As a hospital-based PA working in surgery, the recent changes by the CMS regarding the necessity for physician certification of hospital admissions had me and my entire team concerned about the effect this rule would have on timely care on our unit.
As I discussed in a previous blog post, I am many times the only provider on our team at the hospital when a burn or other emergent reconstruction case presents to our emergency department for care. The physician I work with can't just leave another hospital or interrupt a surgery and come to our facility to "certify" an admission. This would be a bad use of both of our time, and bad for timely and effective patient care. I understand what CMS is trying to accomplish here, but often times, these sorts of rule changes have unintended consequences.
On Sept. 5, after much input from professional and hospital organizations including the American Academy of Physician Assistants (AAPA), CMS issued guidance that reaffirms the ability of PAs, NPs, and medical residents to personally write admission orders and perform the history and physical (H&P) for hospital inpatient admissions. The guidance clarifies language contained in the IPPS rule for 2014, which called into question and appeared to restrict the authority of PAs and certain other professionals to provide these important services. A major purpose of the Hospital Inpatient Perspective Payment System (IPPS) rule was to assist hospitals in defining the appropriate use of hospital admission versus observation status, thereby helping more Medicare beneficiaries become eligible for nursing-home care after a minimum three-day hospital inpatient stay.
Another issue has been exposed by this process and rule: its effect on the ongoing transition to a fully functional electronic health record (EHR) within hospitals. I'm happy to report that in our hospital system, the information technology and medical records folks have control over what needs to be forwarded where, for authorization and countersignature. I also have control over non-mandatory documents, and can forward individual items such as H&P examinations, progress notes, procedure notes, and discharge summaries to my physician partner for review and electronic countersignature. I really like the vast and broad paper trail that the EHR creates when it comes to a PA practice. Furthermore, it makes it easy for physicians practicing with PAs and other providers to sign off on care and orders. This is the promise of the EHR — that is, making processes faster and less burdensome, and giving access to much more information in a timely manner.
That is part of the problem with the new rule. Certain EHRs in hospital facilities are an "all or nothing" proposition. This means that the facility has one of two choices. They can require 100 percent electronic countersignature of all documents and orders by providers practicing with physicians, or none. This has prompted some facilities to create a paper or hardcopy document, to certify admissions, which really defeats the purpose of the EHR, and increased the administrative work of hospital based physicians at a time when they are already overburdened with administrative work load.
At least from the standpoint of PAs, we are continuing to work with CMS, as are physician and hospital groups to clarify the rule, and to ensure that the entire hospital health care team is used to their fullest extent of their training and expertise. The continued transition to full implementation of the EHR is a good thing, but the laws of unintended consequences can be expected to come into play repeatedly as the difference between goals and the actual effects on physicians, providers and patients plays out in the real world.