Will Medicare’s New Efficiency Measurement Harm Patient Safety?
While facing rising Medicare costs and ever-present budget challenges, federal officials are focused on lowering Medicare costs. As part of the federal Affordable Care Act, Medicare is beginning to measure efficiency and per-patient costs to evaluate hospitals and will adjust its payments to them accordingly. The change has angered several hospital administrators and has patient advocates asking whether Medicare’s focus on low costs will improve or damage patient safety and medical care.
“Per Beneficiary” Medicare Spending
Medicare will track hospital efficiency based on “Medicare spending per beneficiary,” equivalent for other measures used for tracking infection rates of surgery patients and mortality rates of heart-attack patients. The intended purpose of the measure is to improve the quality and efficiency of health care by tying Medicare payments to the performance of health-care providers.
In addition to expenses brought on during a patient’s hospitalization, the cost of any medical treatment occurring three days before hospitalization and 90 days after discharge also will be tacked on to the hospitals’ bills for Medicare measurement purposes. Medicare officials claim that using such a long duration should encourage hospitals to coordinate care in an efficient manner over an extended period of time.
Federal officials offered an example of the Medicare spending per beneficiary measurement, which was simplified and republished by The New York Times. In the simplified example, if Medicare spends an average of $9,125 per Medicare beneficiary at one hospital, and the comparable cost at every U.S. hospital is $12,467, the single hospital would receive a higher score for efficiency.
This efficiency score would then be combined with scores from other measures to create an overall performance score for that hospital. Medicare will then use the overall performance scores to determine a higher or lower percentage to be paid for each claim the hospital files. This system, known as value-based purchasing, rewards and distributes more funds to higher-performing hospitals. Full details of the measure are still being finalized, but Medicare began computing performance scores in July 2011 and plans to implement the value-based purchasing system by October 2012.
Concerns Rise Over the Quality of Patient Care
Unsurprisingly, many hospital administrators dislike the notion of being held accountable for expenses arising from care beyond the walls of their facilities. They say they have very little influence over medical treatment occurring after a patient has been discharged and essentially no control over the treatment a patient receives before being admitted.
Additionally, teaching hospitals may earn lower efficiency scores and be penalized by the value-based purchasing system because they often treat patients with more severe conditions, which adds to the cost of treatment. Medicare officials claim that efficiency data will be adjusted to consider factors such as patients’ ages and the severity of their illnesses. Regardless, president of the Greater New York Hospital Association, Kenneth E. Raske, says the efficiency measure “tends to discriminate against inner-city hospitals with large numbers of immigrant, poor and uninsured patients.”
Many in medical community have agreed that paying hospitals based on performance is important, but implementing the right measures of performance is crucial. President of the Federation of American Hospitals, Charles N. Kahn III, says officials are “off track” in holding hospitals responsible for what Medicare ends up spending on patients nearly three months after discharge.
Further, numerous hospital administrators and patient-safety advocates are concerned about the long-term ramifications of a measure that emphasizes low costs rather than quality outcomes, especially in regards to patient safety. For example, the focus on lower costs could result in fewer diagnostic tests being ordered and performed, potentially leading to missed or incorrect diagnoses. Especially in cases where early detection and quick treatment are vital to recovery, such cost-cutting measures could put the very life of a patient at stake.
Health IT to Have a Bigger Role in Improving Patient Safety
According to a recent commentary published in The Journal of the American Medical Association, advances in technology will lead health information technology to play a bigger role in improving patient safety. More specifically, wider adoption of electronic health records (EHRs), as well as computerized provider order entry (CPOE), clinical decision support (CDS) and barcode medication administration, will play increasingly important roles in addressing the Joint Commission’s National Patient Safety Goals.
EHRs and related health IT have been marketed as tools to enhance patient safety, but the promise remains largely unfulfilled at the present time, wrote co-authors Ryan P. Radecki, MD, department of emergency medicine, East Carolina University Brody School of Medicine, in Greenville, N.C., and Dean F. Sittig, PhD, professor at The University of Texas Health Science Center at Houston (UTHealth) School of Biomedical Informatics, in their commentary titled “Application of Electronic Health Records to the Joint Commission’s 2011 National Patient Safety Goals.”
The authors offered the following example: EHRs with CDS interventions integrated into CPOE have been shown to improve clinicians’ performance on process metrics, yet their effect on patient outcomes has yet to be seen.
Joint Commission Pushing EHR Adoption
The Joint Commission’s National Patient Safety Goals for 2011 include correctly identifying patients, delivering test results more quickly and accurately, ensuring that medications are labeled correctly, examining medications for potential adverse reactions, preventing and reducing infections, and identifying patients who may be at risk of suicide.
Improving the rate at which EHRs can be used to address patient safety issues would involve implementing the National Patient Safety Goals into the existing criteria for EHR certification.
The authors stated, “The 2011 National Patient Safety Goals provide high-yield guidance to EHR certification and oversight bodies who should refine their criteria for meaningful use to include incentives for development and use of tools to enhance safety. As with all computer-based interventions, incorporation of EHRs into routine clinical workflow is critical; their effectiveness depends on appropriate maintenance, effective user training, periodic institutional self-assessment of EHR safety and effectiveness, and clinically focused policies to support their use.”
They concluded, “Although EHRs by no means represent all necessary mechanisms to address critical safety problems, they can provide tools to help organizations improve their performance.”
Hospital Checklists Reduce Hospital-Acquired Infections
According to the New York Times, the fourth-leading cause of death in the United States is hospital-acquired infections (nosocomial infections). Nosocomial infections are infections, such as pneumonia, that patients contract while receiving treatment in hospitals. These infections cost the U.S. healthcare system over $40 billion every year.
Hospitals across the nation are taking steps to decrease the prevalence of nosocomial infections, making incredible progress in some areas. Yet, studies show there is still a long way to go.
Safety Checklists Prove Effective
An experiment conducted in 2003 in Michigan demonstrated the effectiveness of a simple checklist in reducing certain types of patient infections. To reduce the occurrence of central-line catheter infections, the Michigan Health and Hospital Association required 103 intensive-care units to use a five-point checklist when inserting catheters into patients. The results were incredible: the median rate of infection dropped to zero and remained at zero throughout 15 months of follow-up monitoring.
The same hospitals implemented a similar checklist method to reduce ventilator-associated pneumonia. Again, by using the checklist method, the hospitals were successful in eliminating this infection, reducing the median infection rate to zero.
Risks of Hospital-Acquired Infections
Despite the success of checklists in reducing hospital-acquired infections, there is still great room for improvement. One of the main causes of nosocomial infections is the hospital workers’ failure to wash their hands frequently enough. A study published in the American Journal of Medicine Quality revealed that most hospitals have hand-washing rates below 50 percent. The study also showed that medical personnel in intensive care units only wash their hands one quarter as often as they should.
Atul Gawande, author of The Checklist Manifesto, says implementing checklist systems in more hospitals nationwide will help improve rates of basic tasks such as hand washing. He says hospital checklists work well for several key reasons. First, lists are reminders to busy hospital personnel who may overlook a step in a routine procedure when doing many things at once. Second, lists instill a sense of responsibility among the people involved in performing a procedure; everyone is responsible for the success or failure of the procedure. Each person has the right and the duty to say something if someone is skipping a step on the checklist.
AAMI Cite Alarm Management among Top 10 Biomedical Challenges
In a recent survey conducted by the Association for the Advancement of Medical Instrumentation (AAMI), clinical engineers and biomedical engineering technicians were asked to report the biggest biomedical challenges they see in their hospitals. Interfacing devices and information systems were the top challenges, but managing alarm systems and computerized IT systems were also ranked highly (#3 and #2, respectively).
The information was collected through a research survey conducted in November 2010 by Stratton Research. There were 418 responses to the survey, which was sent to more than 2,500 hospital biomedical technicians and clinical engineers. The results were published in the March/April 2011 issue of the Biomedical Instrumentation & Technology. Clinical engineers and hospital professionals discussed the findings at the recent AAMI conference held on June 27.
The top 10 biomedical challenges were:
- Interfacing between devices and information systems
- Maintaining computerized IT systems
- Managing alarms
- Maintaining and processing endoscopes
- Broken connectors
- Wireless management
- Battery management
- Problems with patient monitors
- Problems with dialysis equipment
- Managing the radiation dose from CT
“In terms of solutions to these challenges, clinical engineering veterans and other professionals hit the same broad themes: better education and training, stronger and communication and cooperation among departments, and often a need for standards,” stated Paul W. Kelley, CBET, of Washington Hospital Healthcare System in Fremont, Calif.
“The successful implementation of interoperability requires defined objectives and measurable goals”, noted Carol Davis-Smith, CCE, Premier Healthcare Alliance in Charlotte, N.C., “as well as a complete and well-maintained physical inventory of the applicable items included in the network.” Davis-Smith recommended prioritizing and making data-driven decisions when implementing interoperable devices.
“What we’re finding out there in the community, is that one, our basic CMO mass inventory is not clean. We need to get that cleaned up, and the reason being, because we need to have IT collect this really granular data about each of those individual devices, what can talk and what cannot talk, to what extent does it talk and how does it talk,” Davis-Smith said. “Bringing this level of granularity might be an ice-breaker in the IT department.”
Kelley said, “We learned [from the survey] that IT plays a huge role in biomedical engineering, as three of the top 10 challenges are IT-related. The IT department, clinical engineers, clinicians and vendors have to work together. Healthcare is most definitely a team sport.”
Related to interoperability, alarm management was also a strong focus of Monday’s discussion. Managing alarms has become a widespread issue—gaining media exposure with stories in The Boston Globe, The Washington Post, CBS Nightly News, and National Public Radio—as hospitals are attempting to manage the alarm fatigue caused by the countless visual and audible alarms directed at nurses each day.
“In terms of the top 10 medical device challenges, it really interacts with so many of the other challenges: interfacing, computer updates, broken connectors, patient monitors,” said J. Tobey Clark, CCE, of the University of Vermont in Burlington. “All of those other hazards directly impact clinical alarms.”
Clark said that sounds are actually just a portion of the problem. He said caregivers cannot recognize more than six different alarm sounds and have difficulty distinguishing between high- and low-priority alarms.
“This clinical alarm problem is very complex,” he said. “The stumbling block is human limitations. Because it’s a complex problem, you need a complex solution,” Clark said. “We need a multi-disciplinary approach to resolve this problem. False alarms and nuisance alarms [are] by far the biggest problems that lead to alarm fatigue.”
The issue of clinical alarm fatigue will be the focus of an upcoming AAMI summit in Herndon, Virginia, Oct. 4-5.
ONC to Penalize EHR Accreditors for Poor Performance
The Office of the National Coordinator for Health IT (ONC) has proposed a new method to penalize accreditors that oversee organizations that certify electronic health record (EHR) products when the accreditors engage in improper conduct or perform their duties poorly. To clarify, the ONC plans to select only one approved accreditation organization every three years to oversee smaller bodies that will certify EHR products for use by healthcare providers.
This makes authorized accreditors very important for EHR certification programs because healthcare providers will be relying upon EHR certification bodies to help meet meaningful use requirements.
The rule proposed by the ONC explains both the conduct violations and the possible consequences that could be levied against authorized accreditors and details the ONC’s process for disciplining poor performers, including the possibility of replacement due to conduct violations.
Under the ONC’s permanent certification program, which will be implemented on January 1, 2012, the accreditor must ensure that the authorized certification bodies follow reliable methods of surveillance of vendor products. According to the proposed provisions, conduct violations include fraud, withholding or altering information that would indicate fraud, falsifying accreditations of certifying organizations, and failure to perform in a satisfactory manner.
The ONC will be able to assess the accreditor’s performance through the annual reports made by the certifying organizations which will detail EHR product surveillance. The surveillance results will include feedback from the accreditor as well.
The permanent program will make EHR certification more thorough and reliable than the temporary processes currently used to approve EHRs. Temporary testing and certification will cease on December 31, 2011.
“We believe that a removal process would protect the integrity of the permanent certification program and maintain public confidence in the program,” the ONC said in the proposed rule, which was published in the May 31 Federal Register. The proposed rule is open to public comments until August 1.
