CMS plan would ease doctors' regulatory burden in hospitals

The suggested revisions are designed to keep pace with changes in medical practice, agency says.

By David Glendinning — Posted April 25, 2005

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Washington -- Physicians who have grumbled for years about onerous federal rules that affect their work in hospitals are starting to see some movement from the government.

The Centers for Medicare & Medicaid Services issued a proposed rule last month that aims to make doctors' lives at the hospital easier when it comes to conducting medical history and physical examinations, issuing verbal orders, keeping medications secure, and completing post-anesthesia evaluations. Adherence to the rules is required for hospitals to bill Medicare and Medicaid for services.

"To keep up with changes in effective medical practice, we believe it is in the interest of the health care community as a whole for us to move forward with these changes," said CMS Administrator Mark McClellan, MD, PhD.

The government first proposed revamping a wide number of these hospital rules in 1997 but subsequently put the full effort on the back burner. Smaller sets of revisions targeting more specific regulations have been trickling out since then.

Professional groups such as the American Medical Association and the agency's Physician Regulatory Issues Team were instrumental in pushing for the latest changes, Dr. McClellan said. He noted that the history and physical exam requirements, as well as the post-anesthesia regulations, are of particular interest to the AMA.

Doctors have complained about the fact that they must conduct an H&P exam no more than seven days before a patient is admitted to the hospital. That time frame is too tight, they said.

Pressure on CMS to change this requirement intensified when the Joint Commission on Accreditation of Healthcare Organizations, which evaluates hospitals, recently revised its standard to allow exams that were conducted within 30 days before admission to be used in the patient medical record.

The agency agreed to expand the preadmission window to 30 days but in return has proposed a shorter time frame for completing and recording an H&P exam for patients who come to the hospital without one. Physicians now have up to two days to conduct this examination or to report any changes in patient condition after an admission but will have only one day if the proposed rule is finalized in its current form.

"We believe that expanding the current requirement for completion of a medical history and physical examination ... supports safe patient care as long as the hospital ensures documentation of the patient's current condition in the medical record within 24 hours after admission," Dr. McClellan said.

CMS heeded another AMA recommendation by proposing that any individual qualified to administer anesthesia may conduct a post-treatment evaluation of the patient. The Association repeatedly has stated that requiring the doctor who actually administered the anesthesia to write the follow-up report is overly burdensome and not necessary to ensure the patient's health.

The American Society of Anesthesiologists also saw one of its priorities included in the proposed rule.

Requiring all drugs and biologicals to be locked down in a storage area when not in use causes difficulty for physicians who want to set up anesthesia or epidural carts before procedures in the operating or delivery room, the society says. CMS has proposed changing the regulations to state that noncontrolled drugs should be kept in a secure area and locked down only when appropriate.

This revision will give anesthesiologists the practice flexibility they need without putting controlled drugs at risk for unauthorized use, Dr. McClellan said. The change also will cover the hospital practice of giving patients bedside access to urgently needed drugs and nonprescription medications, he said.

Physicians at hospitals will see more flexibility when it comes to prescribing drugs and biologicals via verbal order.

Under current regulations, doctors who issue such verbal orders must date, time and authenticate the orders in either written or electronic form. Such a mandate becomes difficult in many situations, including ones in which prescribing doctors give orders and then immediately go off-duty, numerous medical groups told CMS.

The proposed rule would allow anyone who is responsible for the care of the patient to authenticate verbal orders within 48 hours, not just the physician who gave the instructions in the first place. This revision, which would last only five years, would reduce the burden on hospitals long enough for the facilities to develop information technology that would facilitate proper authentication by the prescribing physician, according to the agency.

Some hospital industry members had less success convincing federal officials that a related authentication requirement for medical record entries be dropped altogether based on the perception that it does not add value to the quality of the medical record.

"We believe that an authentication requirement is necessary to protect the health and safety of patients," Dr. McClellan said. "Unless all medical record entries are authenticated, patient safety, quality of care, accountability and integrity of the patient medical record are compromised."

Stakeholders in the debate over these hospital regulations are compiling comments on the proposed rule. Submissions are due to CMS by May 24. Electronic comments on specific issues in this regulation can be made online (link).

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Changing the rules

Proposed changes in federal rules governing hospitals' participation in Medicare and Medicaid aim to alleviate regulatory burdens faced by doctors who work in these facilities. Here are some of the suggested modifications:

  • History and physical exams performed within 30 days before or 24 hours after patient admission would be required. Physicians currently must conduct an H&P exam within seven days before and 48 hours after admission.
  • Verbal orders that are not in written or electronic form could be authenticated within 48 hours by someone other than the prescribing physician. Doctors currently must sign their own verbal orders "as soon as possible" when prescribing drugs or biologicals.
  • Noncontrolled drugs would be kept in a secure area but only locked down "when appropriate." All drugs and biologicals currently must be locked down in a secure area.
  • Any individual trained to administer anesthesia would be able to conduct a patient's post-procedure evaluation. Currently, only the person who treated the patient may make the evaluation.

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