The Centers for Medicare & Medicaid Services (CMS) recently released the proposed physician fee schedule for the year 2015. This fee schedule includes a new code for chronic care management (CCM). It also features projected pay cuts required by the sustainable growth rate (SGR) formula used to determine physician payment. Medicare would begin to pay physicians $41.92 that can be billed not more than once per month for managing patients with two or more chronic conditions outside of face-to-face office visits.

Earlier (in the year 2013), CMS had authorized a new medical billing code for chronic-care management to compensate physicians. This code covered tasks such as referring patients to colleagues, developing a detailed home care plan and functioning with home care agencies that are not correctly reimbursed under the existing evaluation and management payment codes. The new billing code was scheduled to take effect in 2015, but CMS failed to assign a dollar amount to the same.

Physicians would begin the billing process for chronic care management using a new G code. Generally, elderly or disabled patients suffering from complex health disorders require the medical attention by a primary-care physician. In most cases, 20 minutes of chronic care services for at least 30 days may be needed for a patient whose multiple chronic conditions are expected to last for a long time or until death. So, chronic care management services must be made available on a 24/7 basis. Clinical staff can offer services at the midnight hour on an “incident-to” billing basis without any direct supervision.

The new billing codes for chronic care recognizes the relative value of additional administrative work that happens outside the exam room. In the current physician fee schedule for 2015, CMS is proposing to require that physicians use certified electronic health record technology (EHR).

The billing code for chronic care management was proposed in an attempt to support those primary care physicians who are struggling financially. Another provision in this fee schedule recommends stoppage of set–fee payments to surgeons for procedures that include postoperative services – think office visits (during 10- day and 90-dayglobal periods). Instead, a new proposal to separately bill postoperative services on a piecemeal basis during these timeframes is recommended.

CMS also proposes to expand the list of reimbursable services provided via telemedicine. The list would now include psychoanalysis, psychotherapy, annual wellness visits and prolonged evaluation and management services. This change is expected to improve patient access to healthcare services in rural areas.

Implementation of electronic health records is considered a practical solution that will help streamline processes in healthcare settings, while also ensuring enhanced patient care and support. However, a recent survey conducted by the American Hospital Association found that most American hospitals have failed to meet the new national standards for electronic health record keeping. It was found that these hospitals have made considerable delay in implementing EHR systems such as online messaging and automatic prescription tracking.

Majority of the hospitals in the United States utilize healthcare EMR system and follow most or many of the 16 requirements lay down by the federal regulators. More than 6% of hospitals meet all the mandates such as automatic medication tracking and online messaging (for patient communication). Those hospitals and healthcare centers that fail to meet the prescribed deadlines may be docked a portion of health insurance reimbursement.

As part of the survey, data was collected from more than 2,647 short-term acute general hospitals that had participated in the survey. It was studied how well these hospitals complied with the required standards.

The HITECH Act (Health Information Technology for Economic and Clinical Health) promotes the adoption and meaningful use of health information technology by offering incentives through Medicaid and Medicare. The Centers for Medicare and Medicaid Services offers financial incentives for the meaningful use of certified EMR technology to improve patient care.

They created benchmarks for the meaningful use of EMR that featured stages such as -

• Stage 1 – This stage promoted a basic EHR adoption and data gathering. Hospitals and healthcare centers were to implement a basic electronic health system that essentially met 14 core objectives starting from patient enrollment, and recording demographic information to monitoring patient medications.
• Stage 2 – This stage focuses on care coordination and exchange of patient information. A more robust usage of systems is essential such as incorporating online lab test results and checking whether they comply with the updated software standards.

CMS released a notice of proposed rule-making in May, which if approved would extend the deadline to meet Stage 2.

A considerable increase was made in the adoption and meaningful usage of electronic health records, which signifies that patients have become more aware about the potential benefits of health IT. A study published in the Journal Health Affairs found that in 2013, about 8 in 10 (that is 78%) office-based physicians adopted usage of some kind of EHR system. When compared to the figures in 2009, about half of the physicians (48%) utilized EHR systems with advanced functionalities in 2013. An ongoing increase in the use of this digital technology would certainly improve the nation’s healthcare delivery system and health outcomes.

With the full implementation of the Affordable care Act (ACA), the demand for healthcare services are expected to increase at a rapid pace. The expansion of the Medicaid program along with the introduction of new health insurance exchanges have enabled people to have increased access to health insurance coverage though access to healthcare services may not be easy.

Telehealth services has become an important tool for increasing access to care as this will allow physicians to reach more number of patients by integrating electronic information and telecommunication technologies into physicians’ patient population. This will in turn help to improve the total quality of care and lead to better patient outcomes thereby reducing the per capita cost of care.

The Centers for Medicare and Medicaid Services (CMS) has introduced a recent proposal to incrementally increase the telehealth services that Medicare will cover, including wellness visits and some behavioral health services. On the other hand, CMS will limit its telehealth coverage to rural areas.

With the proposed rule dealing with regulatory changes affecting physician payments, CMS aims to pay for annual wellness visits including initial and follow-up encounters along with a preventive plan of care. The behavioral health area provides telehealth services for family psychotherapy, psychoanalysis (both with and without the patient present), and extended service in the office or other outpatient setting (that needs direct patient interaction above the usual service).

The president of the American Psychiatric Association, Paul Summergrad, MD welcomed this initiative and said, “Psychiatric conditions are very common illnesses, and they’re highly comorbid with other kinds of conditions. They’re also very costly and cause a lot of human suffering. So anything that can get better behavioral health coverage for these folks, especially in less populated areas, is great.”

CMS necessitates that telehealth consults be confined to authorized “originating sites.” With these services effective from January 1, 2014, CMS expanded these sites with an objective to incorporate “rural census tracts” that fall inside metropolitan statistical areas. Broadening rural coverage for this purpose is an important step as it expands access to healthcare services for Medicare beneficiaries located in rural areas.

However, certain officials in the healthcare domain reveal this new initiative as a small step only. Reports suggest that CMS paid only $12 million for telehealth last year. As per CMS rule, it is important to use an interactive communication system that includes audio and video options and must be performed when the patient is present. It does not allow store and technology option that allows a physician to analyze recorded data or visual images (except in demonstration projects).

A restrictive approach is being followed by CMS by not including “store and forward option.” This option provides a more efficient way to deliver care particularly for specific dermatology conditions. The current option does not allow physicians to view stored radiological images as they may not regard them as part of remote patient consults. It is expected that other potential payers, (particularly Medicaid) will follow the same path that CMS has introduced in its proposed rule for Medicare.

A new study of California Hospitals found that patients admitted into the emergency rooms of a hospital are at greater risk of dying if another emergency room at a hospital nearby has closed its doors. The research was primarily conducted to identify the potential impact of emergency room closures on patient care quality at the hospitals functioning within the same service area.

The study published in the August issue of the medical journal Health Affairs aimed to find out how the disappearance of emergency rooms translated into high mortality rate for hospital patients. Less number of ERs means longer wait times to receive treatment. It also necessitates patients to travel farther to get ER care and this may force them to stay at home. This may in turn force them to stay longer and by the time they are admitted to a hospital, they would have become seriously sick.

Understanding the Implications of ER Closures

Recognizing the possible implications of ER closures is very crucial as they have been disappearing for years. Researchers examined the effects of these ED closures in California between the year 1999- 2010 and found that patients who were treated at nearby hospitals following the closings were 5% more likely to die. The total number of EDs in the US reduced from 4,884 in 1996 to 4,594 in 2009, thereby recording a 6% decline. Whereas patient visits increased from 90 million to 136 million, nearly 51% increase.

As part of the study, researchers analyzed data from the California Office of Statewide Health Planning and Development to determine how many ERs were functioning and the status of those patients who were treated. The key findings of the study are mentioned below -

• About 26 hospitals suffered ED shutdowns and 22 others closed these departments but remained open (from the year 1999-2010). Each of these 48 hospitals affected a geographic area that was identified by the patient ZIP codes who used the facilities.
• It was found that more than 16 million patients who visited California ERs were admitted to the hospital. From that, 25% of them were from nearby hospitals affected by the closure, and 75% were not.
• Patients or non-elderly adults (including African Americans, women or adults) in the age group of 18-65 years have 10% increased risk of suffering death in hospitals than other younger patients not affected by closures. This was the case among uninsured patients or those not covered by Medicaid, the federal health insurance programs for low-income Americans.
• Elderly patients (65 years or more) had more chances of suffering death after being admitted to hospitals from an affected area.

Researchers also conducted a separate analysis of the percentage of patients who went to an ED on account of certain chronic and time-sensitive medical emergency. It was found that patients suffering from certain specific ailments were likely to die in hospitals due to lost ERs.

• Heart attack patients were 15% more likely to die in a hospital
• Patients who suffered stroke were 10% more likely to die in a hospital
• Patients with a life-threatening infection causing sepsis were 8% more likely to die

Experts in the healthcare domain say that the closure of ER rooms puts considerable strain on the healthcare system which in turn leads to overcrowding and high death rates of patients admitted through these rooms. Moreover, such ED closures may increase inpatient mortality in hospitals and communities with more minority, Medicaid and low-income patients.

More young people are enrolling in Obamacare. According to a recent report, the Department of Health and Human Services (HHS) compared the proportion of young enrollees to enrollment data for 2014. It was found that in mid-January last year, 29% of enrollees were under the age of 34 and that this year, this number has risen slightly – people under the age of 34 made up 33% of those who chose a new plan. It is expected that the number of young enrollees will rise by February 15th, 2015, the date which marks the end of Open Enrollment.

In May 2014, HHS reported a surge of young adults (in the age group 18-34) in Health Insurance Marketplace enrollment, which helped Obamacare signups to move beyond the target. The report said that 2.2 million (28 percent) of young adults among eight million selected a marketplace at the end of the first enrollment period that spanned from October 1 to March 31, 2013 while 1.2 million young adults among 3.8 million enrolled in the sixth and final reporting period that began on March 2 and ended on April 19, 2014 pushing the enrollment beyond the target. This is a good sign as there were concerns regarding the viability of Obamacare if mostly sick or elderly people signed up for the marketplace plans.

As per the New York Times report, the President also said that enrollment for health insurance under the Affordable Care Act surpassed the goal and the role of young adults is quite evident. During the early months of enrollment, the number of young people in the age group 18 – 34 and who tend to be healthier who were signing up amounted to only 25%. The number increased at the last minute enrollment as expected by the White House officials. Those who had started the enrollment process, but not completed were given grace period after the March 31 deadline. White House officials opined that the high enrollment rate of young people is likely to keep premiums lower compared to what they would have been otherwise.

So, how does the enrollment of more young adults result in lower premiums? For every older enrollee, a group of young people is required to cover the costs as the older people can’t be charged more for their care as per the Affordable Care Act. Young enrollees effectively subsidize the older enrollees in the 50 to 64 age band who are less healthy than the younger group. If enough healthy people are not signing up, insurance companies will have mostly high-cost consumers on their plans and they will be left with no other option but to increase the premium cost. No doubt, this will drastically affect the long-term viability of Obamacare.

A 2013 Bloomberg report draws attention to a survey conducted by Morning Consult (a Washington-based media company), which revealed that around 56 percent of young people in the age group 18 to 29 support Obamacare. The report lists mainly two reasons for this support.

• Federal Subsidies – People who earn up to 400% (up to $45,960 for an individual and $94,200 for a family of four) of the poverty line are eligible for subsidy in premium cost while those who earn less than 250% of the poverty line ($28,725 for a single person and $58,875 for a family of four) are eligible for extra subsidies in out-of-pocket costs such as deductibles and co-payments. However, the actual amount of subsidy depends upon the income, age and location of the enrollee.
• Handling Emergency Situations – Though younger people rarely use insurance, they may end up paying a larger sum in case of unpredictable healthcare needs (for example, accident) if left uninsured. Marketplace plans are really helpful to handle this kind of emergency situations since they cover a set of health benefits known as ‘essential health benefits’ which include ten categories of healthcare service. This set comprises mental health and brand-name drugs or pre-natal care which is not typically covered by private plans outside the healthcare exchanges.

However, the overall percentage of young people enrolled does not guarantee that the Obamacare program will work perfectly in all the insurance marketplaces across the country. Each state needs to be considered separately as the insurance is pooled at the state level.

In order to receive proper reimbursement, physician practices should verify the insurance details of their patients enrolled into Obamacare plans before scheduling an appointment to know whether they are eligible for federal subsidies. Since verifying each patient’s insurance details with the insurer will be a tedious task for physicians, they can seek the support of a professional medical billing and coding company that offers insurance verification services. They can streamline their billing process effectively with the help of experienced billing and coding professionals in the company.

Drug overdoses have increased rapidly in the United States over the past two decades and is a leading cause of injury or death among people. Drug overdose can happen to people of all age groups and demographic characteristics and include overdose of illicit opioids such as heroin, prescription opioid, and analgesics like methadone, hydrocodone, fentanyl and oxycodone.

As per reports from the Centers for Disease Control and Prevention (CDC), about 41,502 drug poisoning deaths were reported in the US in 2012. Out of this, about 22,114 (53%) were related to pharmaceuticals. It is estimated that every day about 114 people die as a result of over dosage and more than 6,748 are treated in the emergency departments for the misuse of medicines. About 9 out of 10 poisoning deaths are mainly caused by medicines – both illicit and prescribed. Drug overdose can occur due to a wide variety of factors which are mentioned below –

• When a person misuses the physician prescription opiate or an illicit drug such as heroin
• When a person consumes the medicine as directed by the physician but the prescriber miscalculates the dosage
• If the dispensing pharmacist makes a mistake or the patient wrongly understands the directions for usage of medicines
• If a person consumes medications prescribed for someone else
• If a person combines opioids (prescribed or illicit) with alcohol or other medicines or even some over-the-counter products that may lower breathing, heart rate and other functions of the central nervous system

Physicians Can Help Prevent Drug Overdose

Physicians and healthcare providers can help reduce the potential risk of overdose cases by giving more attention when prescribing medications and carefully monitoring the patient’s response in identifying and addressing the case of over dosage.

State Prescription Drug monitoring Programs (PDMP) have also emerged as an effective approach for preventing the problem of prescription drug misuse. This program allows prescribers to check in their PDMP database and verify whether a patient is filling the prescriptions provided and obtaining the correct prescriptions for the same or similar medicine from multiple physicians.

Physicians should take special precautions while treating new patients. When deciding to prescribe opium, physicians need to conduct a complete assessment about the patient history of current medication and alcohol use. This patient assessment may include types of tablets used, quantity and frequency of use, symptoms of dependence, route of administration, prescribed medications, alcohol or tobacco use and their dependence symptoms.

Patients with histories of substance use disorder or mental health problems should receive special attention from pain management specialists. Physicians need to determine the correct dosage, schedule and formulation while prescribing medications. Medication-assisted treatment, along with counseling and other supportive services may help drug overdose survivors lead a healthier life. In addition, regular follow-ups at least once in 2-3 months may help to avoid further risks.

Providers need to keep their knowledge updated about evidence-based practices for the use of opioid analgesics to better manage pain and prevent steps to reduce overdose. Moreover, they need to adhere to the specific regulations of the federal government and other agencies regarding the medical billing and coding changes. It is crucial that healthcare practices document medical necessity correctly by reporting the services and treatments offered. In order to submit accurate medical claims, physicians should have essential billing and coding know-how and should use the correct diagnostic and procedural codes to ensure correct and timely reimbursement. 965.09 is the ICD-9 code to report screening for poisoning by other opiates and related narcotics.

Prescription Opioids Involved in Most Overdoses in Emergency Departments

A new study published online by JAMA Internal Medicine reports that, prescription opioid medications are involved in more than two thirds of emergency department admissions due to overdoses.  The national study of hospital emergency department visits for opiate overdoses found that about 67.8 % of the same were due to prescription opioids including methadone, heroine and other unspecified and multiple narcotics.  With medication overdoses been cited as a leading cause of injury-related mortality in the United States, very limited information is known about how opioid overdoses are present in the emergency departments (EDs).

As part of the study, researchers analyzed the 2010 Nationwide Emergency Department Sample with diagnostic codes for overdose. They identified 135,971 weighted ED visits that were coded for overdose. The key findings of the study are mentioned below –

• 67.8 % of high doses were due to prescription opioids (including methadone), while 16.1% involved heroin, 13.4% involved unspecified and 2.7% involved multiple opioid types.
• Researchers found geographical variations in overdose patterns with a higher proportion (84.1 %) happening in urban areas, in the South 40.2% and among women 53%. In fact, most patients who suffered over dosage had health insurance coverage.
• Many patient cases shared common comorbidities which included chronic mental health problems (33.9%), circulatory diseases (29.1%) and respiratory (25.6%) diseases. Hence, healthcare providers who prescribe opium medications to patients (suffering from these pre-existing conditions) should take extra care in doing so and should counsel the patients about the potential risks of associated with consuming these medicines.
• “Co-intoxication with benzodiazepines” was visible in 22% of patients. This figure indicates the need for careful prescription in conjunction with other sedating medications.

Even though the proportion of patient visits in the emergency departments that resulted in death was highest for overdoses, the overall patient death rate was low (1.4%). This finding supports the need to put in more efforts to expand access and utilization of emergency medical services for high dosages. More than half (50.6%) of overdose patients who visited the EDs were admitted to the hospital and the total costs for both inpatient and ED charges were up to 2.3 billion.

As part of the study, researchers found critical geographical and clinical variations among high dose patients visiting the EDs and this has prominent implications for overdose prevention and response interventions. The study results signify the need to take serious efforts at the local, state and national levels to address the opioid overdose epidemic. More resources should be directed to increase access to naloxone (the antidote for opiate high dose), and promote safe prescribing practices among clinicians. In addition, more awareness about the potential risks of overdose must be spread among patients who regularly use prescription and non-prescription opioids.

Prostate Cancer (PC) is regarded as the most common form of cancer that is a second leading cause of death in American men. Recent reports suggest that each year, approximately 233,000 men are diagnosed with this malignancy. About one in six men in the US will be diagnosed with this condition in their lifetime and nearly 35 will die of it. This condition is mostly found in older men above 65 years or more.

There are different signs and symptoms connected with this syndrome and they may differ from one person to another. Several factors such as age, genetics, dietary habits, prostate inflammation, obesity and other lifestyle habits may increase the risk of developing this condition. As per recommendations from the American Cancer Society, men should undergo cancer screening tests at an early age (right from their early 50s or sooner). The major goal behind these tests is to identify this condition early enough so that it can be treated more effectively. Regular and standard tests help to recognize the correct disease symptoms and thus promote early treatment without any complications.

Although there is no regular screening program suggested for this cancer type, urologists often recommend men to be screened for this condition with tests such as digital rectal exam (DRE), prostate-specific antigen (PSA) test, cystoscopy or bladder scope test in order to confirm whether they have this condition.

Why Diagnosis of Prostate Cancer Is Challenging

Accurate and definitive diagnosis of this disease is often a challenging task for physicians. Appropriate risk stratification for men diagnosed with this syndrome is an initial step in diagnosis. The risk intensity (whether low-risk of death or high-risk of death or reoccurrence) will help to determine the specific treatment modality to be chosen.

In many cases decision making and timing related to the type of treatment approach to be opted for this disease is often complex and it is acknowledged that many patients may be over treated which in turn may cause unnecessary burden for them. Better diagnosis and risk stratification of high-risk men helps in more informed decision-making.

Medicare coverage is offered for annual preventive prostate cancer screening (PSA) test and DRE once every 12 months for all male beneficiaries aged 50 years or above. Healthcare providers can bill for the different therapies they provide that are reimbursable. Accurate diagnostic and procedural codes are to be reported on the claims to receive on-time and adequate reimbursement.

For e.g., ICD-9 code V76.44 indicates “Screening for malignant neoplasms of prostate.”

No Adherence to PSA Screening Guidelines – Finds a New Study

A recent survey shows that important guidelines related to prostate cancer screening across the United States are not being properly adhered to, particularly the recommendations made against screening older men. The study results were published in a research letter (published online on September 1, 2014) in JAMA Internal Medicine. Researchers said that they could not locate any particular data related to the current status of PC screening in the US and this prompted them to do this study.

As part of the survey, researchers examined data from the 2012 Behavioral Risk Factor Surveillance System (a joint initiative of the Centers for Disease Control and Prevention and the states) and analyzed data collected between January 2012 and February 2013. They found that the male respondents aged 50 years or more and without a history of PC or other related problems were reported as undergoing prostate-specific antigen (PSA) testing within the previous year.

The key findings of the survey are mentioned below –

• More than half of the men (48.5% of men aged 70-74 years and 48.4% men aged 65-69 years) who participated in the survey had undergone PSA testing.
• It was found that overall 37.1% men had been tested. However, when compared to younger men, older men had taken more testing.
• 45.7% of men aged above 75 years had taken a routine PSA test about 4 years back (even when the US Preventative Services Task Force (USPSTF) had specifically warned against routine PSA screening for people in this age group).

In October 2011, the USPSTF put forward a draft guideline recommending against conducting routine tests related to this disease at any age. The recommendation was accepted and finalized in May 2012 (while the survey was being conducted). However, the American Cancer Society and the American Urological Association still held the view that there was a strong need for men in the age group 50-74 years to carry out routine PSA testing with their physicians. Further, it was found that only 25% of men belonging to that age group were tested. Researchers say that if the hypothesis is that routine and standard tests have potential benefits, it is the younger men who will get benefited than older men.

The survey results also highlight a wide geographic variability in PSA screening across various states in the US. While adjusting prominent factors such as age, physician access and socio demographic factors the occurrence of PSA testing was recorded highest – 59.4% in Hawaii and lowest – 24.5% in New Hampshire. Moreover, this regional variation was more visible with mammography for breast cancer or colorectal cancer screening. The survey results signify the limited effect of national guidelines on clinical practice among healthcare providers.

September Observed as National Prostate Cancer Awareness Month

Recent reports suggest that about 910,000 cases of cancer of the prostate gland were reported globally (in the year 2008) and this number is expected to increase to 1.7 million by the end of 2030. These figures signify the need to create more awareness among people about this syndrome. The month of September is observed as National Prostate Cancer Awareness month in the United States. The main focus behind this celebration is to increase public understanding of the disease including its prevalence, treatment options and approaches to screening, diagnosis and prevention.

The first report of The Institute of Medicine (IOM), the famous ‘To Err is Human’ published in 1999 revealed that around 7000 deaths occur annually from medication errors alone. In 2006, another report from the IOM pointed out that the extra medical costs for preventable adverse drug events occurring in hospitals amount to $3.5 billion a year. A study published in the Journal of Patient Safety in September 2013 found that a lower limit of 210,000 deaths occurred per year related to preventable drug events in hospitals. The solutions recommended in medical literature required the participation of pharmacists, drug manufacturers, information systems along with the communication efforts of hospital personnel. The American Academy of Orthopedic Surgeons (AAOS) puts forth certain technological solutions for physicians which will help them prevent medication errors. As per the AAOS, these solutions can considerably reduce medication errors, enhance the quality of care and patient management, increase reimbursement and reduce medical billing time. Here are the technological solutions recommended for each phase of medication delivery.

Prescription

• Computerized Physician Order Entry (CPOE) – With the help of CPOE, orthopedic surgeons can order medications, tests and procedures directly into the hospital’s computer system so that missing data errors related to dosage, route and frequency of administration can be avoided. Researches have shown its annual return on investment can range from $180,000-$900,000. Improved data collection would result in accurate medical coding and increased reimbursements. Medication errors can cause lack of continuity of care during hospitalization. CPOE can enhance communication efforts in between the transfer of care. While the centralized charting functions can provide more complete and timely patient information, alert functions can highlight pertinent data (for example, allergies) and help on-call doctors in assessing and planning patient care. CPOE software is customizable so as to allow surgeons to prescribe their routine orders and make modifications as per their needs.
• Computerized Decision Support Systems (CDSS) – CDSS provides the services that would have a greater impact on surgeons’ decisions and plan of patient care such as review of orders as they are written, appropriate dosing schedules, comparison of new and existing orders, scanning for all possible drug interaction and can also give alerts to the surgeon regarding the relevant lab results. This system can provide important reminders and alerts and improve the clinical performance in relation to prescribing practices. It can also recommend alternative medications that are less expensive and thereby reduce patient care costs. CDSS has the ability to detect and prevent duplications associated with medications, testing and imaging.
• Pharmacist-assisted Rounds – Utilization of staff pharmacists during medication decisions is one of the least expensive as well as easily accessible tools. Being familiar with the institution’s formulary, pharmacists can assist doctors in choosing appropriate and efficient medications, especially in case of challenging situations such as patients on multiple medications, organ failure and other conditions. They can also assist physicians in practicing evidence-based medicine. Compared to non-formulary medications, formulary medications have a lower cost and a higher reimbursement rate. Easy availability of formulary medications in adjacent pharmacies increases the possibility of patient compliance with post-operative medications.
• Standardized Order Sets – If CPOE and CDSS are not available, it is required to use standardized order sets and clinical pathways for frequently performed procedures and admissions. This will reduce the length of hospital stay and improve the quality of care. Orthopedic surgeons are required to customize their order sets for clinical preferences and utilize them for minimizing handwriting errors and increasing standardization of care. Order sets need to be reviewed with pharmacy personnel in order to reduce the use of expired or inappropriate medications and ensure compliance with formulary requirements.

CPOE and standardized order sets can help avoid handwriting errors that may result in undesirable consequences for the patient. Abbreviations of drug names should be avoided in prescriptions. Instead of using abbreviations, dosage units should be spelled out. Use a zero to the left of a dose less than 1 and do not use a terminal zero to the right of the decimal point in order to minimize dosing errors.

Transcription

The electronic order transcription accomplished with CPOE can increase the speed and accuracy of transcription so that there will be less medication errors. In the absence of CPOE, reduced handwritten orders and use of standardized order sets would improve the transcription process.

• Verbal Order Verification Avoid verbal orders as far as possible and implement specific procedures to ensure clarity among healthcare personnel. Standing order sets can help avoid many verbal orders. In case a verbal order is given, a ‘read-back and verify’ protocol should be implemented to ensure proper interpretation of that order.

Dispensing

• Automated Dispensing – This technology can prevent human factors errors including “look alike” and “sound alike” drugs and ensure the correct dosage. In 2007, a national forum was convened by the Institute for Safe Medication Practices, along with invited stakeholders for developing updated safe-use guidelines for automated dispensing cabinets.
• Bar Coding – The U.S. Food and Drug Administration (FDA) mandated in 2006 that hospitals should use bar codes for medications. This rule was finalized in 2004 and hospitals were given two years to comply with the rule which required stepping into the use of bar code technologies in human drug products and biologic products. Bar code system can automatically identify the national drug code (NDC) for specific manufactured products which result in better scheduling of medication, less missed doses, more efficient drug monitoring, improved medical records, better communication among healthcare staff and even cost efficiencies. The right patient, right drug and the right dosage can be identified with bar coding.
• Unit Dose Packaging – Package pharmaceuticals in unit dose applications will improve the administration of the proper drug and dose to the right patient when used together with bar code readers and computer systems. To comply with federal regulations, pharmaceutical manufacturers will be instituting this kind of packaging for the next few years.

There should be high-risk drug protocols/policies in place as national patient safety organizations recommend monitoring safety practices while using high-alert medications. Remove concentrated electrolytes including but not limited to sodium chloride, potassium chloride, and potassium phosphate more than 0.9% from patient care units. Hospitals are required to recommend pharmacies to reduce the number, concentrations and volume of high-risk medications (warfarin, theophylline, narcotics, muscle relaxants, magnesium, lidocaine, insulin, immunoglobin, heparin, dextrose injections, chemotherapeutic agents and adrenergic agents) in formulary.

Administering and Monitoring

The administration phase is a prominent source of medication errors and the use of automated drug dispensing, unit dose packaging and bar coding can eliminate most of these errors. A computerized order entry system alone or in concert with a decision support system can identify potential medication errors and offer solutions for them. Additionally, it can record data related to errors and near misses for further uses. If such a system is not available routine patient chart audits can deter flawed practices. Medication errors can also be reduced by educating patients.

• Medication Administration Record (MAR)

  MARs record the time, date and route of administration of medications ordered along with the identity of the healthcare provider who prescribes the     medications. Incorporation of MAR into a computerized system can generate typed orders and administration information instead of handwritten orders, and this which would reduce the number of medication errors. Computerized MAR can also record the data by the time the process occur so that there will be no confusion over the details of administration such as whether a dose was administered, when was it administered and so on. It is possible to program MAR in such a way that it require a co-signer for high-risk medications so as to implement a double-check measure.

Medical literature suggest that environmental factors including fatigue, poor lighting, interruptions, noise, and an excessive workload may cause medication errors. It is the responsibility of hospitals and ambulatory surgical centers to evaluate and monitor these factors and ensure the distractions caused by them are kept to a minimum. If an error occurs, hospital administration, quality assurance, risk management, and physicians should investigate the root cause of the error and rectify it as soon as possible in case it is problematic.

Medication Reconciliation

Medication reconciliation aims at optimizing drug therapy by accurately and completely reconciling medication while minimizing adverse drug events across the continuum of care. There should be a medication list that keeps track of what the patient is currently taking and what medications are subsequently prescribed. The medications may include prescriptions, over-the-counter drugs, vitamins, herbal supplements, and any product that is designated as a drug by the FDA. The Joint Commission insists that home medication (medication taken before patient’s entry to the hospital) list should be obtained within 24 hours of admission as part of the initial assessment. With the help of electronic records, medication can be tracked easily and reconciliation can be more effective.

The Role of Electronic Medical Records (EMRs)

As per AAOS, the implementation of EMRs can significantly reduce the medication adverse events, improve patient health and provide cost savings to healthcare providers. Orthopedic surgeons can access patient records and history very easily. Though the cost benefits won’t be that much evident during the adoption period, gradual increase can be seen in due course of time. EMRs are beneficial only if the information entered into the system is complete and accurate.

However, the EMR drop-down boxes and templates are not much effective in capturing meaningful conversation. It can’t offer 100% accuracy even when used with speech recognition software as the software doesn’t recognize grammatical mistakes and punctuation errors. Moreover, it does not have the capability to expand the acronyms. Though copying information from one file to another in an EMR system may save the time of surgeons, irrelevant or wrong information may be entered by mistake while doing this routinely (copy and paste errors). These kinds of challenges can be resolved by combining EMR with transcription and seeking help from trained medical transcriptionists. With the support of a professional medical billing and coding company that offers EHR/EMR feeds, healthcare specialists can streamline their revenue cycle and achieve better cost benefits.

According to a survey conducted last year by MedData Group, many physicians are dissatisfied with their electronic health record system (EHR). Up to 85% of the physicians said that their EHR resulted in lost productivity due to the need to spend more time on documentation and 66% said that the system resulted in their seeing fewer patients. MedScape’s recent EHR report shows that one year later things have not improved – only around 42 percent of physicians said they were satisfied with their current system. Electronic health record systems that fail to ensure proper clinical documentation would affect patient care, medical billing and coding, and irrevocably, practice revenue.

According to physicians, EHRs pose problems related to usability such as

• Time-consuming data entry
• Poor user experience
• Reduces attention towards the patient
• Hassles posed by cumbersome user interface
• Lack of customizability
• Degradation of clinical documentation

Physicians often need to undergo extensive training to be able to use these systems. However, experts point out that the solution lies in a renewed focus on EHR usability.

Features of a User-friendly EHR System

• Simplicity – Simplicity translates to ‘easy-to-use and understand’. A usable EHR is the one that can be used easily on the same day that a practice implements it. It should be simple enough for physicians and other users to handle without any elaborate training session.
• Efficiency – Starting from the learning process, efficiency should extend to data capture. The process of charting must be fast and also record accurate patient notes for improved outcomes. An efficient electronic health record can keep track of patient’s relevant data, speed up practice workflow, and increase physician productivity.
• Design – A system that lacks effective design can affect usability in the long run. As physicians are the ones who spend a lot of time on it, good design is important.
• Capability – The capability of the EHR is related to successful patient outcomes. This helps the doctor to provide better patient care.
• Accuracy – Efficient EHRs can prevent documentation errors, leading to better patient outcomes.

In view of these considerations, experts say the ideal EHR system is one that:

• Offers customizability and free text options – This means fewer clicks to input information, while permitting users to create diagnosis templates that paste into the required field
• Reduces number of steps – An interface that provides immediate access to most of the physician’s job function and eliminates redundancy
• Meets physician expectations – It would allows users to perform actions that they need such as sending orders to office staff

Improving EHR Usability

Effective communication including doctors, vendors and patients is required to develop an EHR that meets the requirements for optimal usability. Since physicians are the primary users they can provide details on how to improve the usability of the system. They can also ask their patients about their experience, expectations on what kind of data they want to access, etc. Such feedback can be helpful to vendor for improving the usability efficacy of the EHR system.

If physicians find that their EHR product does not meet their requirements and if their optimization efforts fail, they should consider replacing it. A professional medical outsourcing company can help providers select the right system.

As the Obama administration announced recently in the government’s annual report on the 2 programs Medicare and Social Security, Medicare’s financial condition has improved in the last year, partly due to the Affordable Care Act. However, the same cannot be said of Social Security that practically remains unchanged. Medicare’s hospital insurance trust fund will be used up in 2030, 4 years later than the earlier projected figure. However, SS fund will be exhausted in 2033, as expected last year.

Issues Identified

One of Medicare problems is related to healthcare spending, which was found to be growing faster than the overall economy. Though there is a slowdown in healthcare spending in recent times, the exact reasons for this change remain unknown. However, healthcare experts opine that even if the healthcare spending can be kept at pace with inflation, Medicare’s demography related problem is hard to solve. The program provides coverage for everyone above the age of 65. With a growing population of aged people, Medicare’s burden also increases. The program is enrolling more people (around 10,000 new beneficiaries) this year and if the number goes up it will have to struggle to pay for coverage.

Even though the report says Medicare’s Part B monthly premium for outpatient care is estimated to remain unchanged ($104.90) for 2015, average premiums for prescription coverage are projected to increase by less than $2 per month. The hospitalization deductible is also expected to rise to $1,248 in 2015 – an increase of $32 compared to this year.

According to the report, the disability trust fund is expected to be exhausted in two years. It is estimated that this program will be able to collect only enough payroll taxes to pay 81 percent of benefits by that time unless the government acts right. Medicare will be able to collect enough payroll taxes to pay 85 percent of inpatient costs when the hospital trust fund is expected to get exhausted in 2030. The report estimated a 1.5 percent increase in monthly Social Security payments to beneficiaries next year, which would be the lowest among the automatic adjustments adopted in the 1970s. It was also stated that the increase will be based on a measure of inflation by government. Around 58 million beneficiaries are estimated to receive Social Security benefits with 41 million retired workers and dependents, 11 million disabled workers and 6 million survivors of deceased workers.

A Solution Can be Worked Out

Overall, the report suggests both Medicare and Social Security continue to face long-term financial problems though such a situation is not imminent. This may affect the quality of care as more costs will be shifted to the patients. When faced with a situation in which higher payments have to be paid from their own pockets, patients may switch to less expensive genetic drugs or postpone a particular test or an elective procedure. Though the Affordable Care Act (ACA) introduced several developments to restructure Medicare such as creating incentives for doctors and hospitals so that they can keep their patients healthier by managing those having chronic health conditions closely, it will take time to determine the effects of those changes.

Experts say if the two trust funds were combined, both the programs would have enough money to last until 2033. They also opine benefit reductions, tax increases or a combination of both will be required to avoid future cutbacks. However, the President has made it clear that he will not support any proposal that would drastically affect Americans who depend on these programs or that would deny benefits for future retirees. However, the trustee report suggest that lawmakers should address the challenges associated with both programs as soon as possible and take the right action in a timely manner so that the public will get enough time to prepare for the change.