Joyce Frieden

TAMPA — Emergency departments in general and pediatric hospitals did not obtain urine cultures from three-fourths of febrile pediatric patients under 3 years of age, and did not obtain blood cultures from two-thirds of such patients, according to a study of national data.

The study data suggest that “blood and urine cultures are obtained less frequently than we might expect,” Dr. Lara Johnson of Yale University, New Haven, Conn., the study's sole author, said at a meeting on pediatric hospital medicine. Several audience members at the packed session said they were surprised or shocked by the results.

Emergency department (ED) practices regarding the frequency of obtaining blood and urine cultures are unknown, Dr. Johnson said. Guidelines published in 2003 by the American College of Emergency Physicians state that infants between 1 and 28 days old with a fever should be presumed to have a serious bacterial infection, which Dr. Johnson said would call for a full sepsis work-up—including blood and urine cultures as well as a spinal tap.

Dr. Johnson analyzed data from the 2001-2004 Hospital Ambulatory Medical Care Survey, specifically ED visits among children less than 3 years of age. The researchers included all patients with fever listed as the reason for the visit as well as those in the ED for other reasons who had a documented temperature of at least 100.4 degrees Fahrenheit.

Dr. Johnson also looked at several patient factors, including age, acuity, race/ethnicity, and sex, and whether the patient was admitted to the hospital or transferred elsewhere. Hospital-specific factors considered in the analysis included location—urban or rural, and geographic region—public or private ownership, and status as a general or children's hospital.

Of the 37,000 ED visits included in the national survey, 4,358 involved children with either subjective or objective evidence of fever, and Dr. Johnson's study included those patients. In patients less than 3 months of age, blood cultures were obtained in 33.3% of cases and urine cultures in 24.7% of cases, Dr. Johnson said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The numbers for older children “were significantly less,” she said.

Children who were eventually admitted to the hospital or transferred to another institution were 5.53-fold more likely to have a blood culture done than those who were not, and 2.89-fold more likely to have a urine culture. Also, children with higher temperatures were more likely to have blood cultures done, Dr. Johnson said. General hospitals were less likely than children's hospitals to do any cultures. Hispanic patients were less likely to have blood cultures done, compared with non-Hispanic patients. There were also regional differences: Hospitals in the Northeast were less likely to obtain blood cultures, as were general hospitals and hospitals in nonmetropolitan areas.

For urine cultures, the patterns were similar, with patients who were younger and who had higher temperatures being more likely to receive urine cultures. In addition, male patients were more likely than females to receive urine cultures, a difference that was not noted with blood cultures, according to Dr. Johnson.

Hospitals in the Northeast were more likely to obtain urine cultures; as with blood cultures, general and nonmetropolitan hospitals were less likely to obtain urine cultures.

Dr. Johnson noted several limitations of her study, such as the fact that it was a cross-sectional survey and provided “just a snapshot” of the patients who came into the ED.

“It's impossible to know from this data what happened before the patient came to the ED,” she said. “Did they have a blood culture obtained in their practitioner's office? It's [also] impossible to know what happened after they left the ED; did they have blood cultures obtained after admission on the floor?

“We also don't know anything about outcomes [or] results of tests,” she added.

The data suggest that “more evidence is needed to guide laboratory evaluation of febrile infants,” she concluded.

In response to a question, Dr. Johnson noted that a preliminary analysis found that the results did not change significantly if only patients with objective evidence of fever were included.

She also was asked whether some patients may not have had urine cultures taken because a urinalysis suggested that a culture was not necessary. Dr. Johnson replied that she did not look at urinalysis data, but she did look at how many patients had complete blood counts taken in lieu of blood cultures, “and the frequencies were not terribly different.”

Dr. Johnson said that she had no conflicts of interest.

TAMPA — Emergency departments in general and pediatric hospitals did not obtain urine cultures from three-fourths of febrile pediatric patients under 3 years of age, and did not obtain blood cultures from two-thirds of such patients, according to a study of national data.

The study data suggest that “blood and urine cultures are obtained less frequently than we might expect,” Dr. Lara Johnson of Yale University, New Haven, Conn., the study's sole author, said at a meeting on pediatric hospital medicine. Several audience members at the packed session said they were surprised or shocked by the results.

Emergency department (ED) practices regarding the frequency of obtaining blood and urine cultures are unknown, Dr. Johnson said. Guidelines published in 2003 by the American College of Emergency Physicians state that infants between 1 and 28 days old with a fever should be presumed to have a serious bacterial infection, which Dr. Johnson said would call for a full sepsis work-up—including blood and urine cultures as well as a spinal tap.

Dr. Johnson analyzed data from the 2001-2004 Hospital Ambulatory Medical Care Survey, specifically ED visits among children less than 3 years of age. The researchers included all patients with fever listed as the reason for the visit as well as those in the ED for other reasons who had a documented temperature of at least 100.4 degrees Fahrenheit.

Dr. Johnson also looked at several patient factors, including age, acuity, race/ethnicity, and sex, and whether the patient was admitted to the hospital or transferred elsewhere. Hospital-specific factors considered in the analysis included location—urban or rural, and geographic region—public or private ownership, and status as a general or children's hospital.

Of the 37,000 ED visits included in the national survey, 4,358 involved children with either subjective or objective evidence of fever, and Dr. Johnson's study included those patients. In patients less than 3 months of age, blood cultures were obtained in 33.3% of cases and urine cultures in 24.7% of cases, Dr. Johnson said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The numbers for older children “were significantly less,” she said.

Children who were eventually admitted to the hospital or transferred to another institution were 5.53-fold more likely to have a blood culture done than those who were not, and 2.89-fold more likely to have a urine culture. Also, children with higher temperatures were more likely to have blood cultures done, Dr. Johnson said. General hospitals were less likely than children's hospitals to do any cultures. Hispanic patients were less likely to have blood cultures done, compared with non-Hispanic patients. There were also regional differences: Hospitals in the Northeast were less likely to obtain blood cultures, as were general hospitals and hospitals in nonmetropolitan areas.

For urine cultures, the patterns were similar, with patients who were younger and who had higher temperatures being more likely to receive urine cultures. In addition, male patients were more likely than females to receive urine cultures, a difference that was not noted with blood cultures, according to Dr. Johnson.

Hospitals in the Northeast were more likely to obtain urine cultures; as with blood cultures, general and nonmetropolitan hospitals were less likely to obtain urine cultures.

Dr. Johnson noted several limitations of her study, such as the fact that it was a cross-sectional survey and provided “just a snapshot” of the patients who came into the ED.

“It's impossible to know from this data what happened before the patient came to the ED,” she said. “Did they have a blood culture obtained in their practitioner's office? It's [also] impossible to know what happened after they left the ED; did they have blood cultures obtained after admission on the floor?

“We also don't know anything about outcomes [or] results of tests,” she added.

The data suggest that “more evidence is needed to guide laboratory evaluation of febrile infants,” she concluded.

In response to a question, Dr. Johnson noted that a preliminary analysis found that the results did not change significantly if only patients with objective evidence of fever were included.

She also was asked whether some patients may not have had urine cultures taken because a urinalysis suggested that a culture was not necessary. Dr. Johnson replied that she did not look at urinalysis data, but she did look at how many patients had complete blood counts taken in lieu of blood cultures, “and the frequencies were not terribly different.”

Dr. Johnson said that she had no conflicts of interest.

TAMPA — Emergency departments in general and pediatric hospitals did not obtain urine cultures from three-fourths of febrile pediatric patients under 3 years of age, and did not obtain blood cultures from two-thirds of such patients, according to a study of national data.

The study data suggest that “blood and urine cultures are obtained less frequently than we might expect,” Dr. Lara Johnson of Yale University, New Haven, Conn., the study's sole author, said at a meeting on pediatric hospital medicine. Several audience members at the packed session said they were surprised or shocked by the results.

Emergency department (ED) practices regarding the frequency of obtaining blood and urine cultures are unknown, Dr. Johnson said. Guidelines published in 2003 by the American College of Emergency Physicians state that infants between 1 and 28 days old with a fever should be presumed to have a serious bacterial infection, which Dr. Johnson said would call for a full sepsis work-up—including blood and urine cultures as well as a spinal tap.

Dr. Johnson analyzed data from the 2001-2004 Hospital Ambulatory Medical Care Survey, specifically ED visits among children less than 3 years of age. The researchers included all patients with fever listed as the reason for the visit as well as those in the ED for other reasons who had a documented temperature of at least 100.4 degrees Fahrenheit.

Dr. Johnson also looked at several patient factors, including age, acuity, race/ethnicity, and sex, and whether the patient was admitted to the hospital or transferred elsewhere. Hospital-specific factors considered in the analysis included location—urban or rural, and geographic region—public or private ownership, and status as a general or children's hospital.

Of the 37,000 ED visits included in the national survey, 4,358 involved children with either subjective or objective evidence of fever, and Dr. Johnson's study included those patients. In patients less than 3 months of age, blood cultures were obtained in 33.3% of cases and urine cultures in 24.7% of cases, Dr. Johnson said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The numbers for older children “were significantly less,” she said.

Children who were eventually admitted to the hospital or transferred to another institution were 5.53-fold more likely to have a blood culture done than those who were not, and 2.89-fold more likely to have a urine culture. Also, children with higher temperatures were more likely to have blood cultures done, Dr. Johnson said. General hospitals were less likely than children's hospitals to do any cultures. Hispanic patients were less likely to have blood cultures done, compared with non-Hispanic patients. There were also regional differences: Hospitals in the Northeast were less likely to obtain blood cultures, as were general hospitals and hospitals in nonmetropolitan areas.

For urine cultures, the patterns were similar, with patients who were younger and who had higher temperatures being more likely to receive urine cultures. In addition, male patients were more likely than females to receive urine cultures, a difference that was not noted with blood cultures, according to Dr. Johnson.

Hospitals in the Northeast were more likely to obtain urine cultures; as with blood cultures, general and nonmetropolitan hospitals were less likely to obtain urine cultures.

Dr. Johnson noted several limitations of her study, such as the fact that it was a cross-sectional survey and provided “just a snapshot” of the patients who came into the ED.

“It's impossible to know from this data what happened before the patient came to the ED,” she said. “Did they have a blood culture obtained in their practitioner's office? It's [also] impossible to know what happened after they left the ED; did they have blood cultures obtained after admission on the floor?

“We also don't know anything about outcomes [or] results of tests,” she added.

The data suggest that “more evidence is needed to guide laboratory evaluation of febrile infants,” she concluded.

In response to a question, Dr. Johnson noted that a preliminary analysis found that the results did not change significantly if only patients with objective evidence of fever were included.

She also was asked whether some patients may not have had urine cultures taken because a urinalysis suggested that a culture was not necessary. Dr. Johnson replied that she did not look at urinalysis data, but she did look at how many patients had complete blood counts taken in lieu of blood cultures, “and the frequencies were not terribly different.”

Dr. Johnson said that she had no conflicts of interest.

TAMPA — Analyzing your hospital's “throughput” can reveal ways to decrease crowding, increase patient and employee satisfaction, and possibly improve your hospital's bottom line, Dr. Paul Hain said at a meeting on pediatric hospital medicine.

Throughput—the measure of how fast patients enter and exit a facility—is important for several reasons, said Dr. Hain, associate chief of staff at Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville, Tenn. In addition to increasing satisfaction, improving throughput can help with patient safety and boost a hospital's reputation. And improving the bottom line can free up construction capital, a valuable commodity at many hospitals.

To learn more about improving throughput, Dr. Hain suggested that physicians read “The Goal,” a novel by Eliyahu Goldratt and Jeff Cox that incorporates the throughput evaluation process. The novel uses an approach called the “Theory of Constraints,” which involves these steps:

▸ Make sure the organization's goal has been articulated. “This can be a big problem,” Dr. Hain said. “You have to get really focused on what you want to talk about.”

▸ Identify the constraint. Look for the bottleneck or backup that is impeding the flow of patients.

▸ Exploit the constraint. That is, make sure that whatever is causing the bottleneck is at least working at full capacity. For example, if the bottleneck in the emergency department is that it takes 42 minutes to print a patient identification (ID) label, make sure that the label machine is working all the time and is never idle.

▸ Subordinate all other processes to working on the constraint. “Everything else bows to the constraint, so if the constraint is the ID printing machine, the fact that the nurses don't like the triage area, that the doctors don't think the scheduling is fair, that the patients are angry—none of that fixes the problem. The only thing you're focusing on to improve flow is making sure your ID printer prints all the time,” Dr. Hain said.

▸ Elevate the importance of the constraint. This includes allocating capital to the problem if needed, so in this example it might mean buying a faster label machine.

▸ Look for the next bottleneck. Start the process all over again if a new bottleneck becomes apparent after your efforts have resolved the initial problem. “Now that's not your constraint, but something else is. … Look at the entire chain … and find one [place] that's absolutely the backup,” Dr. Hain advised at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Another way to improve throughput is by using “Queuing Theory,” which adjusts capacity to match variation in demand. “Emergency departments aren't unpredictable,” he said. “You never know when the next trauma is coming in, but you know what times of day tend to be busier than others, and you can staff up for them.”

Other methods for examining throughput include “Six Sigma” (applying a theory that says variation is waste), “Statistical Process Control” (graphing data using subsets of events to describe a large set), and “Lean Thinking” (eliminating steps in a process that don't add value).

Dr. Hain described how his hospital used a throughput evaluation to improve triage times in the emergency department (ED). Of the 50,000 patients seen annually in the ED, 16% end up being admitted, and those admissions account for 46% of the hospital's total admissions.

The hospital decided to focus on decreasing the length of stay for its level 4 and level 5 ED patients, which averaged 170 minutes in winter and 110 minutes in summer. The staff set a goal of reducing average length of stay to 60 minutes, without decreasing patient safety or satisfaction and without increasing readmissions.

First, they asked staff members to put up adhesive paper notes explaining why patients didn't leave as fast as they should have. “That was the whole project for 2 weeks,” he said. Based on those results and other information, they changed the location of some triage activities and added staffing for the busier times.

Since the change, “patient satisfaction has gone through the roof” and the average in-and-out-time for “fast track” ED patients who are not very ill is 60 minutes, Dr. Hain said. Staff members originally thought that this change would cost the hospital money, but it appears to be cost-neutral in the long run because the staff is deployed more efficiently.

Dr. Hain said that his hospital improved throughput in other areas, resulting in what he said was one of the lowest severity-adjusted lengths of stay in the country. Measures included setting up an “access center”—a one-stop shopping area for incoming calls, bed management, and environmental services—and using computers to improve communication among the electronic order entry, patient tracking, and bed board areas. These efforts—combined with integrated case management, social work, child life programs, and 24-hour in-house administrative coordinators to oversee beds and throughput—brought down the length of stay, he said.

Although there are many areas in the hospital where the staff could have begun analyzing throughput, starting with the ED worked well because it was a discrete operation and it became an “early win” that staff members could build upon for use in similar projects, he said.

Dr. Hain said he had no conflicts of interest.

A related video is at www.youtube.com/HospitalistNews

TAMPA — Analyzing your hospital's “throughput” can reveal ways to decrease crowding, increase patient and employee satisfaction, and possibly improve your hospital's bottom line, Dr. Paul Hain said at a meeting on pediatric hospital medicine.

Throughput—the measure of how fast patients enter and exit a facility—is important for several reasons, said Dr. Hain, associate chief of staff at Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville, Tenn. In addition to increasing satisfaction, improving throughput can help with patient safety and boost a hospital's reputation. And improving the bottom line can free up construction capital, a valuable commodity at many hospitals.

To learn more about improving throughput, Dr. Hain suggested that physicians read “The Goal,” a novel by Eliyahu Goldratt and Jeff Cox that incorporates the throughput evaluation process. The novel uses an approach called the “Theory of Constraints,” which involves these steps:

▸ Make sure the organization's goal has been articulated. “This can be a big problem,” Dr. Hain said. “You have to get really focused on what you want to talk about.”

▸ Identify the constraint. Look for the bottleneck or backup that is impeding the flow of patients.

▸ Exploit the constraint. That is, make sure that whatever is causing the bottleneck is at least working at full capacity. For example, if the bottleneck in the emergency department is that it takes 42 minutes to print a patient identification (ID) label, make sure that the label machine is working all the time and is never idle.

▸ Subordinate all other processes to working on the constraint. “Everything else bows to the constraint, so if the constraint is the ID printing machine, the fact that the nurses don't like the triage area, that the doctors don't think the scheduling is fair, that the patients are angry—none of that fixes the problem. The only thing you're focusing on to improve flow is making sure your ID printer prints all the time,” Dr. Hain said.

▸ Elevate the importance of the constraint. This includes allocating capital to the problem if needed, so in this example it might mean buying a faster label machine.

▸ Look for the next bottleneck. Start the process all over again if a new bottleneck becomes apparent after your efforts have resolved the initial problem. “Now that's not your constraint, but something else is. … Look at the entire chain … and find one [place] that's absolutely the backup,” Dr. Hain advised at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Another way to improve throughput is by using “Queuing Theory,” which adjusts capacity to match variation in demand. “Emergency departments aren't unpredictable,” he said. “You never know when the next trauma is coming in, but you know what times of day tend to be busier than others, and you can staff up for them.”

Other methods for examining throughput include “Six Sigma” (applying a theory that says variation is waste), “Statistical Process Control” (graphing data using subsets of events to describe a large set), and “Lean Thinking” (eliminating steps in a process that don't add value).

Dr. Hain described how his hospital used a throughput evaluation to improve triage times in the emergency department (ED). Of the 50,000 patients seen annually in the ED, 16% end up being admitted, and those admissions account for 46% of the hospital's total admissions.

The hospital decided to focus on decreasing the length of stay for its level 4 and level 5 ED patients, which averaged 170 minutes in winter and 110 minutes in summer. The staff set a goal of reducing average length of stay to 60 minutes, without decreasing patient safety or satisfaction and without increasing readmissions.

First, they asked staff members to put up adhesive paper notes explaining why patients didn't leave as fast as they should have. “That was the whole project for 2 weeks,” he said. Based on those results and other information, they changed the location of some triage activities and added staffing for the busier times.

Since the change, “patient satisfaction has gone through the roof” and the average in-and-out-time for “fast track” ED patients who are not very ill is 60 minutes, Dr. Hain said. Staff members originally thought that this change would cost the hospital money, but it appears to be cost-neutral in the long run because the staff is deployed more efficiently.

Dr. Hain said that his hospital improved throughput in other areas, resulting in what he said was one of the lowest severity-adjusted lengths of stay in the country. Measures included setting up an “access center”—a one-stop shopping area for incoming calls, bed management, and environmental services—and using computers to improve communication among the electronic order entry, patient tracking, and bed board areas. These efforts—combined with integrated case management, social work, child life programs, and 24-hour in-house administrative coordinators to oversee beds and throughput—brought down the length of stay, he said.

Although there are many areas in the hospital where the staff could have begun analyzing throughput, starting with the ED worked well because it was a discrete operation and it became an “early win” that staff members could build upon for use in similar projects, he said.

Dr. Hain said he had no conflicts of interest.

A related video is at www.youtube.com/HospitalistNews

TAMPA — Analyzing your hospital's “throughput” can reveal ways to decrease crowding, increase patient and employee satisfaction, and possibly improve your hospital's bottom line, Dr. Paul Hain said at a meeting on pediatric hospital medicine.

Throughput—the measure of how fast patients enter and exit a facility—is important for several reasons, said Dr. Hain, associate chief of staff at Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville, Tenn. In addition to increasing satisfaction, improving throughput can help with patient safety and boost a hospital's reputation. And improving the bottom line can free up construction capital, a valuable commodity at many hospitals.

To learn more about improving throughput, Dr. Hain suggested that physicians read “The Goal,” a novel by Eliyahu Goldratt and Jeff Cox that incorporates the throughput evaluation process. The novel uses an approach called the “Theory of Constraints,” which involves these steps:

▸ Make sure the organization's goal has been articulated. “This can be a big problem,” Dr. Hain said. “You have to get really focused on what you want to talk about.”

▸ Identify the constraint. Look for the bottleneck or backup that is impeding the flow of patients.

▸ Exploit the constraint. That is, make sure that whatever is causing the bottleneck is at least working at full capacity. For example, if the bottleneck in the emergency department is that it takes 42 minutes to print a patient identification (ID) label, make sure that the label machine is working all the time and is never idle.

▸ Subordinate all other processes to working on the constraint. “Everything else bows to the constraint, so if the constraint is the ID printing machine, the fact that the nurses don't like the triage area, that the doctors don't think the scheduling is fair, that the patients are angry—none of that fixes the problem. The only thing you're focusing on to improve flow is making sure your ID printer prints all the time,” Dr. Hain said.

▸ Elevate the importance of the constraint. This includes allocating capital to the problem if needed, so in this example it might mean buying a faster label machine.

▸ Look for the next bottleneck. Start the process all over again if a new bottleneck becomes apparent after your efforts have resolved the initial problem. “Now that's not your constraint, but something else is. … Look at the entire chain … and find one [place] that's absolutely the backup,” Dr. Hain advised at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Another way to improve throughput is by using “Queuing Theory,” which adjusts capacity to match variation in demand. “Emergency departments aren't unpredictable,” he said. “You never know when the next trauma is coming in, but you know what times of day tend to be busier than others, and you can staff up for them.”

Other methods for examining throughput include “Six Sigma” (applying a theory that says variation is waste), “Statistical Process Control” (graphing data using subsets of events to describe a large set), and “Lean Thinking” (eliminating steps in a process that don't add value).

Dr. Hain described how his hospital used a throughput evaluation to improve triage times in the emergency department (ED). Of the 50,000 patients seen annually in the ED, 16% end up being admitted, and those admissions account for 46% of the hospital's total admissions.

The hospital decided to focus on decreasing the length of stay for its level 4 and level 5 ED patients, which averaged 170 minutes in winter and 110 minutes in summer. The staff set a goal of reducing average length of stay to 60 minutes, without decreasing patient safety or satisfaction and without increasing readmissions.

First, they asked staff members to put up adhesive paper notes explaining why patients didn't leave as fast as they should have. “That was the whole project for 2 weeks,” he said. Based on those results and other information, they changed the location of some triage activities and added staffing for the busier times.

Since the change, “patient satisfaction has gone through the roof” and the average in-and-out-time for “fast track” ED patients who are not very ill is 60 minutes, Dr. Hain said. Staff members originally thought that this change would cost the hospital money, but it appears to be cost-neutral in the long run because the staff is deployed more efficiently.

Dr. Hain said that his hospital improved throughput in other areas, resulting in what he said was one of the lowest severity-adjusted lengths of stay in the country. Measures included setting up an “access center”—a one-stop shopping area for incoming calls, bed management, and environmental services—and using computers to improve communication among the electronic order entry, patient tracking, and bed board areas. These efforts—combined with integrated case management, social work, child life programs, and 24-hour in-house administrative coordinators to oversee beds and throughput—brought down the length of stay, he said.

Although there are many areas in the hospital where the staff could have begun analyzing throughput, starting with the ED worked well because it was a discrete operation and it became an “early win” that staff members could build upon for use in similar projects, he said.

Dr. Hain said he had no conflicts of interest.

A related video is at www.youtube.com/HospitalistNews

The concept of “bundling” of payments to physicians and hospitals has emerged as a potential element of health care reform, but some hospitalists are expressing concerns about the potential effects of untested bundling proposals.

Under at least one of the health care reform proposals being considered by Congress at press time, the Secretary of Health and Human Services would be required to “develop a detailed plan to reform payment for post acute care (PAC) services under the Medicare program.” The plan is to consider, among other things, “the nature of payments under a post acute care bundle, including the type of provider or entity to whom payment should be made, the scope of activities and services included in the bundle, whether payment for physicians' services should be included in the bundle, and the period covered by the bundle.”

Proponents of bundling say it would create a good incentive for hospitals to avoid readmissions by providing high-quality care, calling that an improvement over the current system, in which physicians get paid for every test or procedure they perform and hospitals get more money each time a patient is admitted.

But private-practice hospitalists—those who contract separately with the hospital—are concerned about how such arrangements would affect their revenues.

“Healthcare reform legislation holds the potential for a cataclysmic uprooting of the traditional fee-for-service payment system,” wrote the authors of a white paper from the Phoenix Group, an organization of private-practice hospitalists. Reform might “leave hospital medicine in a position of vulnerability, particularly with respect to the security and reliability of compensation. No longer would even a portion of a hospitalist's revenues remain free of control by the hospital.” (See www.phoenixgroupwhitepaper.com

Dr. Eric Siegal, chair of the public policy committee of the Society of Hospital Medicine (SHM), said that recent surveys show that roughly one-third of hospitalists are employed by hospitals, another third work in academia, and the remaining third are in private practice. “Depending on how you're reimbursed and how you structure relationships with hospitals, bundling has the potential to either be perceived as a positive or a negative.”

Bundling is “certainly worth exploring” as part of efforts to change the current “flawed payment methodology,” said Dr. Ron Greeno, who is cofounder and chief medical officer of hospitalist firm Cogent Healthcare and a member of the Phoenix Group. “The way we're paying doctors and hospitals now isn't working. It's misaligned, creates waste, and [incentivizes] for the wrong things.”

But bundling has not been tested enough to prove that it works, added Dr. Greeno, a member of the SHM's public policy committee. “There's no proof that [bundling] will lead to better care or less wasteful care. If it's going to be done, there needs to be careful consideration about how it's done, and they should try it a few places” before instituting it.

A key issue is how bundled payments will be administered, he said. “If there is a bundled payment, who is it going to go to? If you're dealing with a Kaiser or another fully integrated system, that's not a problem—it just goes to that entity. But for the average community hospital that doesn't employ physicians and has a volunteer medical staff, who does that payment go to? The hospital, most likely. Then the hospital has a bundled payment with no formal financial relationship with all the doctors that are going to take care of that patient. Are you going to negotiate a different arrangement with every single doctor on the staff?”

If the hospital has a hospitalist program in which hospitalists see 60% of the patients in the hospital, “that makes it a little easier because there is already a financial framework,” he continued. “But those doctors need surgeons and cardiologists to help them, so they still have to work out arrangements with them.”

Dr. Greeno noted that his company is already using bundling with some of its hospital clients. “We're pooling Part A and Part B [Medicare] dollars and using incentives for better care.”

Any discussion of bundling must include the view of hospitalists, he added. “Any discussion that doesn't involve the hospitalists' point of view is probably not going to work, because in the future the vast majority of hospital care is going to be provided by hospitalists. That's a very important point of view they need to consider.”

The concept of “bundling” of payments to physicians and hospitals has emerged as a potential element of health care reform, but some hospitalists are expressing concerns about the potential effects of untested bundling proposals.

Under at least one of the health care reform proposals being considered by Congress at press time, the Secretary of Health and Human Services would be required to “develop a detailed plan to reform payment for post acute care (PAC) services under the Medicare program.” The plan is to consider, among other things, “the nature of payments under a post acute care bundle, including the type of provider or entity to whom payment should be made, the scope of activities and services included in the bundle, whether payment for physicians' services should be included in the bundle, and the period covered by the bundle.”

Proponents of bundling say it would create a good incentive for hospitals to avoid readmissions by providing high-quality care, calling that an improvement over the current system, in which physicians get paid for every test or procedure they perform and hospitals get more money each time a patient is admitted.

But private-practice hospitalists—those who contract separately with the hospital—are concerned about how such arrangements would affect their revenues.

“Healthcare reform legislation holds the potential for a cataclysmic uprooting of the traditional fee-for-service payment system,” wrote the authors of a white paper from the Phoenix Group, an organization of private-practice hospitalists. Reform might “leave hospital medicine in a position of vulnerability, particularly with respect to the security and reliability of compensation. No longer would even a portion of a hospitalist's revenues remain free of control by the hospital.” (See www.phoenixgroupwhitepaper.com

Dr. Eric Siegal, chair of the public policy committee of the Society of Hospital Medicine (SHM), said that recent surveys show that roughly one-third of hospitalists are employed by hospitals, another third work in academia, and the remaining third are in private practice. “Depending on how you're reimbursed and how you structure relationships with hospitals, bundling has the potential to either be perceived as a positive or a negative.”

Bundling is “certainly worth exploring” as part of efforts to change the current “flawed payment methodology,” said Dr. Ron Greeno, who is cofounder and chief medical officer of hospitalist firm Cogent Healthcare and a member of the Phoenix Group. “The way we're paying doctors and hospitals now isn't working. It's misaligned, creates waste, and [incentivizes] for the wrong things.”

But bundling has not been tested enough to prove that it works, added Dr. Greeno, a member of the SHM's public policy committee. “There's no proof that [bundling] will lead to better care or less wasteful care. If it's going to be done, there needs to be careful consideration about how it's done, and they should try it a few places” before instituting it.

A key issue is how bundled payments will be administered, he said. “If there is a bundled payment, who is it going to go to? If you're dealing with a Kaiser or another fully integrated system, that's not a problem—it just goes to that entity. But for the average community hospital that doesn't employ physicians and has a volunteer medical staff, who does that payment go to? The hospital, most likely. Then the hospital has a bundled payment with no formal financial relationship with all the doctors that are going to take care of that patient. Are you going to negotiate a different arrangement with every single doctor on the staff?”

If the hospital has a hospitalist program in which hospitalists see 60% of the patients in the hospital, “that makes it a little easier because there is already a financial framework,” he continued. “But those doctors need surgeons and cardiologists to help them, so they still have to work out arrangements with them.”

Dr. Greeno noted that his company is already using bundling with some of its hospital clients. “We're pooling Part A and Part B [Medicare] dollars and using incentives for better care.”

Any discussion of bundling must include the view of hospitalists, he added. “Any discussion that doesn't involve the hospitalists' point of view is probably not going to work, because in the future the vast majority of hospital care is going to be provided by hospitalists. That's a very important point of view they need to consider.”

The concept of “bundling” of payments to physicians and hospitals has emerged as a potential element of health care reform, but some hospitalists are expressing concerns about the potential effects of untested bundling proposals.

Under at least one of the health care reform proposals being considered by Congress at press time, the Secretary of Health and Human Services would be required to “develop a detailed plan to reform payment for post acute care (PAC) services under the Medicare program.” The plan is to consider, among other things, “the nature of payments under a post acute care bundle, including the type of provider or entity to whom payment should be made, the scope of activities and services included in the bundle, whether payment for physicians' services should be included in the bundle, and the period covered by the bundle.”

Proponents of bundling say it would create a good incentive for hospitals to avoid readmissions by providing high-quality care, calling that an improvement over the current system, in which physicians get paid for every test or procedure they perform and hospitals get more money each time a patient is admitted.

But private-practice hospitalists—those who contract separately with the hospital—are concerned about how such arrangements would affect their revenues.

“Healthcare reform legislation holds the potential for a cataclysmic uprooting of the traditional fee-for-service payment system,” wrote the authors of a white paper from the Phoenix Group, an organization of private-practice hospitalists. Reform might “leave hospital medicine in a position of vulnerability, particularly with respect to the security and reliability of compensation. No longer would even a portion of a hospitalist's revenues remain free of control by the hospital.” (See www.phoenixgroupwhitepaper.com

Dr. Eric Siegal, chair of the public policy committee of the Society of Hospital Medicine (SHM), said that recent surveys show that roughly one-third of hospitalists are employed by hospitals, another third work in academia, and the remaining third are in private practice. “Depending on how you're reimbursed and how you structure relationships with hospitals, bundling has the potential to either be perceived as a positive or a negative.”

Bundling is “certainly worth exploring” as part of efforts to change the current “flawed payment methodology,” said Dr. Ron Greeno, who is cofounder and chief medical officer of hospitalist firm Cogent Healthcare and a member of the Phoenix Group. “The way we're paying doctors and hospitals now isn't working. It's misaligned, creates waste, and [incentivizes] for the wrong things.”

But bundling has not been tested enough to prove that it works, added Dr. Greeno, a member of the SHM's public policy committee. “There's no proof that [bundling] will lead to better care or less wasteful care. If it's going to be done, there needs to be careful consideration about how it's done, and they should try it a few places” before instituting it.

A key issue is how bundled payments will be administered, he said. “If there is a bundled payment, who is it going to go to? If you're dealing with a Kaiser or another fully integrated system, that's not a problem—it just goes to that entity. But for the average community hospital that doesn't employ physicians and has a volunteer medical staff, who does that payment go to? The hospital, most likely. Then the hospital has a bundled payment with no formal financial relationship with all the doctors that are going to take care of that patient. Are you going to negotiate a different arrangement with every single doctor on the staff?”

If the hospital has a hospitalist program in which hospitalists see 60% of the patients in the hospital, “that makes it a little easier because there is already a financial framework,” he continued. “But those doctors need surgeons and cardiologists to help them, so they still have to work out arrangements with them.”

Dr. Greeno noted that his company is already using bundling with some of its hospital clients. “We're pooling Part A and Part B [Medicare] dollars and using incentives for better care.”

Any discussion of bundling must include the view of hospitalists, he added. “Any discussion that doesn't involve the hospitalists' point of view is probably not going to work, because in the future the vast majority of hospital care is going to be provided by hospitalists. That's a very important point of view they need to consider.”

Harvard Medical School's decision to suspend funding to its primary care division has drawn sharp criticism from many in the health care community.

Based on an ongoing review of Harvard's department of ambulatory care and prevention, “funding for the division of primary care has been suspended until the review is complete, at which point we expect to have a much clearer vision of the most meaningful structure for the programs within the division and how they can be most effectively leveraged for primary care education and clinical training.”

David Cameron, spokesman for the medical school, said that the suspended funding—about $200,000—mainly paid for “lectures and symposia.” There is no timeline for completion of the review, he added.

Members of the Harvard community protested the suspension via a petition urging support for primary care.

“We request that the administration renew its commitment to primary care and present a detailed action plan for expanding institutional support despite this budget cut,” the petition reads. “As a leader in medicine, you have an opportunity to help solve [the] crisis in primary care and we look forward to working with you on this important task.”

The petition, which had garnered nearly 1,200 signatures at press time, asked Harvard to reaffirm that “leadership in primary care research and education is central to Harvard's mission as the nation's premier academic medical institution,” that “Harvard must continue to expand loan forgiveness initiatives that encourage students to pursue primary care specialties,” and that “Harvard should support initiatives to train future leaders and innovators in primary care.” It also asked the administration to “solicit and implement proposals from the [medical school] community that support the above goals.”

Petition signer Dr. David Himmelstein, an internist and faculty member, said that the primary care division “has been a joke for years,” and as a result the suspension of funding “is a largely symbolic act.”

When Harvard initially set up the department of ambulatory care and prevention, “primary care was going to be part of that …and they were going to do more preventive and primary care,” he said. “But the department changed leadership and there was no money to pursue research and initiatives in primary care, so they followed the money and focused on epidemiologic research … and the primary care division became really a minor afterthought.”

The move to withdraw funding from the division raised hackles because it represented the last straw, Dr. Himmelstein said. “There weren't significant resources going to it, but at least there was the symbolism of being part of Harvard Medical School, and they didn't see fit to continue that.”

Mr. Cameron said that the decision to suspend funding “in no way reflects on Harvard Medical School's commitment to primary care training. Rather, it is an administrative matter.” He pointed out that the medical school currently has 31 centers, divisions, and institutes, “and not all receive funding from us.”

One program that does receive significant funding from the medical school, Mr. Cameron said, is the primary care clerkship program, in which students are assigned to a general internist, general pediatrician, or family physician with whom they see patients three or four afternoons a month for 8 months beginning in September of their third year. The school's investment in the clerkship is increasing by roughly 20% this year, Mr. Cameron said.

Harvard Medical School's decision to suspend funding to its primary care division has drawn sharp criticism from many in the health care community.

Based on an ongoing review of Harvard's department of ambulatory care and prevention, “funding for the division of primary care has been suspended until the review is complete, at which point we expect to have a much clearer vision of the most meaningful structure for the programs within the division and how they can be most effectively leveraged for primary care education and clinical training.”

David Cameron, spokesman for the medical school, said that the suspended funding—about $200,000—mainly paid for “lectures and symposia.” There is no timeline for completion of the review, he added.

Members of the Harvard community protested the suspension via a petition urging support for primary care.

“We request that the administration renew its commitment to primary care and present a detailed action plan for expanding institutional support despite this budget cut,” the petition reads. “As a leader in medicine, you have an opportunity to help solve [the] crisis in primary care and we look forward to working with you on this important task.”

The petition, which had garnered nearly 1,200 signatures at press time, asked Harvard to reaffirm that “leadership in primary care research and education is central to Harvard's mission as the nation's premier academic medical institution,” that “Harvard must continue to expand loan forgiveness initiatives that encourage students to pursue primary care specialties,” and that “Harvard should support initiatives to train future leaders and innovators in primary care.” It also asked the administration to “solicit and implement proposals from the [medical school] community that support the above goals.”

Petition signer Dr. David Himmelstein, an internist and faculty member, said that the primary care division “has been a joke for years,” and as a result the suspension of funding “is a largely symbolic act.”

When Harvard initially set up the department of ambulatory care and prevention, “primary care was going to be part of that …and they were going to do more preventive and primary care,” he said. “But the department changed leadership and there was no money to pursue research and initiatives in primary care, so they followed the money and focused on epidemiologic research … and the primary care division became really a minor afterthought.”

The move to withdraw funding from the division raised hackles because it represented the last straw, Dr. Himmelstein said. “There weren't significant resources going to it, but at least there was the symbolism of being part of Harvard Medical School, and they didn't see fit to continue that.”

Mr. Cameron said that the decision to suspend funding “in no way reflects on Harvard Medical School's commitment to primary care training. Rather, it is an administrative matter.” He pointed out that the medical school currently has 31 centers, divisions, and institutes, “and not all receive funding from us.”

One program that does receive significant funding from the medical school, Mr. Cameron said, is the primary care clerkship program, in which students are assigned to a general internist, general pediatrician, or family physician with whom they see patients three or four afternoons a month for 8 months beginning in September of their third year. The school's investment in the clerkship is increasing by roughly 20% this year, Mr. Cameron said.

Harvard Medical School's decision to suspend funding to its primary care division has drawn sharp criticism from many in the health care community.

Based on an ongoing review of Harvard's department of ambulatory care and prevention, “funding for the division of primary care has been suspended until the review is complete, at which point we expect to have a much clearer vision of the most meaningful structure for the programs within the division and how they can be most effectively leveraged for primary care education and clinical training.”

David Cameron, spokesman for the medical school, said that the suspended funding—about $200,000—mainly paid for “lectures and symposia.” There is no timeline for completion of the review, he added.

Members of the Harvard community protested the suspension via a petition urging support for primary care.

“We request that the administration renew its commitment to primary care and present a detailed action plan for expanding institutional support despite this budget cut,” the petition reads. “As a leader in medicine, you have an opportunity to help solve [the] crisis in primary care and we look forward to working with you on this important task.”

The petition, which had garnered nearly 1,200 signatures at press time, asked Harvard to reaffirm that “leadership in primary care research and education is central to Harvard's mission as the nation's premier academic medical institution,” that “Harvard must continue to expand loan forgiveness initiatives that encourage students to pursue primary care specialties,” and that “Harvard should support initiatives to train future leaders and innovators in primary care.” It also asked the administration to “solicit and implement proposals from the [medical school] community that support the above goals.”

Petition signer Dr. David Himmelstein, an internist and faculty member, said that the primary care division “has been a joke for years,” and as a result the suspension of funding “is a largely symbolic act.”

When Harvard initially set up the department of ambulatory care and prevention, “primary care was going to be part of that …and they were going to do more preventive and primary care,” he said. “But the department changed leadership and there was no money to pursue research and initiatives in primary care, so they followed the money and focused on epidemiologic research … and the primary care division became really a minor afterthought.”

The move to withdraw funding from the division raised hackles because it represented the last straw, Dr. Himmelstein said. “There weren't significant resources going to it, but at least there was the symbolism of being part of Harvard Medical School, and they didn't see fit to continue that.”

Mr. Cameron said that the decision to suspend funding “in no way reflects on Harvard Medical School's commitment to primary care training. Rather, it is an administrative matter.” He pointed out that the medical school currently has 31 centers, divisions, and institutes, “and not all receive funding from us.”

One program that does receive significant funding from the medical school, Mr. Cameron said, is the primary care clerkship program, in which students are assigned to a general internist, general pediatrician, or family physician with whom they see patients three or four afternoons a month for 8 months beginning in September of their third year. The school's investment in the clerkship is increasing by roughly 20% this year, Mr. Cameron said.

The idea of “family-centered rounding” may sound like a daunting task: coordinating a dozen schedules and cramming 12 or more people into a small hospital room to meet with patients and their family members.

But those who have tried it say it's worth it, because it improves communication among physicians, nurses, and other patient caregivers, and it makes the patient's family members feel more like a part of the team.

“The big advantage of family-centered rounding is family engagement and getting the family involved in the process,” said Dr. Glen Tamura, medical director of the inpatient unit at Seattle Children's Hospital, which has been using family-centered rounding (FCR) for about 5 years. “We are really trying to engage families and get their feedback on the plan, as well as make sure they understand how we think their child is doing.”

Dr. Nanci Rascoff, a third-year resident who has participated in FCR at Seattle Children's, agreed. “I like that we give them this role and responsibility to become really involved in their child's care,” she said. “It's easy to give them the 'worried parent' role, but by including them in the rounding process, they are empowered to become part of their child's care plan.”

Dr. Rascoff said she sees a change occur in the parents, even if their child is only in the hospital for a few days. “On the first day, they are like a deer in the headlights, overwhelmed and thinking, 'There are 12 people in the circle and they're in white coats and they're talking about my child.' But then a transition happens, and they join us the next day with a notebook in hand filled with questions. It gives them an additional focus and outlet for their concerns.”

Another benefit to having the whole care team and the family there is that the afternoon “rework” that happens with some cases can often be avoided, said Dr. Tamura, who was one of several speakers on the subject at a pediatric hospital medicine meeting in Tampa.

“When the family isn't present, the [care] plan seems reasonable to the team, but for some reason it won't work,” maybe because there is some issue with the patient that the team didn't know about. But later when the intern tries to get consensus on an alternative plan, “the resident has gone to continuity clinic and the attending has gone somewhere else, so the poor intern is trying to get everyone to agree on a plan when the team has scattered. A conversation that could be completed in person in 10 seconds can take the intern an hour or more to resolve.” With family-centered rounding, Dr. Tamura said, “we avoid that 90% of the time by having everybody there so we can have this discussion and resolve those issues at the time.”

Building a Team

At Seattle Children's, the FCR team includes the attending pediatrician; all of the house staff—residents and interns, and medical students if they're on the team; a team coordinator; a care coordinator who makes home care arrangements; a nutritionist; and a pharmacist, who can be very helpful with specific cases.

“We had one patient who had a urinary tract infection that was very hard to treat,” Dr. Tamura said. “We had pharmacy [with us] on rounds, and we said to them, 'Look at the options and tell us what's reasonable and get back to us with answers.' Them being there means they understand what we're really grappling with.”

Team coordinators are not clinicians, “but they help the team get prepared by making patient lists and letting the team know how many patients there are to round on. As we move through rounds, they call the nurses ahead of time so they know we are coming. They know the most efficient route through the hospital.”

Having a care coordinator on rounds to help create a discharge plan with the family can also help prevent having the plan fall apart on discharge day, said Dr. Tamura, who is also assistant professor of pediatrics at the University of Washington. “We can make sure the family feels comfortable with the discharge plan and is confident they can do all that we are asking them to do.”

Making an FCR program work requires buy-in from hospital management, Dr. Tamura said. Before FCR, “people were used to showing up whenever and having the residents at their beck and call, and you just can't run a family-centered rounds program this way. We created a system where attending physicians have standard rounding times, but it wouldn't have worked if they weren't told that they had to be there. Someone at the top has to say that.”

Getting Past Hurdles

But although family-centered rounding has benefits, there are also disadvantages, according to Dr. Tamura. For one thing, he has found that at his hospital, it adds time to rounds. “It takes an extra 3 minutes a patient, which doesn't sound like a big deal until you have 20 patients,” he said. “We are continuing to work on making sure there is time to round with all the families.”

Despite all of the challenges, Dr. Rascoff said she loves involving families in rounds. “One thing people worry about is the teaching component,” she said. “Due to time constraints, we don't have as much time to do formal teaching with medical terminology, because we're trying to make it parent friendly. But what you are teaching that's essential are communication skills for residents and medical students, like how to console a parent who breaks into tears when you start talking about why their child came into the hospital. That's incredibly valuable.”

The idea of “family-centered rounding” may sound like a daunting task: coordinating a dozen schedules and cramming 12 or more people into a small hospital room to meet with patients and their family members.

But those who have tried it say it's worth it, because it improves communication among physicians, nurses, and other patient caregivers, and it makes the patient's family members feel more like a part of the team.

“The big advantage of family-centered rounding is family engagement and getting the family involved in the process,” said Dr. Glen Tamura, medical director of the inpatient unit at Seattle Children's Hospital, which has been using family-centered rounding (FCR) for about 5 years. “We are really trying to engage families and get their feedback on the plan, as well as make sure they understand how we think their child is doing.”

Dr. Nanci Rascoff, a third-year resident who has participated in FCR at Seattle Children's, agreed. “I like that we give them this role and responsibility to become really involved in their child's care,” she said. “It's easy to give them the 'worried parent' role, but by including them in the rounding process, they are empowered to become part of their child's care plan.”

Dr. Rascoff said she sees a change occur in the parents, even if their child is only in the hospital for a few days. “On the first day, they are like a deer in the headlights, overwhelmed and thinking, 'There are 12 people in the circle and they're in white coats and they're talking about my child.' But then a transition happens, and they join us the next day with a notebook in hand filled with questions. It gives them an additional focus and outlet for their concerns.”

Another benefit to having the whole care team and the family there is that the afternoon “rework” that happens with some cases can often be avoided, said Dr. Tamura, who was one of several speakers on the subject at a pediatric hospital medicine meeting in Tampa.

“When the family isn't present, the [care] plan seems reasonable to the team, but for some reason it won't work,” maybe because there is some issue with the patient that the team didn't know about. But later when the intern tries to get consensus on an alternative plan, “the resident has gone to continuity clinic and the attending has gone somewhere else, so the poor intern is trying to get everyone to agree on a plan when the team has scattered. A conversation that could be completed in person in 10 seconds can take the intern an hour or more to resolve.” With family-centered rounding, Dr. Tamura said, “we avoid that 90% of the time by having everybody there so we can have this discussion and resolve those issues at the time.”

Building a Team

At Seattle Children's, the FCR team includes the attending pediatrician; all of the house staff—residents and interns, and medical students if they're on the team; a team coordinator; a care coordinator who makes home care arrangements; a nutritionist; and a pharmacist, who can be very helpful with specific cases.

“We had one patient who had a urinary tract infection that was very hard to treat,” Dr. Tamura said. “We had pharmacy [with us] on rounds, and we said to them, 'Look at the options and tell us what's reasonable and get back to us with answers.' Them being there means they understand what we're really grappling with.”

Team coordinators are not clinicians, “but they help the team get prepared by making patient lists and letting the team know how many patients there are to round on. As we move through rounds, they call the nurses ahead of time so they know we are coming. They know the most efficient route through the hospital.”

Having a care coordinator on rounds to help create a discharge plan with the family can also help prevent having the plan fall apart on discharge day, said Dr. Tamura, who is also assistant professor of pediatrics at the University of Washington. “We can make sure the family feels comfortable with the discharge plan and is confident they can do all that we are asking them to do.”

Making an FCR program work requires buy-in from hospital management, Dr. Tamura said. Before FCR, “people were used to showing up whenever and having the residents at their beck and call, and you just can't run a family-centered rounds program this way. We created a system where attending physicians have standard rounding times, but it wouldn't have worked if they weren't told that they had to be there. Someone at the top has to say that.”

Getting Past Hurdles

But although family-centered rounding has benefits, there are also disadvantages, according to Dr. Tamura. For one thing, he has found that at his hospital, it adds time to rounds. “It takes an extra 3 minutes a patient, which doesn't sound like a big deal until you have 20 patients,” he said. “We are continuing to work on making sure there is time to round with all the families.”

Despite all of the challenges, Dr. Rascoff said she loves involving families in rounds. “One thing people worry about is the teaching component,” she said. “Due to time constraints, we don't have as much time to do formal teaching with medical terminology, because we're trying to make it parent friendly. But what you are teaching that's essential are communication skills for residents and medical students, like how to console a parent who breaks into tears when you start talking about why their child came into the hospital. That's incredibly valuable.”

The idea of “family-centered rounding” may sound like a daunting task: coordinating a dozen schedules and cramming 12 or more people into a small hospital room to meet with patients and their family members.

But those who have tried it say it's worth it, because it improves communication among physicians, nurses, and other patient caregivers, and it makes the patient's family members feel more like a part of the team.

“The big advantage of family-centered rounding is family engagement and getting the family involved in the process,” said Dr. Glen Tamura, medical director of the inpatient unit at Seattle Children's Hospital, which has been using family-centered rounding (FCR) for about 5 years. “We are really trying to engage families and get their feedback on the plan, as well as make sure they understand how we think their child is doing.”

Dr. Nanci Rascoff, a third-year resident who has participated in FCR at Seattle Children's, agreed. “I like that we give them this role and responsibility to become really involved in their child's care,” she said. “It's easy to give them the 'worried parent' role, but by including them in the rounding process, they are empowered to become part of their child's care plan.”

Dr. Rascoff said she sees a change occur in the parents, even if their child is only in the hospital for a few days. “On the first day, they are like a deer in the headlights, overwhelmed and thinking, 'There are 12 people in the circle and they're in white coats and they're talking about my child.' But then a transition happens, and they join us the next day with a notebook in hand filled with questions. It gives them an additional focus and outlet for their concerns.”

Another benefit to having the whole care team and the family there is that the afternoon “rework” that happens with some cases can often be avoided, said Dr. Tamura, who was one of several speakers on the subject at a pediatric hospital medicine meeting in Tampa.

“When the family isn't present, the [care] plan seems reasonable to the team, but for some reason it won't work,” maybe because there is some issue with the patient that the team didn't know about. But later when the intern tries to get consensus on an alternative plan, “the resident has gone to continuity clinic and the attending has gone somewhere else, so the poor intern is trying to get everyone to agree on a plan when the team has scattered. A conversation that could be completed in person in 10 seconds can take the intern an hour or more to resolve.” With family-centered rounding, Dr. Tamura said, “we avoid that 90% of the time by having everybody there so we can have this discussion and resolve those issues at the time.”

Building a Team

At Seattle Children's, the FCR team includes the attending pediatrician; all of the house staff—residents and interns, and medical students if they're on the team; a team coordinator; a care coordinator who makes home care arrangements; a nutritionist; and a pharmacist, who can be very helpful with specific cases.

“We had one patient who had a urinary tract infection that was very hard to treat,” Dr. Tamura said. “We had pharmacy [with us] on rounds, and we said to them, 'Look at the options and tell us what's reasonable and get back to us with answers.' Them being there means they understand what we're really grappling with.”

Team coordinators are not clinicians, “but they help the team get prepared by making patient lists and letting the team know how many patients there are to round on. As we move through rounds, they call the nurses ahead of time so they know we are coming. They know the most efficient route through the hospital.”

Having a care coordinator on rounds to help create a discharge plan with the family can also help prevent having the plan fall apart on discharge day, said Dr. Tamura, who is also assistant professor of pediatrics at the University of Washington. “We can make sure the family feels comfortable with the discharge plan and is confident they can do all that we are asking them to do.”

Making an FCR program work requires buy-in from hospital management, Dr. Tamura said. Before FCR, “people were used to showing up whenever and having the residents at their beck and call, and you just can't run a family-centered rounds program this way. We created a system where attending physicians have standard rounding times, but it wouldn't have worked if they weren't told that they had to be there. Someone at the top has to say that.”

Getting Past Hurdles

But although family-centered rounding has benefits, there are also disadvantages, according to Dr. Tamura. For one thing, he has found that at his hospital, it adds time to rounds. “It takes an extra 3 minutes a patient, which doesn't sound like a big deal until you have 20 patients,” he said. “We are continuing to work on making sure there is time to round with all the families.”

Despite all of the challenges, Dr. Rascoff said she loves involving families in rounds. “One thing people worry about is the teaching component,” she said. “Due to time constraints, we don't have as much time to do formal teaching with medical terminology, because we're trying to make it parent friendly. But what you are teaching that's essential are communication skills for residents and medical students, like how to console a parent who breaks into tears when you start talking about why their child came into the hospital. That's incredibly valuable.”

More coordinated care can reduce the rate of hospital readmissions among Medicare beneficiaries by more than 25%, a study has found.

“Policymakers should take notice of this and other studies that demonstrate what's already working in some health care plans,” Len Nichols, Ph.D., director of the health policy program at the New America Foundation, a Washington think tank, said in a statement. “It's time to move away from the current fee-for-service payment system toward one that emphasizes value rather than volume, enhances the value of primary care, and holds providers accountable for quality and efficiency.”

The study involved 13 plans in the Medicare Advantage program, under which private health plans contract with Medicare to care for beneficiaries. The study was sponsored by the Alliance of Community Health Plans (ACHP), an organization of nonprofit, community-based, and regional health plans. All of the plans in the study were members of ACHP.

Gerard Anderson, Ph.D., of Johns Hopkins University, and colleagues focused their research on two areas: hospital readmissions and preventable hospital admissions/emergency department (ED) visits.

“These measures were chosen for several reasons,” they wrote in a report released by ACHP. “First, readmissions and preventable hospitalizations are expensive for the Medicare program. Second, there is an established literature on how to measure readmissions and preventable hospitalizations. Third, they can be used to evaluate if health plans can improve outcomes for Medicare beneficiaries and save money for the Medicare program.”

The researchers compared the rates of readmissions and preventable admissions/ED visits in the fee-for-service Medicare program with those of the 13 health plans studied. The study spanned the first 6 months of 2007 and used the third quarter of that year to monitor any readmissions or follow-up care.

The investigators found that the national Medicare fee-for-service readmission rate was 18.6%, while the ACHP plans in the study had an average rate of 13.6%—a rate that was 27% lower. Based on previous readmission cost data, the Medicare fee-for-service plan could have saved nearly $5 billion if it had had the same readmission rate as the ACHP plans in the study, Dr. Anderson and his associates said.

On average, ACHP member plans had preventable inpatient hospitalization rates in 2007 that were 13% of the national average, the researchers noted. Based on an average payment per discharge of nearly $8,400 in 2007, bringing Medicare's fee-for-service preventable hospitalizations down to the same level as the ACHP plans would have saved the program $4.5 billion, according to the study.

As for preventable ED visits, the rate among the Medicare fee-for-service patients was 15.5 visits per 100 beneficiary months, compared with an average of 2.2 visits for the ACHP plans studied (range, 0.5–7.8). The average ACHP plan had 86% fewer preventable emergency dept. visits than the Medicare fee-for-service program. Based on an average ED visit payment of $510, reducing Medicare fee-for-service preventable ED visit rate to the rate experienced by the 13 plans studied would have saved Medicare $900 million.

The results suggest that “the approaches adopted by these plans—which include greater focus on primary care, care coordination, transitional planning post-discharge, prevention measures, and active case management—are improving care for their beneficiaries, keeping people out of the hospital, and lowering costs,” the authors wrote in the ACHP report. “If the Medicare fee-for-service program had similar rates of readmissions and preventable hospitalizations, then the Medicare program would have saved approximately $10 billion in the year of the study.”

More coordinated care can reduce the rate of hospital readmissions among Medicare beneficiaries by more than 25%, a study has found.

“Policymakers should take notice of this and other studies that demonstrate what's already working in some health care plans,” Len Nichols, Ph.D., director of the health policy program at the New America Foundation, a Washington think tank, said in a statement. “It's time to move away from the current fee-for-service payment system toward one that emphasizes value rather than volume, enhances the value of primary care, and holds providers accountable for quality and efficiency.”

The study involved 13 plans in the Medicare Advantage program, under which private health plans contract with Medicare to care for beneficiaries. The study was sponsored by the Alliance of Community Health Plans (ACHP), an organization of nonprofit, community-based, and regional health plans. All of the plans in the study were members of ACHP.

Gerard Anderson, Ph.D., of Johns Hopkins University, and colleagues focused their research on two areas: hospital readmissions and preventable hospital admissions/emergency department (ED) visits.

“These measures were chosen for several reasons,” they wrote in a report released by ACHP. “First, readmissions and preventable hospitalizations are expensive for the Medicare program. Second, there is an established literature on how to measure readmissions and preventable hospitalizations. Third, they can be used to evaluate if health plans can improve outcomes for Medicare beneficiaries and save money for the Medicare program.”

The researchers compared the rates of readmissions and preventable admissions/ED visits in the fee-for-service Medicare program with those of the 13 health plans studied. The study spanned the first 6 months of 2007 and used the third quarter of that year to monitor any readmissions or follow-up care.

The investigators found that the national Medicare fee-for-service readmission rate was 18.6%, while the ACHP plans in the study had an average rate of 13.6%—a rate that was 27% lower. Based on previous readmission cost data, the Medicare fee-for-service plan could have saved nearly $5 billion if it had had the same readmission rate as the ACHP plans in the study, Dr. Anderson and his associates said.

On average, ACHP member plans had preventable inpatient hospitalization rates in 2007 that were 13% of the national average, the researchers noted. Based on an average payment per discharge of nearly $8,400 in 2007, bringing Medicare's fee-for-service preventable hospitalizations down to the same level as the ACHP plans would have saved the program $4.5 billion, according to the study.

As for preventable ED visits, the rate among the Medicare fee-for-service patients was 15.5 visits per 100 beneficiary months, compared with an average of 2.2 visits for the ACHP plans studied (range, 0.5–7.8). The average ACHP plan had 86% fewer preventable emergency dept. visits than the Medicare fee-for-service program. Based on an average ED visit payment of $510, reducing Medicare fee-for-service preventable ED visit rate to the rate experienced by the 13 plans studied would have saved Medicare $900 million.

The results suggest that “the approaches adopted by these plans—which include greater focus on primary care, care coordination, transitional planning post-discharge, prevention measures, and active case management—are improving care for their beneficiaries, keeping people out of the hospital, and lowering costs,” the authors wrote in the ACHP report. “If the Medicare fee-for-service program had similar rates of readmissions and preventable hospitalizations, then the Medicare program would have saved approximately $10 billion in the year of the study.”

More coordinated care can reduce the rate of hospital readmissions among Medicare beneficiaries by more than 25%, a study has found.

“Policymakers should take notice of this and other studies that demonstrate what's already working in some health care plans,” Len Nichols, Ph.D., director of the health policy program at the New America Foundation, a Washington think tank, said in a statement. “It's time to move away from the current fee-for-service payment system toward one that emphasizes value rather than volume, enhances the value of primary care, and holds providers accountable for quality and efficiency.”

The study involved 13 plans in the Medicare Advantage program, under which private health plans contract with Medicare to care for beneficiaries. The study was sponsored by the Alliance of Community Health Plans (ACHP), an organization of nonprofit, community-based, and regional health plans. All of the plans in the study were members of ACHP.

Gerard Anderson, Ph.D., of Johns Hopkins University, and colleagues focused their research on two areas: hospital readmissions and preventable hospital admissions/emergency department (ED) visits.

“These measures were chosen for several reasons,” they wrote in a report released by ACHP. “First, readmissions and preventable hospitalizations are expensive for the Medicare program. Second, there is an established literature on how to measure readmissions and preventable hospitalizations. Third, they can be used to evaluate if health plans can improve outcomes for Medicare beneficiaries and save money for the Medicare program.”

The researchers compared the rates of readmissions and preventable admissions/ED visits in the fee-for-service Medicare program with those of the 13 health plans studied. The study spanned the first 6 months of 2007 and used the third quarter of that year to monitor any readmissions or follow-up care.

The investigators found that the national Medicare fee-for-service readmission rate was 18.6%, while the ACHP plans in the study had an average rate of 13.6%—a rate that was 27% lower. Based on previous readmission cost data, the Medicare fee-for-service plan could have saved nearly $5 billion if it had had the same readmission rate as the ACHP plans in the study, Dr. Anderson and his associates said.

On average, ACHP member plans had preventable inpatient hospitalization rates in 2007 that were 13% of the national average, the researchers noted. Based on an average payment per discharge of nearly $8,400 in 2007, bringing Medicare's fee-for-service preventable hospitalizations down to the same level as the ACHP plans would have saved the program $4.5 billion, according to the study.

As for preventable ED visits, the rate among the Medicare fee-for-service patients was 15.5 visits per 100 beneficiary months, compared with an average of 2.2 visits for the ACHP plans studied (range, 0.5–7.8). The average ACHP plan had 86% fewer preventable emergency dept. visits than the Medicare fee-for-service program. Based on an average ED visit payment of $510, reducing Medicare fee-for-service preventable ED visit rate to the rate experienced by the 13 plans studied would have saved Medicare $900 million.

The results suggest that “the approaches adopted by these plans—which include greater focus on primary care, care coordination, transitional planning post-discharge, prevention measures, and active case management—are improving care for their beneficiaries, keeping people out of the hospital, and lowering costs,” the authors wrote in the ACHP report. “If the Medicare fee-for-service program had similar rates of readmissions and preventable hospitalizations, then the Medicare program would have saved approximately $10 billion in the year of the study.”

Harvard Medical School's decision to suspend funding to its primary care division has drawn sharp criticism from many in the health care community.

Based on an ongoing review of Harvard's department of ambulatory care and prevention, “funding for the division of primary care has been suspended until the review is complete, at which point we expect to have a much clearer vision of the most meaningful structure for the programs within the division and how they can be most effectively leveraged for primary care education and clinical training.”

David Cameron, spokesman for the medical school, said that the suspended funding—about $200,000—mainly paid for “lectures and symposia.” There is no timeline for completion of the review, he added.

Members of the Harvard community protested the suspension via a petition urging the school to support primary care.

“We request that the administration renew its commitment to primary care and present a detailed action plan for expanding institutional support despite this budget cut,” the petition reads. “As a leader in medicine, you have an opportunity to help solve [the] crisis in primary care and we look forward to working with you on this important task.”

The petition, which had garnered nearly 1,200 signatures at press time, asked Harvard to reaffirm that “leadership in primary care research and education is central to Harvard's mission as the nation's premier academic medical institution,” that “Harvard must continue to expand loan forgiveness initiatives that encourage students to pursue primary care specialties,” and that “Harvard should support initiatives to train future leaders and innovators in primary care.” It also asked the administration to “solicit and implement proposals from the [medical school] community that support the above goals.”

Dr. David Himmelstein, an internist and faculty member who signed the petition, said that the primary care division “has been a joke for years,” and as a result the suspension of funding “is a largely symbolic act.”

When Harvard initially set up the department of ambulatory care and prevention, “primary care was going to be part of that …and they were going to do more preventive and primary care,” he said. “But the department changed leadership and there was no money to pursue research and initiatives in primary care, so they followed the money and focused on epidemiologic research … and the primary care division became really a minor afterthought.”

The move to de-fund the division raised hackles because it represented the last straw, said Dr. Himmelstein. “There weren't significant resources going to it, but at least there was the symbolism of being part of Harvard Medical School, and they didn't see fit to continue that.”

Dr. Ted Epperly, president of the American Academy of Family Physicians, said he found Harvard's action ironic in light of Massachusetts' recent move to provide health care for all its residents.

“I find it incomprehensible that at a time when [the state needs primary care physicians] that Harvard is turning its back on the people that produce them,” he said. “Medical schools are very good at training a workforce good for medical schools and teaching centers, but very bad at producing a workforce good for the community and people in the state.”

He noted that Harvard's is one of 10 U.S. medical schools that does not have a family medicine department. “They have never invested the resources in training the doctors to shore up the primary care base,” he added.

Mr. Cameron said that the decision to suspend funding “in no way reflects on Harvard Medical School's commitment to primary care training. Rather, it is an administrative matter.”

He pointed out that the medical school currently has 31 centers, divisions, and institutes, “and not all receive funding from us.”

One program that does receive significant funding from the medical school, Mr. Cameron said, is the primary care clerkship program, in which students are assigned to a general internist, general pediatrician, or family physician with whom they see patients three or four afternoons a month for 8 months beginning in September of their third year. The school's investment in the clerkship is increasing by roughly 20% this year, Mr. Cameron said.

Harvard Medical School's decision to suspend funding to its primary care division has drawn sharp criticism from many in the health care community.

Based on an ongoing review of Harvard's department of ambulatory care and prevention, “funding for the division of primary care has been suspended until the review is complete, at which point we expect to have a much clearer vision of the most meaningful structure for the programs within the division and how they can be most effectively leveraged for primary care education and clinical training.”

David Cameron, spokesman for the medical school, said that the suspended funding—about $200,000—mainly paid for “lectures and symposia.” There is no timeline for completion of the review, he added.

Members of the Harvard community protested the suspension via a petition urging the school to support primary care.

“We request that the administration renew its commitment to primary care and present a detailed action plan for expanding institutional support despite this budget cut,” the petition reads. “As a leader in medicine, you have an opportunity to help solve [the] crisis in primary care and we look forward to working with you on this important task.”

The petition, which had garnered nearly 1,200 signatures at press time, asked Harvard to reaffirm that “leadership in primary care research and education is central to Harvard's mission as the nation's premier academic medical institution,” that “Harvard must continue to expand loan forgiveness initiatives that encourage students to pursue primary care specialties,” and that “Harvard should support initiatives to train future leaders and innovators in primary care.” It also asked the administration to “solicit and implement proposals from the [medical school] community that support the above goals.”

Dr. David Himmelstein, an internist and faculty member who signed the petition, said that the primary care division “has been a joke for years,” and as a result the suspension of funding “is a largely symbolic act.”

When Harvard initially set up the department of ambulatory care and prevention, “primary care was going to be part of that …and they were going to do more preventive and primary care,” he said. “But the department changed leadership and there was no money to pursue research and initiatives in primary care, so they followed the money and focused on epidemiologic research … and the primary care division became really a minor afterthought.”

The move to de-fund the division raised hackles because it represented the last straw, said Dr. Himmelstein. “There weren't significant resources going to it, but at least there was the symbolism of being part of Harvard Medical School, and they didn't see fit to continue that.”

Dr. Ted Epperly, president of the American Academy of Family Physicians, said he found Harvard's action ironic in light of Massachusetts' recent move to provide health care for all its residents.

“I find it incomprehensible that at a time when [the state needs primary care physicians] that Harvard is turning its back on the people that produce them,” he said. “Medical schools are very good at training a workforce good for medical schools and teaching centers, but very bad at producing a workforce good for the community and people in the state.”

He noted that Harvard's is one of 10 U.S. medical schools that does not have a family medicine department. “They have never invested the resources in training the doctors to shore up the primary care base,” he added.

Mr. Cameron said that the decision to suspend funding “in no way reflects on Harvard Medical School's commitment to primary care training. Rather, it is an administrative matter.”

He pointed out that the medical school currently has 31 centers, divisions, and institutes, “and not all receive funding from us.”

One program that does receive significant funding from the medical school, Mr. Cameron said, is the primary care clerkship program, in which students are assigned to a general internist, general pediatrician, or family physician with whom they see patients three or four afternoons a month for 8 months beginning in September of their third year. The school's investment in the clerkship is increasing by roughly 20% this year, Mr. Cameron said.

Harvard Medical School's decision to suspend funding to its primary care division has drawn sharp criticism from many in the health care community.

Based on an ongoing review of Harvard's department of ambulatory care and prevention, “funding for the division of primary care has been suspended until the review is complete, at which point we expect to have a much clearer vision of the most meaningful structure for the programs within the division and how they can be most effectively leveraged for primary care education and clinical training.”

David Cameron, spokesman for the medical school, said that the suspended funding—about $200,000—mainly paid for “lectures and symposia.” There is no timeline for completion of the review, he added.

Members of the Harvard community protested the suspension via a petition urging the school to support primary care.

“We request that the administration renew its commitment to primary care and present a detailed action plan for expanding institutional support despite this budget cut,” the petition reads. “As a leader in medicine, you have an opportunity to help solve [the] crisis in primary care and we look forward to working with you on this important task.”

The petition, which had garnered nearly 1,200 signatures at press time, asked Harvard to reaffirm that “leadership in primary care research and education is central to Harvard's mission as the nation's premier academic medical institution,” that “Harvard must continue to expand loan forgiveness initiatives that encourage students to pursue primary care specialties,” and that “Harvard should support initiatives to train future leaders and innovators in primary care.” It also asked the administration to “solicit and implement proposals from the [medical school] community that support the above goals.”

Dr. David Himmelstein, an internist and faculty member who signed the petition, said that the primary care division “has been a joke for years,” and as a result the suspension of funding “is a largely symbolic act.”

When Harvard initially set up the department of ambulatory care and prevention, “primary care was going to be part of that …and they were going to do more preventive and primary care,” he said. “But the department changed leadership and there was no money to pursue research and initiatives in primary care, so they followed the money and focused on epidemiologic research … and the primary care division became really a minor afterthought.”

The move to de-fund the division raised hackles because it represented the last straw, said Dr. Himmelstein. “There weren't significant resources going to it, but at least there was the symbolism of being part of Harvard Medical School, and they didn't see fit to continue that.”

Dr. Ted Epperly, president of the American Academy of Family Physicians, said he found Harvard's action ironic in light of Massachusetts' recent move to provide health care for all its residents.

“I find it incomprehensible that at a time when [the state needs primary care physicians] that Harvard is turning its back on the people that produce them,” he said. “Medical schools are very good at training a workforce good for medical schools and teaching centers, but very bad at producing a workforce good for the community and people in the state.”

He noted that Harvard's is one of 10 U.S. medical schools that does not have a family medicine department. “They have never invested the resources in training the doctors to shore up the primary care base,” he added.

Mr. Cameron said that the decision to suspend funding “in no way reflects on Harvard Medical School's commitment to primary care training. Rather, it is an administrative matter.”

He pointed out that the medical school currently has 31 centers, divisions, and institutes, “and not all receive funding from us.”

One program that does receive significant funding from the medical school, Mr. Cameron said, is the primary care clerkship program, in which students are assigned to a general internist, general pediatrician, or family physician with whom they see patients three or four afternoons a month for 8 months beginning in September of their third year. The school's investment in the clerkship is increasing by roughly 20% this year, Mr. Cameron said.

WASHINGTON — Electronic health records systems should be precertified to comply with Recovery Act requirements even before the government issues final certification rules, a federal advisory panel recommends.

The final rules may not go into effect until next year, so “the suggestion is to establish something called preliminary certification based on the assumption that vendors would be willing to take a reasonable risk that what has been proposed in the regulatory process is probably pretty close to what is going to come out the other side,” Paul Egerman, cochair of the certification/adoption workgroup of the Health and Human Services Department's Health Information Technology (HIT) Policy Committee, said at a meeting of the committee.

Vendors then could start certifying based on the proposed criteria, “and when the regulatory process is completed, hopefully there's only a very small adjustment that we can tack on” for HHS certification, he added.

Whether and when the HHS will adopt its committee's recommendation is uncertain, said Dr. David Blumenthal, the committee's chair and national HIT coordinator at the HHS. “We'll have to do this in a deliberate way that includes public comment and takes the necessary steps within the department and in the federal government generally,” he said during a conference call. “I think the rule-making process we have to go through will make it very difficult to react in that time frame.”

Despite Dr. Blumenthal's cautious response, the Certification Commission for Health Information Technology (CCHIT)—currently the only federally approved certification body for EHR systems—is moving ahead. During a Sept. 3 conference call, CCHIT officials announced plans to publish precertification criteria in late September. The organization plans to begin accepting precertification applications on Oct. 7. CCHIT will revise its criteria after certification requirements are final—slated for next spring—and perform any additional testing needed to ensure that precertified systems conform to the final regulations.

The Recovery Act provides $19 billion to encourage HIT adoption, including electronic health records. The money includes up to $44,000 in incentives for each physician who purchases a certified EHR system and makes “meaningful use” of it by 2011. Physicians who adopt EHRs later will also get an incentive, but the amount will diminish over several years and disappear after 2014. Providers who have not adopted EHRs by 2015 will see reductions in Medicare reimbursement.

The Obama administration is making $598 million in Recovery Act funds available to establish 70 HIT “extension centers” that will assist hospitals and clinicians in acquiring and implementing certified EHRs. The first grants will be issued in fiscal year 2010, which begins on Oct. 1.

In other business, the committee refined its proposed definition of certification: “HHS certification means that a system is able to support the achievement of privacy and interoperability, and that the system is able to support the achievement of the meaningful use results that the government expects.”

The workgroup on the definition of meaningful use outlined its plans, including a meeting in October to hear from specialist physicians about how to make criteria for meaningful use relevant to them. The workgroup also wants to address the needs of smaller practices and hospitals, and of safety net providers.

The committee also discussed barriers to widespread EHR adoption. Committee member Judith Faulkner of Epic Systems Corp., Verona, Wis., said cost was not the biggest issue for many providers she had spoken with.

“It doesn't matter what the incentive money is,” she said. “The real barrier is legal concerns. Our customers are not jumping on [EHRs] because lawyers and their other advisers are much more [concerned] about legal issues, and I don't think the money matters as much.”

WASHINGTON — Electronic health records systems should be precertified to comply with Recovery Act requirements even before the government issues final certification rules, a federal advisory panel recommends.

The final rules may not go into effect until next year, so “the suggestion is to establish something called preliminary certification based on the assumption that vendors would be willing to take a reasonable risk that what has been proposed in the regulatory process is probably pretty close to what is going to come out the other side,” Paul Egerman, cochair of the certification/adoption workgroup of the Health and Human Services Department's Health Information Technology (HIT) Policy Committee, said at a meeting of the committee.

Vendors then could start certifying based on the proposed criteria, “and when the regulatory process is completed, hopefully there's only a very small adjustment that we can tack on” for HHS certification, he added.

Whether and when the HHS will adopt its committee's recommendation is uncertain, said Dr. David Blumenthal, the committee's chair and national HIT coordinator at the HHS. “We'll have to do this in a deliberate way that includes public comment and takes the necessary steps within the department and in the federal government generally,” he said during a conference call. “I think the rule-making process we have to go through will make it very difficult to react in that time frame.”

Despite Dr. Blumenthal's cautious response, the Certification Commission for Health Information Technology (CCHIT)—currently the only federally approved certification body for EHR systems—is moving ahead. During a Sept. 3 conference call, CCHIT officials announced plans to publish precertification criteria in late September. The organization plans to begin accepting precertification applications on Oct. 7. CCHIT will revise its criteria after certification requirements are final—slated for next spring—and perform any additional testing needed to ensure that precertified systems conform to the final regulations.

The Recovery Act provides $19 billion to encourage HIT adoption, including electronic health records. The money includes up to $44,000 in incentives for each physician who purchases a certified EHR system and makes “meaningful use” of it by 2011. Physicians who adopt EHRs later will also get an incentive, but the amount will diminish over several years and disappear after 2014. Providers who have not adopted EHRs by 2015 will see reductions in Medicare reimbursement.

The Obama administration is making $598 million in Recovery Act funds available to establish 70 HIT “extension centers” that will assist hospitals and clinicians in acquiring and implementing certified EHRs. The first grants will be issued in fiscal year 2010, which begins on Oct. 1.

In other business, the committee refined its proposed definition of certification: “HHS certification means that a system is able to support the achievement of privacy and interoperability, and that the system is able to support the achievement of the meaningful use results that the government expects.”

The workgroup on the definition of meaningful use outlined its plans, including a meeting in October to hear from specialist physicians about how to make criteria for meaningful use relevant to them. The workgroup also wants to address the needs of smaller practices and hospitals, and of safety net providers.

The committee also discussed barriers to widespread EHR adoption. Committee member Judith Faulkner of Epic Systems Corp., Verona, Wis., said cost was not the biggest issue for many providers she had spoken with.

“It doesn't matter what the incentive money is,” she said. “The real barrier is legal concerns. Our customers are not jumping on [EHRs] because lawyers and their other advisers are much more [concerned] about legal issues, and I don't think the money matters as much.”

WASHINGTON — Electronic health records systems should be precertified to comply with Recovery Act requirements even before the government issues final certification rules, a federal advisory panel recommends.

The final rules may not go into effect until next year, so “the suggestion is to establish something called preliminary certification based on the assumption that vendors would be willing to take a reasonable risk that what has been proposed in the regulatory process is probably pretty close to what is going to come out the other side,” Paul Egerman, cochair of the certification/adoption workgroup of the Health and Human Services Department's Health Information Technology (HIT) Policy Committee, said at a meeting of the committee.

Vendors then could start certifying based on the proposed criteria, “and when the regulatory process is completed, hopefully there's only a very small adjustment that we can tack on” for HHS certification, he added.

Whether and when the HHS will adopt its committee's recommendation is uncertain, said Dr. David Blumenthal, the committee's chair and national HIT coordinator at the HHS. “We'll have to do this in a deliberate way that includes public comment and takes the necessary steps within the department and in the federal government generally,” he said during a conference call. “I think the rule-making process we have to go through will make it very difficult to react in that time frame.”

Despite Dr. Blumenthal's cautious response, the Certification Commission for Health Information Technology (CCHIT)—currently the only federally approved certification body for EHR systems—is moving ahead. During a Sept. 3 conference call, CCHIT officials announced plans to publish precertification criteria in late September. The organization plans to begin accepting precertification applications on Oct. 7. CCHIT will revise its criteria after certification requirements are final—slated for next spring—and perform any additional testing needed to ensure that precertified systems conform to the final regulations.

The Recovery Act provides $19 billion to encourage HIT adoption, including electronic health records. The money includes up to $44,000 in incentives for each physician who purchases a certified EHR system and makes “meaningful use” of it by 2011. Physicians who adopt EHRs later will also get an incentive, but the amount will diminish over several years and disappear after 2014. Providers who have not adopted EHRs by 2015 will see reductions in Medicare reimbursement.

The Obama administration is making $598 million in Recovery Act funds available to establish 70 HIT “extension centers” that will assist hospitals and clinicians in acquiring and implementing certified EHRs. The first grants will be issued in fiscal year 2010, which begins on Oct. 1.

In other business, the committee refined its proposed definition of certification: “HHS certification means that a system is able to support the achievement of privacy and interoperability, and that the system is able to support the achievement of the meaningful use results that the government expects.”

The workgroup on the definition of meaningful use outlined its plans, including a meeting in October to hear from specialist physicians about how to make criteria for meaningful use relevant to them. The workgroup also wants to address the needs of smaller practices and hospitals, and of safety net providers.

The committee also discussed barriers to widespread EHR adoption. Committee member Judith Faulkner of Epic Systems Corp., Verona, Wis., said cost was not the biggest issue for many providers she had spoken with.

“It doesn't matter what the incentive money is,” she said. “The real barrier is legal concerns. Our customers are not jumping on [EHRs] because lawyers and their other advisers are much more [concerned] about legal issues, and I don't think the money matters as much.”

WASHINGTON — The federal Red Flags Rule that requires creditors to check for identity theft may mean a few new procedures for office-based physicians, Patricia King said at the American Health Lawyers Association's annual meeting.

“Do health care providers have to comply with the Red Flags Rule? Yes, if they're [considered] creditors,” said Ms. King, assistant general counsel at Swedish Covenant Hospital in Chicago.

The rule requires creditors to establish formal identify theft prevention programs to protect consumers. Aimed primarily at the financial industry, the regulation was originally scheduled to go into effect on Nov. 1, 2008. However, to give small businesses more time to prepare for compliance, the Federal Trade Commission (FTC) delayed enforcement until May 1, and then until Aug. 1, and most recently until Nov. 1.

Earlier this year, the AMA and physician specialty societies argued that physicians are not creditors because they bill insurance companies, not individual consumers, Ms. King said. “But the patient does get billed for copays, deductibles, and excluded services, so unless all those charges are collected up front, the health care provider is billing and possibly deferring payment for the cost of services.”

The FTC has published guidance and developed a template for an identity theft prevention program for low-risk creditors (www.ftc.gov/bcp/edu/pubs/articles/art11.shtm

Low-risk providers who see the same patients regularly can adopt a simple identity theft program, and personnel involved with front desk, medical records, and patient account functions should be involved in the program, Ms King said.

Physicians need to identify which patient accounts will be covered by the rule—such as those patients who need to make repeat payments—and develop appropriate policies and procedures. “The final [Red Flags] rule had 26 examples of identity theft. Look through them and see which ones are most applicable to you,” she advised

Physicians also need to look at what information they collect when patients register. “Many of us need to re-think our standard registration procedures and beef them up,” said Ms. King. One example might be to ask for a photo ID.

Procedures for guarding against identity theft must be approved by the organization's board of directors and overseen by senior management, according to the rule.

Typical “red flags” that practices should watch for include:

▸ Insurance information that cannot be verified;

▸ No identification;

▸ A photo ID that does not match the patient;

▸ Documents that appear to be altered or forged;

▸ Information given that is different from information already on file;

▸ An invalid Social Security number;

▸ A patient who receives a bill or an explanation of benefits for services that he or she didn't receive;

▸ A patient who finds inaccurate information on a credit report or medical record; or

▸ A payer that says its patient information does not match that supplied by the provider.

In responding to a red flag, Ms. King said, a practice may refuse to provide service, but this might raise a problem under the Emergency Medical Treatment and Labor Act (EMTALA), which prohibits providers from not treating persons with questionable identification who require emergency care. The other option is to provide the service, but ask the patient to bring in the correct information at the next visit. Ms. King cautioned about freely providing medical records to a patient suspected of identity theft, because that could lead to more identity theft.

Patients also will have to be educated about the new rule, she said. “Providers are going to run into problems with patient expectations. Patients have gotten used to coming to their doctor … with either no identifying documents or only their insurance card. They will need some education in advance.”

Under EMTALA, a hospital cannot delay a medical screening examination or stabilizing treatment to inquire about insurance or payment, “but it can follow reasonable registration processes as long as the medical screening exam is not delayed by the process. So after the patient has been triaged and is sitting in the waiting room waiting to be seen for the medical screening exam, you can ask them for identifying information. But if they don't have identifying information, you can't turn them away.”

Providers also should note that compliance with the Health Insurance Portability and Accountability Act (HIPAA) does not shield them from complying with the Red Flags Rule.

“One of the questions we get is, 'I already comply with HIPAA; aren't I done?' The answer is, 'Probably not,'” said Naomi Lefkowitz of the division of privacy and identity protection at the Federal Trade Commission.

“The Red Flags Rule is really about fraud protection, and HIPAA is more about data security. There is certainly some overlap, and to the extent that, for example, someone is checking photo IDs … to make sure that the person only has access to their [own] medical record, that's a policy that might do double duty under the client's identity theft program as far as verifying ID,” Ms. Lefkowitz said. But merely having the HIPAA program is probably not going to make [providers] compliant with Red Flags.”

Mary Ellen Schneider contributed to this report.

WASHINGTON — The federal Red Flags Rule that requires creditors to check for identity theft may mean a few new procedures for office-based physicians, Patricia King said at the American Health Lawyers Association's annual meeting.

“Do health care providers have to comply with the Red Flags Rule? Yes, if they're [considered] creditors,” said Ms. King, assistant general counsel at Swedish Covenant Hospital in Chicago.

The rule requires creditors to establish formal identify theft prevention programs to protect consumers. Aimed primarily at the financial industry, the regulation was originally scheduled to go into effect on Nov. 1, 2008. However, to give small businesses more time to prepare for compliance, the Federal Trade Commission (FTC) delayed enforcement until May 1, and then until Aug. 1, and most recently until Nov. 1.

Earlier this year, the AMA and physician specialty societies argued that physicians are not creditors because they bill insurance companies, not individual consumers, Ms. King said. “But the patient does get billed for copays, deductibles, and excluded services, so unless all those charges are collected up front, the health care provider is billing and possibly deferring payment for the cost of services.”

The FTC has published guidance and developed a template for an identity theft prevention program for low-risk creditors (www.ftc.gov/bcp/edu/pubs/articles/art11.shtm

Low-risk providers who see the same patients regularly can adopt a simple identity theft program, and personnel involved with front desk, medical records, and patient account functions should be involved in the program, Ms King said.

Physicians need to identify which patient accounts will be covered by the rule—such as those patients who need to make repeat payments—and develop appropriate policies and procedures. “The final [Red Flags] rule had 26 examples of identity theft. Look through them and see which ones are most applicable to you,” she advised

Physicians also need to look at what information they collect when patients register. “Many of us need to re-think our standard registration procedures and beef them up,” said Ms. King. One example might be to ask for a photo ID.

Procedures for guarding against identity theft must be approved by the organization's board of directors and overseen by senior management, according to the rule.

Typical “red flags” that practices should watch for include:

▸ Insurance information that cannot be verified;

▸ No identification;

▸ A photo ID that does not match the patient;

▸ Documents that appear to be altered or forged;

▸ Information given that is different from information already on file;

▸ An invalid Social Security number;

▸ A patient who receives a bill or an explanation of benefits for services that he or she didn't receive;

▸ A patient who finds inaccurate information on a credit report or medical record; or

▸ A payer that says its patient information does not match that supplied by the provider.

In responding to a red flag, Ms. King said, a practice may refuse to provide service, but this might raise a problem under the Emergency Medical Treatment and Labor Act (EMTALA), which prohibits providers from not treating persons with questionable identification who require emergency care. The other option is to provide the service, but ask the patient to bring in the correct information at the next visit. Ms. King cautioned about freely providing medical records to a patient suspected of identity theft, because that could lead to more identity theft.

Patients also will have to be educated about the new rule, she said. “Providers are going to run into problems with patient expectations. Patients have gotten used to coming to their doctor … with either no identifying documents or only their insurance card. They will need some education in advance.”

Under EMTALA, a hospital cannot delay a medical screening examination or stabilizing treatment to inquire about insurance or payment, “but it can follow reasonable registration processes as long as the medical screening exam is not delayed by the process. So after the patient has been triaged and is sitting in the waiting room waiting to be seen for the medical screening exam, you can ask them for identifying information. But if they don't have identifying information, you can't turn them away.”

Providers also should note that compliance with the Health Insurance Portability and Accountability Act (HIPAA) does not shield them from complying with the Red Flags Rule.

“One of the questions we get is, 'I already comply with HIPAA; aren't I done?' The answer is, 'Probably not,'” said Naomi Lefkowitz of the division of privacy and identity protection at the Federal Trade Commission.

“The Red Flags Rule is really about fraud protection, and HIPAA is more about data security. There is certainly some overlap, and to the extent that, for example, someone is checking photo IDs … to make sure that the person only has access to their [own] medical record, that's a policy that might do double duty under the client's identity theft program as far as verifying ID,” Ms. Lefkowitz said. But merely having the HIPAA program is probably not going to make [providers] compliant with Red Flags.”

Mary Ellen Schneider contributed to this report.

WASHINGTON — The federal Red Flags Rule that requires creditors to check for identity theft may mean a few new procedures for office-based physicians, Patricia King said at the American Health Lawyers Association's annual meeting.

“Do health care providers have to comply with the Red Flags Rule? Yes, if they're [considered] creditors,” said Ms. King, assistant general counsel at Swedish Covenant Hospital in Chicago.

The rule requires creditors to establish formal identify theft prevention programs to protect consumers. Aimed primarily at the financial industry, the regulation was originally scheduled to go into effect on Nov. 1, 2008. However, to give small businesses more time to prepare for compliance, the Federal Trade Commission (FTC) delayed enforcement until May 1, and then until Aug. 1, and most recently until Nov. 1.

Earlier this year, the AMA and physician specialty societies argued that physicians are not creditors because they bill insurance companies, not individual consumers, Ms. King said. “But the patient does get billed for copays, deductibles, and excluded services, so unless all those charges are collected up front, the health care provider is billing and possibly deferring payment for the cost of services.”

The FTC has published guidance and developed a template for an identity theft prevention program for low-risk creditors (www.ftc.gov/bcp/edu/pubs/articles/art11.shtm

Low-risk providers who see the same patients regularly can adopt a simple identity theft program, and personnel involved with front desk, medical records, and patient account functions should be involved in the program, Ms King said.

Physicians need to identify which patient accounts will be covered by the rule—such as those patients who need to make repeat payments—and develop appropriate policies and procedures. “The final [Red Flags] rule had 26 examples of identity theft. Look through them and see which ones are most applicable to you,” she advised

Physicians also need to look at what information they collect when patients register. “Many of us need to re-think our standard registration procedures and beef them up,” said Ms. King. One example might be to ask for a photo ID.

Procedures for guarding against identity theft must be approved by the organization's board of directors and overseen by senior management, according to the rule.

Typical “red flags” that practices should watch for include:

▸ Insurance information that cannot be verified;

▸ No identification;

▸ A photo ID that does not match the patient;

▸ Documents that appear to be altered or forged;

▸ Information given that is different from information already on file;

▸ An invalid Social Security number;

▸ A patient who receives a bill or an explanation of benefits for services that he or she didn't receive;

▸ A patient who finds inaccurate information on a credit report or medical record; or

▸ A payer that says its patient information does not match that supplied by the provider.

In responding to a red flag, Ms. King said, a practice may refuse to provide service, but this might raise a problem under the Emergency Medical Treatment and Labor Act (EMTALA), which prohibits providers from not treating persons with questionable identification who require emergency care. The other option is to provide the service, but ask the patient to bring in the correct information at the next visit. Ms. King cautioned about freely providing medical records to a patient suspected of identity theft, because that could lead to more identity theft.

Patients also will have to be educated about the new rule, she said. “Providers are going to run into problems with patient expectations. Patients have gotten used to coming to their doctor … with either no identifying documents or only their insurance card. They will need some education in advance.”

Under EMTALA, a hospital cannot delay a medical screening examination or stabilizing treatment to inquire about insurance or payment, “but it can follow reasonable registration processes as long as the medical screening exam is not delayed by the process. So after the patient has been triaged and is sitting in the waiting room waiting to be seen for the medical screening exam, you can ask them for identifying information. But if they don't have identifying information, you can't turn them away.”

Providers also should note that compliance with the Health Insurance Portability and Accountability Act (HIPAA) does not shield them from complying with the Red Flags Rule.

“One of the questions we get is, 'I already comply with HIPAA; aren't I done?' The answer is, 'Probably not,'” said Naomi Lefkowitz of the division of privacy and identity protection at the Federal Trade Commission.

“The Red Flags Rule is really about fraud protection, and HIPAA is more about data security. There is certainly some overlap, and to the extent that, for example, someone is checking photo IDs … to make sure that the person only has access to their [own] medical record, that's a policy that might do double duty under the client's identity theft program as far as verifying ID,” Ms. Lefkowitz said. But merely having the HIPAA program is probably not going to make [providers] compliant with Red Flags.”

Mary Ellen Schneider contributed to this report.

Can't get enough policy & practice? Check out our new podcast each Monday. egmnblog.wordpress.com

Florida: No Subbing Levothyroxine

The Florida Board of Pharmacy has voted to reaffirm levothyroxine's place on the state's negative formulary, making it illegal to substitute a generic product when a physician writes a branded prescription for the drug. The action was in response to a ruling by Florida's First District Court of Appeal. The state had in effect removed levothyroxine from the negative formulary in April 2008 after an administrative law judge ruled, in Mylan v. Abbott, that generic levothyroxine could be substituted because it was “A” rated for therapeutic equivalence in the federal Orange Book. But the appeals court disagreed in its in June ruling. “To minimize confusion, it is recommended that physicians write 'Brand Medically Necessary' on prescriptions when branded products are wanted,” the American Thyroid Association advised in a press release.

More HIPAA Goes to Rights Office

The Health and Human Services' Office for Civil Rights will now enforce the confidentiality of electronic health information as well as other patient records, HHS Secretary Kathleen Sebelius announced. The office already had responsibility for enforcing the HIPAA's “privacy” rule, which guards nonelectronic personal health information. But enforcement of HIPAA's “security” rule for electronic health information had been delegated to the Centers for Medicare and Medicaid Services. Legislation approved as part of the Recovery Act of 2009 mandated better enforcement of both rules. Ms. Sebelius noted in a statement that electronic and nonelectronic health information increasingly overlaps. “Combining the enforcement authority [for both rules] in one agency within HHS will facilitate improvements by eliminating duplication and increasing efficiency,” she said. The CMS will continue to have authority for the administration and enforcement of other HIPAA regulations.

Obesity Medicine Exam to Come

Ten professional societies are jointly developing an Obesity Medicine Physician Certification Examination to credential physicians who care for obese adults and children. The societies have begun writing questions for the exam, scheduled to be completed by March 2010, according to the Obesity Society. The 10 groups are the Obesity Society, the American Academy of Pediatrics, the American Association of Clinical Endocrinologists, the American Diabetes Association, the American Gastroenterological Association, the American Heart Association, the American Society for Parenteral and Enteral Nutrition, the American Society for Metabolic and Bariatric Surgery, the American Society for Nutrition, and the Endocrine Society.

Lilly Payment Data Now Public

Eli Lilly & Co. will publish how much it pays physicians and other health care professionals in consulting fees, honoraria, and the like. The drugmaker detailed the payments for the first quarter of 2009 at

www.lillyfacultyregistry.com

Family Insurance Tops $12K

Employer-sponsored insurance for a family of four in 2008 cost employers and workers an average of $12,298, according to the Agency for Healthcare Research and Quality. The employees' contribution averaged $3,394 for family-of-four plans and $882 for single workers, the agency reported. Employers paid the entire premium for 22% of workers with single-coverage plans, for 11% of workers with family-of-four plans, and for 9% of employees with one covered family member. About 31 million of the more than 62 million workers enrolled in employer-based insurance in 2008 had single plans, whereas 20 million had family-of-four coverage.

Medical Bankruptcy Would Ease

A bill introduced last month by Sen. Sheldon Whitehouse (D-R.I.) would eliminate some hurdles for families forced to file for bankruptcy because of medical debt. The Medical Bankruptcy Fairness Act (S. 1624) would allow a family to retain at least $250,000 of its home's value through bankruptcy. The bill includes a provisions that would deem credit counseling unnecessary when the cause of bankruptcy is a medical crisis rather than poor financial management. The bill also would make it easier for families to enter Chapter 7, the simplest bankruptcy process. “As we work to fix the larger problems with our broken health care system, it's equally important that we help those already struggling” with medical expenses, the senator said.

Can't get enough policy & practice? Check out our new podcast each Monday. egmnblog.wordpress.com

Florida: No Subbing Levothyroxine

The Florida Board of Pharmacy has voted to reaffirm levothyroxine's place on the state's negative formulary, making it illegal to substitute a generic product when a physician writes a branded prescription for the drug. The action was in response to a ruling by Florida's First District Court of Appeal. The state had in effect removed levothyroxine from the negative formulary in April 2008 after an administrative law judge ruled, in Mylan v. Abbott, that generic levothyroxine could be substituted because it was “A” rated for therapeutic equivalence in the federal Orange Book. But the appeals court disagreed in its in June ruling. “To minimize confusion, it is recommended that physicians write 'Brand Medically Necessary' on prescriptions when branded products are wanted,” the American Thyroid Association advised in a press release.

More HIPAA Goes to Rights Office

The Health and Human Services' Office for Civil Rights will now enforce the confidentiality of electronic health information as well as other patient records, HHS Secretary Kathleen Sebelius announced. The office already had responsibility for enforcing the HIPAA's “privacy” rule, which guards nonelectronic personal health information. But enforcement of HIPAA's “security” rule for electronic health information had been delegated to the Centers for Medicare and Medicaid Services. Legislation approved as part of the Recovery Act of 2009 mandated better enforcement of both rules. Ms. Sebelius noted in a statement that electronic and nonelectronic health information increasingly overlaps. “Combining the enforcement authority [for both rules] in one agency within HHS will facilitate improvements by eliminating duplication and increasing efficiency,” she said. The CMS will continue to have authority for the administration and enforcement of other HIPAA regulations.

Obesity Medicine Exam to Come

Ten professional societies are jointly developing an Obesity Medicine Physician Certification Examination to credential physicians who care for obese adults and children. The societies have begun writing questions for the exam, scheduled to be completed by March 2010, according to the Obesity Society. The 10 groups are the Obesity Society, the American Academy of Pediatrics, the American Association of Clinical Endocrinologists, the American Diabetes Association, the American Gastroenterological Association, the American Heart Association, the American Society for Parenteral and Enteral Nutrition, the American Society for Metabolic and Bariatric Surgery, the American Society for Nutrition, and the Endocrine Society.

Lilly Payment Data Now Public

Eli Lilly & Co. will publish how much it pays physicians and other health care professionals in consulting fees, honoraria, and the like. The drugmaker detailed the payments for the first quarter of 2009 at

www.lillyfacultyregistry.com

Family Insurance Tops $12K

Employer-sponsored insurance for a family of four in 2008 cost employers and workers an average of $12,298, according to the Agency for Healthcare Research and Quality. The employees' contribution averaged $3,394 for family-of-four plans and $882 for single workers, the agency reported. Employers paid the entire premium for 22% of workers with single-coverage plans, for 11% of workers with family-of-four plans, and for 9% of employees with one covered family member. About 31 million of the more than 62 million workers enrolled in employer-based insurance in 2008 had single plans, whereas 20 million had family-of-four coverage.

Medical Bankruptcy Would Ease

A bill introduced last month by Sen. Sheldon Whitehouse (D-R.I.) would eliminate some hurdles for families forced to file for bankruptcy because of medical debt. The Medical Bankruptcy Fairness Act (S. 1624) would allow a family to retain at least $250,000 of its home's value through bankruptcy. The bill includes a provisions that would deem credit counseling unnecessary when the cause of bankruptcy is a medical crisis rather than poor financial management. The bill also would make it easier for families to enter Chapter 7, the simplest bankruptcy process. “As we work to fix the larger problems with our broken health care system, it's equally important that we help those already struggling” with medical expenses, the senator said.

Can't get enough policy & practice? Check out our new podcast each Monday. egmnblog.wordpress.com

Florida: No Subbing Levothyroxine

The Florida Board of Pharmacy has voted to reaffirm levothyroxine's place on the state's negative formulary, making it illegal to substitute a generic product when a physician writes a branded prescription for the drug. The action was in response to a ruling by Florida's First District Court of Appeal. The state had in effect removed levothyroxine from the negative formulary in April 2008 after an administrative law judge ruled, in Mylan v. Abbott, that generic levothyroxine could be substituted because it was “A” rated for therapeutic equivalence in the federal Orange Book. But the appeals court disagreed in its in June ruling. “To minimize confusion, it is recommended that physicians write 'Brand Medically Necessary' on prescriptions when branded products are wanted,” the American Thyroid Association advised in a press release.

More HIPAA Goes to Rights Office

The Health and Human Services' Office for Civil Rights will now enforce the confidentiality of electronic health information as well as other patient records, HHS Secretary Kathleen Sebelius announced. The office already had responsibility for enforcing the HIPAA's “privacy” rule, which guards nonelectronic personal health information. But enforcement of HIPAA's “security” rule for electronic health information had been delegated to the Centers for Medicare and Medicaid Services. Legislation approved as part of the Recovery Act of 2009 mandated better enforcement of both rules. Ms. Sebelius noted in a statement that electronic and nonelectronic health information increasingly overlaps. “Combining the enforcement authority [for both rules] in one agency within HHS will facilitate improvements by eliminating duplication and increasing efficiency,” she said. The CMS will continue to have authority for the administration and enforcement of other HIPAA regulations.

Obesity Medicine Exam to Come

Ten professional societies are jointly developing an Obesity Medicine Physician Certification Examination to credential physicians who care for obese adults and children. The societies have begun writing questions for the exam, scheduled to be completed by March 2010, according to the Obesity Society. The 10 groups are the Obesity Society, the American Academy of Pediatrics, the American Association of Clinical Endocrinologists, the American Diabetes Association, the American Gastroenterological Association, the American Heart Association, the American Society for Parenteral and Enteral Nutrition, the American Society for Metabolic and Bariatric Surgery, the American Society for Nutrition, and the Endocrine Society.

Lilly Payment Data Now Public

Eli Lilly & Co. will publish how much it pays physicians and other health care professionals in consulting fees, honoraria, and the like. The drugmaker detailed the payments for the first quarter of 2009 at

www.lillyfacultyregistry.com

Family Insurance Tops $12K

Employer-sponsored insurance for a family of four in 2008 cost employers and workers an average of $12,298, according to the Agency for Healthcare Research and Quality. The employees' contribution averaged $3,394 for family-of-four plans and $882 for single workers, the agency reported. Employers paid the entire premium for 22% of workers with single-coverage plans, for 11% of workers with family-of-four plans, and for 9% of employees with one covered family member. About 31 million of the more than 62 million workers enrolled in employer-based insurance in 2008 had single plans, whereas 20 million had family-of-four coverage.

Medical Bankruptcy Would Ease

A bill introduced last month by Sen. Sheldon Whitehouse (D-R.I.) would eliminate some hurdles for families forced to file for bankruptcy because of medical debt. The Medical Bankruptcy Fairness Act (S. 1624) would allow a family to retain at least $250,000 of its home's value through bankruptcy. The bill includes a provisions that would deem credit counseling unnecessary when the cause of bankruptcy is a medical crisis rather than poor financial management. The bill also would make it easier for families to enter Chapter 7, the simplest bankruptcy process. “As we work to fix the larger problems with our broken health care system, it's equally important that we help those already struggling” with medical expenses, the senator said.