Hospitals have been put on notice. Starting Oct. 1, 2008, Medicare will no longer pay the additional costs incurred when certain hospital-acquired infections (HAI) or medical errors occur. "Are hospitals prepared?" asks Suzanne DelBlanco, CEO of the Washington-based Leapfrog Group. "Many are not. The vast majority are likely to suffer financially."
The final rule implements congressional law Section 5001(c) of the Deficit Reduction Act of 2005. When the new rule takes effect, hospitals will no longer receive additional payment for eight conditions identified by the CDC unless they were present at the time of admission (POA.)
The financial costs associated with hospital-acquired infections are staggering. According to the CDC, HAIs result in up to $27.5 billion in additional healthcare expenses annually. And for the majority of those cases, Medicare is the payer.
But Medicare is no longer picking up that tab — and since the new rule prohibits passing those charges onto the patient, hospitals will end up absorbing the cost. Though CMS has said it will allow a three month grace period, the writing is already on the wall. "I received an e-mail from a hospital CIO yesterday," says Stan Pestotnik, M.S., R.Ph., CEO of Salt Lake City-based TheraDoc. "It said, 'The wolves are at the door.' They're in a panic."
The strongest HAI-related initiatives are at the state level. Pennsylvania was the first state that mandated electronic surveillance systems, and it's also led the country in mandating public reporting of infections. Twenty-two states are now on the books mandating HAI reporting.
So where should a hospital begin in order to protect its bottom line? Technology can help, but it doesn't necessarily come first. "Hospitals first have to establish a culture of safety," Pestotnik says. "I don't care how much technology you throw at a problem if you don't have the culture that is going to embrace and understand it. You have to admit you have a problem before you can fix it."
Emily McCracken, director of infection control at 343-bed Hamot Medical Center in Erie, Pa. agrees. For many hospitals, such as Hamot, safe infection control processes have been developing before the CMS ruling was announced. "It's not really going to be the mandate that's pushing the process," she says. "It's absolutely the right thing to do."
Many feel there will be more extensive investigation for pre-existing conditions at POA, with additional tests and even photographic documentation of state of skin care. "We suggest doing the best with what you have," says Tim Ward, a partner at New York-based Tefen USA. Ward believes that in many cases the technology is already there. "It's just a question of setting up a standard process and following it," he says. Changes in protocols will certainly affect throughput. "It already may take hours to get an ED patient in a bed. Add another process and we've extended that timeframe — and it's already pretty bad."
Ward says many hospitals are not well positioned to address these throughput issues and need to work on streamlining and standardizing their processes. "They'll do a pretty good job of addressing this initial onslaught of issues from CMS, but that list is just going to get bigger over time."
Though there are many early intervention process improvements that can be made, most people in the industry agree on one thing: There will come a point where hospitals cannot attack the problem without the aid of technology.
Pennsylvania was an early adopter of infection control guidelines, and the University of Pittsburgh Medical Center, (UPMC), had a novel IT solution — it became a partner in an infection control IT company.
"Three years ago, like many academic centers, we recognized that the infection control explosion was right around the corner," says Tami Merryman, CIO of UPMC. "We decided to look for a product to facilitate and automate the detection, identification and treatment of infections." Through an RFP, they chose TheraDoc. "It was attractive to us because of its decision support model, and the fact that it utilizes real time alerts."
When UPMC sat down to negotiate the cost to install the system across their 13 acute care hospitals and six rehabs, they decided a better financial approach was to invest in the company — with a good reason. Merryman says that today's infection control environment can't thrive off retrospective data analysis. "Our system has the ability to send out clinical alerts the minute lab results are available: auto or text pages are sent to the doctor's cell phone. Real time alert monitoring is a lot more proactive than reactive in infection control."
The system integrates the ADT patient ID system with pharmacy data, lab data and clinical data, and links to the electronic medical record. "It basically takes the raw data you're used to seeing in IT systems and turns it into information. We're a Cerner shop, but we could have been using Eclipsys or any other vendor and TheraDoc would still work."
Root cause is also automated, eliminating a lot of the work that used to be done through hunting and gathering — it's put together in reports delivered to the desktop. The second level of reporting is sending infection information directly to the state reporting agency by one click instead of printing and faxing.
Merryman says the manpower savings for infection control nurses is huge. "When we projected our staffing needs, we anticipated we were going to need 10 more infection control nurses doing manual reporting to meet the minimum requirements. We haven't had to add any infection control nurses. Pulling people from the bedside is a huge issue."
The minimum data sets to run the TheraDoc system are an ADT for registration, a lab system and a pharmacy system. "100 percent of the hospitals in the United States over 100 beds have those systems in place," Pestotnik says. "But interoperability standards remain a major problem." Hospitals needs messaging standards which are usually based on HL7, the terminology standard (usually based on Snomed) and knowledge representation standards. "That's what I would be asking my vendors if I was shopping for a system today to meet the new mandates," says Pestotnik. "Does the system support standards, and if so which ones?"
Another hospital prepared for the CMS ruling is Hamot. "We had the foresight to be early adopters of technology," says McCracken. "Our infection control surveillance program has been in place for three years. We are ready when this does turn on."
Hamot's MedMined (Birmingham, Ala.) system looks at every patient admitted to the hospital, and through advanced algorithms, identifies infections that might not have been present or incubating at the time of admission. This 'virtual surveillance technology' takes away any subjectivity about the data. "One problem CMS has identified is that I am going to be biased for not reporting an infection for my facility," says McCracken. "What this system does is make it an objective measure."
McCracken says that before her facility went live with MedMined, she typically looked at only certain patient populations — usually in critical care and ICU — for the big, heavy hitter, high cost infections like ventilator assisted pneumonias. "The downfall to that?" she asks. "It was identifying the tip of the iceberg. We were only reaching 20 percent of our inpatient admissions. What about the other 80 percent? That meant being in the dark about which specific infections Hamot's HAI patients had. Since going live with MedMined, the facility tracks all infections. "We can look at the entire house and get the entire scope of where we may have issues," McCracken says. "You can't make an impact if you don't know the scope of the problem."
But ironically, the CMS mandate may impair some hospitals' ability to implement IT solutions such as these. Large urban hospitals, disproportionate-share hospitals, and teaching hospitals have received extra capital-related payments, known as adjustments, from Medicare for 15 years. Without that money, some say the CMS regulation could impair urban hospitals' ability to buy advanced technology and equipment. The ultimate effect might be a negative impact on patient safety and patient care. The National Association of Public Hospitals and Health Systems has expressed "deep concern over the impact" of the proposed CMS rule change.
DelBlanco believes there may be a deeper financial impact. "The list from Medicare covers a list of conditions that are fairly prevalent, and now hospitals will have to eat the cost. The real question is will they find ways of subsidizing that cost by passing it on to the private sector? Healthcare financing is as complex as it gets, and I don't know that we could ever trace that trail."
With implications like these, hospital executives need to be careful in considering what IT systems they may purchase to address the issue — and not make a hasty judgment as a reactive measure. "We need to be thinking about what are the requirements going to be down the road," Ward says. "Whenever you're going to make an IT purchase that costs, say, half a million dollars or more, you really need to identify that future state and make sure the IT system supports it. Linking process improvement and the IT purchase is really important. The latest round of CMS regulations is just a case in point for that."
Most say that automating the infection control processes is a very necessary step to facing these measures. "Assuring the quality of care is one of the costs of doing business," DelBlanco says. "If a hospital can't invest in protecting patients from harm, then they probably shouldn't be delivering care."
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