Coming to a Hospital Near You: E-prescribe
Will hospitalists and hospital medicine groups get to participate in the Centers for Medicare and Medicaid e-prescribe program?
Jettie Eddleman, BSN, RN, Quality Initiatives Program Director North Texas Specialty Physicians (NTSP), Fort Worth, Texas
Dr. Hospitalist responds: According to a December 2007 study by SureScripts, only 6% of U.S. physicians prescribe medications electronically. Medicare would like more physicians to electronically prescribe prescriptions because “e-prescribing is more efficient and convenient for consumers, improves the quality of care, lowers administrative costs, and its widespread use would eliminate thousands of medication errors every year.”
Medicare is not the only organization encouraging e-prescribing. Blue Cross Blue Shield of Massachusetts (BCBSMA) recently announced e-prescribing will be required for any physician to participate in any of the BCBSMA physician incentive programs, effective January, 2011. To speed the adoption of e-prescribing, Medicare will provide financial incentives to physicians who e-prescribe. Starting in this year, Medicare will pay a 2% bonus to physicians who prescribe under Part D. This incentive bonus will decrease to 1% in 2011 and 0.5% in 2013. Starting in 2012, physicians who are not e-prescribing will lose 1% of their Medicare payment. This penalty will increase to 1.5% in 2013 and 2% in 2014. In other words, you can e-prescribe sooner or later, but hospital medicine groups will increase revenue if they start sooner.
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E-prescribing is, however, not without barriers. For example, the Drug Enforcement Agency (DEA) presently prohibits e-prescription of controlled substances. Medicare is working with the DEA to address this issue. In the meantime, providers who implement e-prescription will need to continue a separate system for prescription of controlled substances.
Some physicians have electronic medical record (EMR) systems, which send prescriptions to pharmacies via facsimile machines. For clarification, this is not considered e-prescribing. In fact, under Medicare statute, most EMR-faxed prescriptions no longer are allowed for Part D. As the plan currently stands, this incentive is tied to specific Current Procedural Terminology (CPT) codes, used primarily by primary care providers and not by hospitalists. Unless the hospitalists in your group also provide outpatient care, it is unlikely any will be able to participate in this Medicare e-prescribing incentive plan.
Test Results Post-Discharge
Some of my patients have laboratory test results pending at the time of discharge from the hospital. Most of my patients do not have a routine outpatient provider. At the time of discharge, I always set them up with outpatient follow-up with a new primary care provider, but I have no way of knowing if the patients are showing up at their appointments. My concern is if they don’t show up, they won’t know about their test results. Is this something I need to address? If so, how do you suggest I go about doing it?
Z. Taylor, Durant, Okla.
Dr. Hospitalist responds: This definitely is an issue that needs to be addressed. It is not only a quality of care issue, but also potentially a medical/legal issue. Transitions in care are risky for patients because these are periods with increased risk for medical error. For example, this is why the Joint Commission mandates medication reconciliation each time a patient sees a provider.
When patients are discharged from the hospital, which provider is responsible for notifying the patient of pending laboratory test results? Is it the primary care provider (PCP) or the hospitalist? As you described in your question, what if the patient does not have a regular PCP? Does the responsibility then rest with the hospitalist who discharged the patient? One could argue the physician who ordered the test is responsible. What if the hospitalist who ordered the test is not the same hospitalist who discharged the patient? It would seem under that circumstance, the hospitalist who discharged the patient bears more responsibility than the hospitalist who ordered the study.
To further complicate matters, what if the physician who ordered the test was a consultant? I am not aware of any rules specifying provider responsibility for notifying the patient. I typically recommend the hospitalist in charge of discharging the patient from the hospital make a practice of looking for studies whose results are pending at the time of discharge. The hospitalist should inform the patient the results are pending and discuss a plan of action for the patient to get the study results. Then I suggest the hospitalist document this discussion and plan/forward this documentation to the provider who is scheduled to see the patient in follow up. It is typically easier for hospitalists to include this information as part of the discharge summary sent to the PCP.
As you suggested, these steps may be insufficient when the patient does not follow up with the designated PCP. For that reason, it is necessary for the hospitalist who discharged the patient to follow up on these pending results. The hospitalist must notify the patient if the results are abnormal. To do this, prior to hospital discharge, one needs to know how to contact a patient post-discharge. Always document the fact you have notified the patient of the abnormal result. I recognize this type of follow up is not easy after a patient is discharged, especially when most results will return as normal studies. The volume-to-noise ratio is not great. But it is that one out of 100 abnormal result that will end up hurting the patient and potentially result in litigation.
One important piece of advice: Only order necessary tests. The fewer tests you order, the less it is likely you will have test results pending at discharge. If a test is not likely to change how you manage a patient during their inpatient stay, consider not ordering the test. Such practice is not only more cost-effective care, but also simplifies the system and minimizes the risk of error associated with notifying patients of abnormal test results.
A Little Common Courtesy, Please
I find it incredibly annoying when we are holding a staff meeting and some of my colleagues are checking e-mail on their Blackberry. At the risk of sounding like a codger, is it too much to ask for some common courtesy?
K. Moore, Austin, Texas
Dr. Hospitalist responds: You are, of course, correct at pointing out it is rude for people to check messages during meetings, not to mention anytime a supervisor or colleague is speaking. Do I condone the behavior? No. Do I understand the behavior? Yes. (In the spirit of full disclosure, I am addicted to my Blackberry and, occasionally, am guilty of checking for messages when I should be paying attention).
We live in an information age and the expectation for communication is greater than ever. As hospitalists, we know this all too well. For many of us, the Blackberry affords us the opportunity to multitask, shaving minutes or hours off our workday. I agree it is not an unreasonable request to ask everyone to turn off their cell phones and put down their Blackberrys during meetings.
That said, doing without the Blackberry for much longer than an hour or two is not an option for many of us.
Please note President-elect Obama will have to ditch his Blackberry this month, if not sooner, due to concerns surrounding e-mail privacy. He also is subject to the Presidential Records Act, which eliminates any privacy regarding this correspondence. (Memo to self, another reason not to run for president.) TH