promised to be responsive to Congress, particularly in addressing issues related to the Affordable Care Act. She also said she was eager to work on a replacement for Medicare’s Sustainable Growth Rate factor.
Ms. Burwell is currently the director of the White House Office of Management and Budget.
Sen. Johnny Isakson (R-Ga.) said that at that earlier hearing, he found Ms. Burwell to be "forthright, and she was honest." He added, "I didn’t support the Affordable Care Act, but I believe with her in place, we’ll get answers to questions when they are asked, we’ll get accountability and honesty in the management of the department, and that’s a step in the right direction."
He said that he would vote for Ms. Burwell when the full Senate took up her nomination.
"I think we have a chance at having a really great administrator," said Sen. Orrin Hatch (R-Utah) of Ms. Burwell. "I very much support her."
Three Republican committee members voted against the nomination: Pat Roberts (Kan.), John Cornyn (Texas), and John Thune (S.D.).
The full Senate likely will vote on her nomination soon, possibly before the Senate recesses for a week beginning May 23.
On Twitter @aliciaault
President Obama’s choice to be the new Secretary of the Department of Health & Human Services moved one step closer to that position with a Senate panel voting in favor of the nominee.
The Senate Finance Committee voted 21-3 May 21 to approve Sylvia Mathews Burwell as the new chief of HHS. She will replace Kathleen Sebelius, who has said she will step down when there is a new secretary in place.
"Ms. Burwell is highly qualified and well respected by Democrats and Republicans in government and in the private sector," said Sen. Ron Wyden (D-Ore.), chairman of the Finance Committee. "My view is that she will hit the ground running at the Department of Health & Human Services," he said.
At a Finance Committee hearing May 14, Ms. Burwell promised to be responsive to Congress, particularly in addressing issues related to the Affordable Care Act. She also said she was eager to work on a replacement for Medicare’s Sustainable Growth Rate factor.
Ms. Burwell is currently the director of the White House Office of Management and Budget.
Sen. Johnny Isakson (R-Ga.) said that at that earlier hearing, he found Ms. Burwell to be "forthright, and she was honest." He added, "I didn’t support the Affordable Care Act, but I believe with her in place, we’ll get answers to questions when they are asked, we’ll get accountability and honesty in the management of the department, and that’s a step in the right direction."
He said that he would vote for Ms. Burwell when the full Senate took up her nomination.
"I think we have a chance at having a really great administrator," said Sen. Orrin Hatch (R-Utah) of Ms. Burwell. "I very much support her."
Three Republican committee members voted against the nomination: Pat Roberts (Kan.), John Cornyn (Texas), and John Thune (S.D.).
The full Senate likely will vote on her nomination soon, possibly before the Senate recesses for a week beginning May 23.
On Twitter @aliciaault
HHS grants expedited review for nonformulary drug requests
Patients undergoing treatment with nonformulary drugs will soon get a speedier decision from their health plans about whether those drugs can be covered.
On May 16, the Health & Human Services (HHS) department released a final rule outlining standards for health plans participating in the Affordable Care Act’s insurance exchanges in 2015. The rule creates an expedited process for determining coverage for nonformulary drugs in emergency situations.
In 2015, health plans in the ACA exchanges will have no more than 24 hours to make a decision on whether to cover a nonformulary drug when it is requested under "exigent circumstances." These situations include when a patient’s diagnosis may seriously jeopardize their life, health, or ability to regain maximum function. It also includes situations in which a patient is undergoing a current course of treatment using a nonformulary drug, according to the final rule.
Under the rule, patients or their designees – including prescribing physicians – can request coverage of a nonformulary drug.
HHS said the 24-hour review period begins as soon as a request is received, and cautioned insurers not to hold up the review if "largely procedural" information is missing from the request. The agency also instructed health plans not to require "irrelevant or overly burdensome information" in the application.
If a request for a nonformulary drug is approved, health plans must make it available for the duration of the emergency situation.
On Twitter @maryellenny
Patients undergoing treatment with nonformulary drugs will soon get a speedier decision from their health plans about whether those drugs can be covered.
On May 16, the Health & Human Services (HHS) department released a final rule outlining standards for health plans participating in the Affordable Care Act’s insurance exchanges in 2015. The rule creates an expedited process for determining coverage for nonformulary drugs in emergency situations.
In 2015, health plans in the ACA exchanges will have no more than 24 hours to make a decision on whether to cover a nonformulary drug when it is requested under "exigent circumstances." These situations include when a patient’s diagnosis may seriously jeopardize their life, health, or ability to regain maximum function. It also includes situations in which a patient is undergoing a current course of treatment using a nonformulary drug, according to the final rule.
Under the rule, patients or their designees – including prescribing physicians – can request coverage of a nonformulary drug.
HHS said the 24-hour review period begins as soon as a request is received, and cautioned insurers not to hold up the review if "largely procedural" information is missing from the request. The agency also instructed health plans not to require "irrelevant or overly burdensome information" in the application.
If a request for a nonformulary drug is approved, health plans must make it available for the duration of the emergency situation.
On Twitter @maryellenny
Patients undergoing treatment with nonformulary drugs will soon get a speedier decision from their health plans about whether those drugs can be covered.
On May 16, the Health & Human Services (HHS) department released a final rule outlining standards for health plans participating in the Affordable Care Act’s insurance exchanges in 2015. The rule creates an expedited process for determining coverage for nonformulary drugs in emergency situations.
In 2015, health plans in the ACA exchanges will have no more than 24 hours to make a decision on whether to cover a nonformulary drug when it is requested under "exigent circumstances." These situations include when a patient’s diagnosis may seriously jeopardize their life, health, or ability to regain maximum function. It also includes situations in which a patient is undergoing a current course of treatment using a nonformulary drug, according to the final rule.
Under the rule, patients or their designees – including prescribing physicians – can request coverage of a nonformulary drug.
HHS said the 24-hour review period begins as soon as a request is received, and cautioned insurers not to hold up the review if "largely procedural" information is missing from the request. The agency also instructed health plans not to require "irrelevant or overly burdensome information" in the application.
If a request for a nonformulary drug is approved, health plans must make it available for the duration of the emergency situation.
On Twitter @maryellenny
AMA calls for ‘course correction’ on meaningful use
Doctors will continue to drop out of the federal government’s Electronic Health Records Incentive Programs unless officials ease some program requirements, the American Medical Association warned in a May 8 letter to government officials.
The AMA offered a laundry list of needed changes from abandoning the "all-or-nothing" approach for meeting meaningful use standards to removing requirements that are outside the control of physicians.
"In any other grading system a 99% is an A+, but it’s a fail in the meaningful use program, which just seems entirely inconsistent with what Congress intended, which was to foster the adoption of these tools," Dr. Steven J. Stack, an emergency physician and immediate past chairman of the AMA’s board of trustees, said in an interview.
In the letter to officials at the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), the AMA advocated for ending the "all-or-nothing" approach, which requires physicians to successfully meet all meaningful use requirements to earn incentives. The AMA instead recommended a 75% threshold for qualifying for incentives and a 50% threshold to avoid penalties.
The AMA also urged the government not to measure activities outside of the physician’s control, such as whether a patient views or downloads information from a portal.
While the government has been touting widespread participation in the Electronic Health Records Incentive Programs, the AMA said that physicians are beginning to abandon the program. The AMA said that partial data from 2013 showed that there was already a 20% drop out rate in the meaningful use program. It will only grow if the program continues as is, Dr. Stack said.
But there’s time to make changes both to Stage 2 and Stage 3 of the program, Dr. Stack added.
"We don’t see this as a done deal. We see this as a live program that requires ongoing adjustment and tailoring," he said. "The federal government, in order to advance the policy objective of fostering electronic health record adoption and health information exchange, should have a mid-course correction immediately for Stage 2 to make it more possible to have flexibility and a better opportunity for success for the clinicians and the hospitals."
On Twitter @maryellenny
Doctors will continue to drop out of the federal government’s Electronic Health Records Incentive Programs unless officials ease some program requirements, the American Medical Association warned in a May 8 letter to government officials.
The AMA offered a laundry list of needed changes from abandoning the "all-or-nothing" approach for meeting meaningful use standards to removing requirements that are outside the control of physicians.
"In any other grading system a 99% is an A+, but it’s a fail in the meaningful use program, which just seems entirely inconsistent with what Congress intended, which was to foster the adoption of these tools," Dr. Steven J. Stack, an emergency physician and immediate past chairman of the AMA’s board of trustees, said in an interview.
In the letter to officials at the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), the AMA advocated for ending the "all-or-nothing" approach, which requires physicians to successfully meet all meaningful use requirements to earn incentives. The AMA instead recommended a 75% threshold for qualifying for incentives and a 50% threshold to avoid penalties.
The AMA also urged the government not to measure activities outside of the physician’s control, such as whether a patient views or downloads information from a portal.
While the government has been touting widespread participation in the Electronic Health Records Incentive Programs, the AMA said that physicians are beginning to abandon the program. The AMA said that partial data from 2013 showed that there was already a 20% drop out rate in the meaningful use program. It will only grow if the program continues as is, Dr. Stack said.
But there’s time to make changes both to Stage 2 and Stage 3 of the program, Dr. Stack added.
"We don’t see this as a done deal. We see this as a live program that requires ongoing adjustment and tailoring," he said. "The federal government, in order to advance the policy objective of fostering electronic health record adoption and health information exchange, should have a mid-course correction immediately for Stage 2 to make it more possible to have flexibility and a better opportunity for success for the clinicians and the hospitals."
On Twitter @maryellenny
Doctors will continue to drop out of the federal government’s Electronic Health Records Incentive Programs unless officials ease some program requirements, the American Medical Association warned in a May 8 letter to government officials.
The AMA offered a laundry list of needed changes from abandoning the "all-or-nothing" approach for meeting meaningful use standards to removing requirements that are outside the control of physicians.
"In any other grading system a 99% is an A+, but it’s a fail in the meaningful use program, which just seems entirely inconsistent with what Congress intended, which was to foster the adoption of these tools," Dr. Steven J. Stack, an emergency physician and immediate past chairman of the AMA’s board of trustees, said in an interview.
In the letter to officials at the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), the AMA advocated for ending the "all-or-nothing" approach, which requires physicians to successfully meet all meaningful use requirements to earn incentives. The AMA instead recommended a 75% threshold for qualifying for incentives and a 50% threshold to avoid penalties.
The AMA also urged the government not to measure activities outside of the physician’s control, such as whether a patient views or downloads information from a portal.
While the government has been touting widespread participation in the Electronic Health Records Incentive Programs, the AMA said that physicians are beginning to abandon the program. The AMA said that partial data from 2013 showed that there was already a 20% drop out rate in the meaningful use program. It will only grow if the program continues as is, Dr. Stack said.
But there’s time to make changes both to Stage 2 and Stage 3 of the program, Dr. Stack added.
"We don’t see this as a done deal. We see this as a live program that requires ongoing adjustment and tailoring," he said. "The federal government, in order to advance the policy objective of fostering electronic health record adoption and health information exchange, should have a mid-course correction immediately for Stage 2 to make it more possible to have flexibility and a better opportunity for success for the clinicians and the hospitals."
On Twitter @maryellenny
Burwell gets a step closer to HHS helm
Sylvia Mathews Burwell, the nominee to become the next secretary of the Department of Health & Human Services, got a warm reception from senators in her first confirmation hearing.
Ms. Burwell, who is the current director of the Office of Management and Budget, was widely praised for her competence, compassion, and willingness to work with lawmakers of both parties. She was endorsed by Sen. John McCain (R-Ariz.), who favors replacing the Affordable Care Act. He said that regardless of how senators feel about the health law, they should confirm Ms. Burwell, because she is well qualified to lead HHS and will be more responsive than the current secretary, Kathleen Sebelius.
Sen. McCain added that he tried to discourage her from accepting the "thankless" job. "Who would recommend their friend take over as captain of the Titanic after it hit the iceberg?" he said.
During the 2-hour hearing, lawmakers on the Senate Committee on Health, Education, Labor & Pensions took advantage of their first chance to question Ms. Burwell, querying her on a range of issues from the shortage of primary care providers to the speed of drug approvals at the Food and Drug Administration.
When asked about her approach to employing the controversial Independent Payment Advisory Board, Ms. Burwell said she hopes that it will never be triggered, because the government will keep health care costs under control.
And when it comes to the past failures of HHS in managing the healthcare.gov rollout, Ms. Burwell said she learned that there needs to be a different approach to handling information technology procurement and delivery. She pledged to ensure there was "ownership and accountability" in the IT operations in the future.
She also promised GOP senators that she would share information with them. "I am here to serve the American people," she said.
Ms. Burwell is not expected to have a tough confirmation battle. New Senate rules allow her to be confirmed with only a majority vote, and she received a unanimous confirmation vote for her current post last April. She will face questioning next from the Senate Finance Committee.
Ms. Burwell, a Rhodes Scholar from Hinton, W.Va., previously served as president of the Walmart Foundation and as president of the global development program at the Bill & Melinda Gates Foundation. During the Clinton administration, she worked as deputy director of the Office of Management and Budget.
On Twitter @maryellenny
Sylvia Mathews Burwell, the nominee to become the next secretary of the Department of Health & Human Services, got a warm reception from senators in her first confirmation hearing.
Ms. Burwell, who is the current director of the Office of Management and Budget, was widely praised for her competence, compassion, and willingness to work with lawmakers of both parties. She was endorsed by Sen. John McCain (R-Ariz.), who favors replacing the Affordable Care Act. He said that regardless of how senators feel about the health law, they should confirm Ms. Burwell, because she is well qualified to lead HHS and will be more responsive than the current secretary, Kathleen Sebelius.
Sen. McCain added that he tried to discourage her from accepting the "thankless" job. "Who would recommend their friend take over as captain of the Titanic after it hit the iceberg?" he said.
During the 2-hour hearing, lawmakers on the Senate Committee on Health, Education, Labor & Pensions took advantage of their first chance to question Ms. Burwell, querying her on a range of issues from the shortage of primary care providers to the speed of drug approvals at the Food and Drug Administration.
When asked about her approach to employing the controversial Independent Payment Advisory Board, Ms. Burwell said she hopes that it will never be triggered, because the government will keep health care costs under control.
And when it comes to the past failures of HHS in managing the healthcare.gov rollout, Ms. Burwell said she learned that there needs to be a different approach to handling information technology procurement and delivery. She pledged to ensure there was "ownership and accountability" in the IT operations in the future.
She also promised GOP senators that she would share information with them. "I am here to serve the American people," she said.
Ms. Burwell is not expected to have a tough confirmation battle. New Senate rules allow her to be confirmed with only a majority vote, and she received a unanimous confirmation vote for her current post last April. She will face questioning next from the Senate Finance Committee.
Ms. Burwell, a Rhodes Scholar from Hinton, W.Va., previously served as president of the Walmart Foundation and as president of the global development program at the Bill & Melinda Gates Foundation. During the Clinton administration, she worked as deputy director of the Office of Management and Budget.
On Twitter @maryellenny
Sylvia Mathews Burwell, the nominee to become the next secretary of the Department of Health & Human Services, got a warm reception from senators in her first confirmation hearing.
Ms. Burwell, who is the current director of the Office of Management and Budget, was widely praised for her competence, compassion, and willingness to work with lawmakers of both parties. She was endorsed by Sen. John McCain (R-Ariz.), who favors replacing the Affordable Care Act. He said that regardless of how senators feel about the health law, they should confirm Ms. Burwell, because she is well qualified to lead HHS and will be more responsive than the current secretary, Kathleen Sebelius.
Sen. McCain added that he tried to discourage her from accepting the "thankless" job. "Who would recommend their friend take over as captain of the Titanic after it hit the iceberg?" he said.
During the 2-hour hearing, lawmakers on the Senate Committee on Health, Education, Labor & Pensions took advantage of their first chance to question Ms. Burwell, querying her on a range of issues from the shortage of primary care providers to the speed of drug approvals at the Food and Drug Administration.
When asked about her approach to employing the controversial Independent Payment Advisory Board, Ms. Burwell said she hopes that it will never be triggered, because the government will keep health care costs under control.
And when it comes to the past failures of HHS in managing the healthcare.gov rollout, Ms. Burwell said she learned that there needs to be a different approach to handling information technology procurement and delivery. She pledged to ensure there was "ownership and accountability" in the IT operations in the future.
She also promised GOP senators that she would share information with them. "I am here to serve the American people," she said.
Ms. Burwell is not expected to have a tough confirmation battle. New Senate rules allow her to be confirmed with only a majority vote, and she received a unanimous confirmation vote for her current post last April. She will face questioning next from the Senate Finance Committee.
Ms. Burwell, a Rhodes Scholar from Hinton, W.Va., previously served as president of the Walmart Foundation and as president of the global development program at the Bill & Melinda Gates Foundation. During the Clinton administration, she worked as deputy director of the Office of Management and Budget.
On Twitter @maryellenny