Mary Ellen Schneider

LAS VEGAS — The federal government is stepping up its audit activities in Medicare, and that could mean greater scrutiny of billing practices.

One development that physicians should keep a close eye on is the recent nationwide rollout of Medicare's Recovery Audit Contractor program, said Edward R. Gaines III, vice president and chief compliance officer at CBIZ Medical Management Professionals Inc. The program, known as the RAC, began as a demonstration project in New York, California, and Florida.

Under the program, private contractors are given contingency fees for identifying improper Medicare payments to health care providers, including over- and underpayments.

But Mr. Gaines said the experience in the demonstration project showed that the contractors concentrated much more on detecting overpayments made to providers.

Now that the RAC program has been rolled out nationwide, four private contractors, each assigned to different regions of the country, will use data mining, outlier analysis, and referrals to root out improper payments. The RACs will earn contingency fees for finding errors, with fees that vary from around 9% to 12%.

Physicians need to be aware of the RAC activities and do their own outlier analyses so they can be ready to defend against an audit, Mr. Gaines advised during a meeting on reimbursement sponsored by the American College of Emergency Physicians.

The RACs will look at evaluation and management services. During the demonstration project, evaluation and management services were exempt from audit—but that is not the case now that the RAC is a permanent program.

Medicare is raising the bar for audits because they are in a financial squeeze, Mr. Gaines said.

Right now, Medicare receives more than 1.2 billion medical claims a year—and that's before the bulk of the baby boomer generation has entered the program. Add to that recent news reports that the Medicare and Medicaid programs are hemorrhaging tens of billions of dollars to fraud, and the federal government is in a position in which it needs to act to contain costs.

During the pilot phase of the program, the RACs collected $1 for every 20 cents spent by the government. “So, if you can get five times the rate of return and you're the federal government, this is a no-brainer,” Mr. Gaines said.

One area of specific concern with the RACs is that they have the power, at least in certain limited circumstances, to extrapolate an error rate across a larger number of Medicare claims. For example, if a RAC finds a 10% error rate on 50 medical records, extrapolation would allow the contractor to apply that error rate across all of a physician's Medicare patients over multiple years—potentially dramatically increasing the penalty.

There are restrictions to that power. For example, it can't be applied during the initial audit phase, and officials at the Centers for Medicare and Medicaid Services have stated that it can only be employed in cases where there is a sustained or a high level of payment error, or a failure to correct the error. In addition, penalties cannot be applied to claims before Oct. 1, 2007.

But the ability to perform extrapolation at all is making physicians uneasy. Although there are restrictions on when extrapolation could be applied, Mr. Gaines said, it's unclear how CMS would put it into practice. And the fact that the RACs would earn contingency fees on extrapolated claims seems to increase the likelihood that the method would be used, he said. “That's where the money is,” he said.

Physicians who are audited by the RAC and have errors in 1 out of 50 charts would likely be at low risk for extrapolation. he said. However, the risk likely is higher for a physician or group that has been subject to audits in the past or been subject to corrective action.

LAS VEGAS — The federal government is stepping up its audit activities in Medicare, and that could mean greater scrutiny of billing practices.

One development that physicians should keep a close eye on is the recent nationwide rollout of Medicare's Recovery Audit Contractor program, said Edward R. Gaines III, vice president and chief compliance officer at CBIZ Medical Management Professionals Inc. The program, known as the RAC, began as a demonstration project in New York, California, and Florida.

Under the program, private contractors are given contingency fees for identifying improper Medicare payments to health care providers, including over- and underpayments.

But Mr. Gaines said the experience in the demonstration project showed that the contractors concentrated much more on detecting overpayments made to providers.

Now that the RAC program has been rolled out nationwide, four private contractors, each assigned to different regions of the country, will use data mining, outlier analysis, and referrals to root out improper payments. The RACs will earn contingency fees for finding errors, with fees that vary from around 9% to 12%.

Physicians need to be aware of the RAC activities and do their own outlier analyses so they can be ready to defend against an audit, Mr. Gaines advised during a meeting on reimbursement sponsored by the American College of Emergency Physicians.

The RACs will look at evaluation and management services. During the demonstration project, evaluation and management services were exempt from audit—but that is not the case now that the RAC is a permanent program.

Medicare is raising the bar for audits because they are in a financial squeeze, Mr. Gaines said.

Right now, Medicare receives more than 1.2 billion medical claims a year—and that's before the bulk of the baby boomer generation has entered the program. Add to that recent news reports that the Medicare and Medicaid programs are hemorrhaging tens of billions of dollars to fraud, and the federal government is in a position in which it needs to act to contain costs.

During the pilot phase of the program, the RACs collected $1 for every 20 cents spent by the government. “So, if you can get five times the rate of return and you're the federal government, this is a no-brainer,” Mr. Gaines said.

One area of specific concern with the RACs is that they have the power, at least in certain limited circumstances, to extrapolate an error rate across a larger number of Medicare claims. For example, if a RAC finds a 10% error rate on 50 medical records, extrapolation would allow the contractor to apply that error rate across all of a physician's Medicare patients over multiple years—potentially dramatically increasing the penalty.

There are restrictions to that power. For example, it can't be applied during the initial audit phase, and officials at the Centers for Medicare and Medicaid Services have stated that it can only be employed in cases where there is a sustained or a high level of payment error, or a failure to correct the error. In addition, penalties cannot be applied to claims before Oct. 1, 2007.

But the ability to perform extrapolation at all is making physicians uneasy. Although there are restrictions on when extrapolation could be applied, Mr. Gaines said, it's unclear how CMS would put it into practice. And the fact that the RACs would earn contingency fees on extrapolated claims seems to increase the likelihood that the method would be used, he said. “That's where the money is,” he said.

Physicians who are audited by the RAC and have errors in 1 out of 50 charts would likely be at low risk for extrapolation. he said. However, the risk likely is higher for a physician or group that has been subject to audits in the past or been subject to corrective action.

LAS VEGAS — The federal government is stepping up its audit activities in Medicare, and that could mean greater scrutiny of billing practices.

One development that physicians should keep a close eye on is the recent nationwide rollout of Medicare's Recovery Audit Contractor program, said Edward R. Gaines III, vice president and chief compliance officer at CBIZ Medical Management Professionals Inc. The program, known as the RAC, began as a demonstration project in New York, California, and Florida.

Under the program, private contractors are given contingency fees for identifying improper Medicare payments to health care providers, including over- and underpayments.

But Mr. Gaines said the experience in the demonstration project showed that the contractors concentrated much more on detecting overpayments made to providers.

Now that the RAC program has been rolled out nationwide, four private contractors, each assigned to different regions of the country, will use data mining, outlier analysis, and referrals to root out improper payments. The RACs will earn contingency fees for finding errors, with fees that vary from around 9% to 12%.

Physicians need to be aware of the RAC activities and do their own outlier analyses so they can be ready to defend against an audit, Mr. Gaines advised during a meeting on reimbursement sponsored by the American College of Emergency Physicians.

The RACs will look at evaluation and management services. During the demonstration project, evaluation and management services were exempt from audit—but that is not the case now that the RAC is a permanent program.

Medicare is raising the bar for audits because they are in a financial squeeze, Mr. Gaines said.

Right now, Medicare receives more than 1.2 billion medical claims a year—and that's before the bulk of the baby boomer generation has entered the program. Add to that recent news reports that the Medicare and Medicaid programs are hemorrhaging tens of billions of dollars to fraud, and the federal government is in a position in which it needs to act to contain costs.

During the pilot phase of the program, the RACs collected $1 for every 20 cents spent by the government. “So, if you can get five times the rate of return and you're the federal government, this is a no-brainer,” Mr. Gaines said.

One area of specific concern with the RACs is that they have the power, at least in certain limited circumstances, to extrapolate an error rate across a larger number of Medicare claims. For example, if a RAC finds a 10% error rate on 50 medical records, extrapolation would allow the contractor to apply that error rate across all of a physician's Medicare patients over multiple years—potentially dramatically increasing the penalty.

There are restrictions to that power. For example, it can't be applied during the initial audit phase, and officials at the Centers for Medicare and Medicaid Services have stated that it can only be employed in cases where there is a sustained or a high level of payment error, or a failure to correct the error. In addition, penalties cannot be applied to claims before Oct. 1, 2007.

But the ability to perform extrapolation at all is making physicians uneasy. Although there are restrictions on when extrapolation could be applied, Mr. Gaines said, it's unclear how CMS would put it into practice. And the fact that the RACs would earn contingency fees on extrapolated claims seems to increase the likelihood that the method would be used, he said. “That's where the money is,” he said.

Physicians who are audited by the RAC and have errors in 1 out of 50 charts would likely be at low risk for extrapolation. he said. However, the risk likely is higher for a physician or group that has been subject to audits in the past or been subject to corrective action.

The Federal Trade Commission once again has delayed enforcement of the Red Flags Rule, giving physicians until June 1, 2010, before they have to comply with new requirements aimed at preventing identity theft.

The rule, issued by the Federal Trade Commission (FTC) in 2007, most recently had been scheduled to go into effect Nov. 1, 2009. But this is not the first time that the FTC has delayed the enforcement date. The agency has been pushing back enforcement of the rule every few months for about a year.

Congress has been working on a legislative solution to exempt some physician practices and other small businesses from the identity theft requirements. On Oct. 20, the House passed a bill (H.R. 3763) that would exempt physician practices with 20 or fewer employees–as well as small accounting and legal practices–from the Red Flags Rule. The Senate has yet to act on the bill. The rule also is being challenged in court. On Oct. 30, the U.S. District Court for the District of Columbia ruled that the FTC could not apply the regulation to lawyers.

Under the Red Flags Rule, all creditors, including physician practices, must establish a written identify theft–prevention program to protect consumers. The Red Flags Rule requires physician offices and other health care institutions to conduct risk assessments to determine their vulnerabilities to identity theft and respond to those risks.

The FTC has published a list of frequently asked questions about the Red Flags Rule on its Web site at www.ftc.gov/bcp/edu/microsites/redflagsrule/faqs.shtm

The Federal Trade Commission once again has delayed enforcement of the Red Flags Rule, giving physicians until June 1, 2010, before they have to comply with new requirements aimed at preventing identity theft.

The rule, issued by the Federal Trade Commission (FTC) in 2007, most recently had been scheduled to go into effect Nov. 1, 2009. But this is not the first time that the FTC has delayed the enforcement date. The agency has been pushing back enforcement of the rule every few months for about a year.

Congress has been working on a legislative solution to exempt some physician practices and other small businesses from the identity theft requirements. On Oct. 20, the House passed a bill (H.R. 3763) that would exempt physician practices with 20 or fewer employees–as well as small accounting and legal practices–from the Red Flags Rule. The Senate has yet to act on the bill. The rule also is being challenged in court. On Oct. 30, the U.S. District Court for the District of Columbia ruled that the FTC could not apply the regulation to lawyers.

Under the Red Flags Rule, all creditors, including physician practices, must establish a written identify theft–prevention program to protect consumers. The Red Flags Rule requires physician offices and other health care institutions to conduct risk assessments to determine their vulnerabilities to identity theft and respond to those risks.

The FTC has published a list of frequently asked questions about the Red Flags Rule on its Web site at www.ftc.gov/bcp/edu/microsites/redflagsrule/faqs.shtm

The Federal Trade Commission once again has delayed enforcement of the Red Flags Rule, giving physicians until June 1, 2010, before they have to comply with new requirements aimed at preventing identity theft.

The rule, issued by the Federal Trade Commission (FTC) in 2007, most recently had been scheduled to go into effect Nov. 1, 2009. But this is not the first time that the FTC has delayed the enforcement date. The agency has been pushing back enforcement of the rule every few months for about a year.

Congress has been working on a legislative solution to exempt some physician practices and other small businesses from the identity theft requirements. On Oct. 20, the House passed a bill (H.R. 3763) that would exempt physician practices with 20 or fewer employees–as well as small accounting and legal practices–from the Red Flags Rule. The Senate has yet to act on the bill. The rule also is being challenged in court. On Oct. 30, the U.S. District Court for the District of Columbia ruled that the FTC could not apply the regulation to lawyers.

Under the Red Flags Rule, all creditors, including physician practices, must establish a written identify theft–prevention program to protect consumers. The Red Flags Rule requires physician offices and other health care institutions to conduct risk assessments to determine their vulnerabilities to identity theft and respond to those risks.

The FTC has published a list of frequently asked questions about the Red Flags Rule on its Web site at www.ftc.gov/bcp/edu/microsites/redflagsrule/faqs.shtm

The Obama administration wants to combat waste, fraud, and abuse in the Medicare and Medicaid programs and plans to spend more than $500 million to do it.

As part of the administration's budget proposal for fiscal year 2011, the Health and Human Services department is proposing to invest $561 million in discretionary funding to fight health care fraud, a $250 million increase over FY 2010. Specifically, the department plans to expand the Health Care Fraud Prevention and Enforcement Action Team (HEAT), which brings together high-level officials at HHS and the U.S. Department of Justice to spot trends and develop new fraud prevention tools.

HHS said the new funding also would be used to minimize inappropriate payments, pinpoint potential weaknesses in program oversight, and target emerging fraud schemes. Department officials estimate that the efforts to fight fraud and abuse would save $9.9 billion over the next decade.

HHS also expects to squeeze more savings out of the Medicare and Medicaid programs by giving more scrutiny to the provider enrollment process, increasing oversight of claims, improving the data analysis within Medicare, and reducing the overutilization of prescription drugs in Medicaid.

“This budget sends a clear message to those who commit fraud: Stop stealing from seniors and taxpayers or we'll put you behind bars,” Kathleen Sebelius, HHS Secretary, said during a press conference to release the HHS budget proposal.

The FY 2011 budget proposal focuses on fraud prevention, wellness, and building the public health infrastructure. While the budget documents note that the HHS proposal lays the “groundwork” for health reform, it is a stark contrast to last year's proposal, which included a $635 billion “reserve fund” dedicated to health reform over the next decade. With the prospect for passing comprehensive health reform legislation waning, there was a much smaller emphasis on health reform in the current budget proposal.

Ms. Sebelius said that while the current budget proposal tries to increase coverage and curb costs, it would do little to affect the overall trajectory of health care costs if it is not accompanied by health reform legislation. The FY 2011 budget aims to invest in wellness, health information technology, and comparative effectiveness research, but it won't significantly alter the rise in health care costs, fill the coverage gap, or provide security to those with coverage that they can remain insured, she said.

Overall, the Obama administration is seeking $911 billion in funding for HHS in FY 2011, an increase of $51 billion over the current fiscal year. Since the bulk of HHS's funding is tied up in mandatory obligations including Medicare and Medicaid, the budget includes $81 billion in discretionary program spending, an increase of $2.3 billion over last year.

The Obama administration's budget request assumes that Congress will step in to correct the Medicare physician payment formula, known as the Sustainable Growth Rate. At press time, physicians were scheduled to face a 21% across-the-board cut to their Medicare payments as of March 1, unless Congress passes legislation to avert the cut. The budget proposal assumes no growth in Medicare physician payment over the next 10 years, at a cost of $371 billion, Ms. Sebelius said.

The budget request also calls for a $290 million investment in community health centers, bringing their funding to $2.5 billion. The increase should allow the health centers to continue to serve the new patients they began caring for when the centers got an infusion of funding under the American Recovery and Reinvestment Act (stimulus bill) last year. HHS estimates that community health centers will be able to serve more than 20 million patients in FY 2011.

The budget request also calls for nearly $1 billion, an increase of about $33 million, to help shore up the health care workforce. The money will help to expand loan repayment programs for physicians, nurses, and dentists who agree to practice medically underserved areas.

The Obama administration also proposes to spend $4 billion to fund the Food and Drug Administration, with $1.4 billion going toward medical product safety, including drugs, devices, vaccines, and the blood supply. The funding represents an increase of $101 million in FY 2011.

The new money would go toward import safety, high-risk products, and partnerships for patient safety. About $40 million of that new funding is slated to go toward the generic drugs program, including new investments in postmarket drug safety and the establishment of a medical device registry.

The Obama administration wants to combat waste, fraud, and abuse in the Medicare and Medicaid programs and plans to spend more than $500 million to do it.

As part of the administration's budget proposal for fiscal year 2011, the Health and Human Services department is proposing to invest $561 million in discretionary funding to fight health care fraud, a $250 million increase over FY 2010. Specifically, the department plans to expand the Health Care Fraud Prevention and Enforcement Action Team (HEAT), which brings together high-level officials at HHS and the U.S. Department of Justice to spot trends and develop new fraud prevention tools.

HHS said the new funding also would be used to minimize inappropriate payments, pinpoint potential weaknesses in program oversight, and target emerging fraud schemes. Department officials estimate that the efforts to fight fraud and abuse would save $9.9 billion over the next decade.

HHS also expects to squeeze more savings out of the Medicare and Medicaid programs by giving more scrutiny to the provider enrollment process, increasing oversight of claims, improving the data analysis within Medicare, and reducing the overutilization of prescription drugs in Medicaid.

“This budget sends a clear message to those who commit fraud: Stop stealing from seniors and taxpayers or we'll put you behind bars,” Kathleen Sebelius, HHS Secretary, said during a press conference to release the HHS budget proposal.

The FY 2011 budget proposal focuses on fraud prevention, wellness, and building the public health infrastructure. While the budget documents note that the HHS proposal lays the “groundwork” for health reform, it is a stark contrast to last year's proposal, which included a $635 billion “reserve fund” dedicated to health reform over the next decade. With the prospect for passing comprehensive health reform legislation waning, there was a much smaller emphasis on health reform in the current budget proposal.

Ms. Sebelius said that while the current budget proposal tries to increase coverage and curb costs, it would do little to affect the overall trajectory of health care costs if it is not accompanied by health reform legislation. The FY 2011 budget aims to invest in wellness, health information technology, and comparative effectiveness research, but it won't significantly alter the rise in health care costs, fill the coverage gap, or provide security to those with coverage that they can remain insured, she said.

Overall, the Obama administration is seeking $911 billion in funding for HHS in FY 2011, an increase of $51 billion over the current fiscal year. Since the bulk of HHS's funding is tied up in mandatory obligations including Medicare and Medicaid, the budget includes $81 billion in discretionary program spending, an increase of $2.3 billion over last year.

The Obama administration's budget request assumes that Congress will step in to correct the Medicare physician payment formula, known as the Sustainable Growth Rate. At press time, physicians were scheduled to face a 21% across-the-board cut to their Medicare payments as of March 1, unless Congress passes legislation to avert the cut. The budget proposal assumes no growth in Medicare physician payment over the next 10 years, at a cost of $371 billion, Ms. Sebelius said.

The budget request also calls for a $290 million investment in community health centers, bringing their funding to $2.5 billion. The increase should allow the health centers to continue to serve the new patients they began caring for when the centers got an infusion of funding under the American Recovery and Reinvestment Act (stimulus bill) last year. HHS estimates that community health centers will be able to serve more than 20 million patients in FY 2011.

The budget request also calls for nearly $1 billion, an increase of about $33 million, to help shore up the health care workforce. The money will help to expand loan repayment programs for physicians, nurses, and dentists who agree to practice medically underserved areas.

The Obama administration also proposes to spend $4 billion to fund the Food and Drug Administration, with $1.4 billion going toward medical product safety, including drugs, devices, vaccines, and the blood supply. The funding represents an increase of $101 million in FY 2011.

The new money would go toward import safety, high-risk products, and partnerships for patient safety. About $40 million of that new funding is slated to go toward the generic drugs program, including new investments in postmarket drug safety and the establishment of a medical device registry.

The Obama administration wants to combat waste, fraud, and abuse in the Medicare and Medicaid programs and plans to spend more than $500 million to do it.

As part of the administration's budget proposal for fiscal year 2011, the Health and Human Services department is proposing to invest $561 million in discretionary funding to fight health care fraud, a $250 million increase over FY 2010. Specifically, the department plans to expand the Health Care Fraud Prevention and Enforcement Action Team (HEAT), which brings together high-level officials at HHS and the U.S. Department of Justice to spot trends and develop new fraud prevention tools.

HHS said the new funding also would be used to minimize inappropriate payments, pinpoint potential weaknesses in program oversight, and target emerging fraud schemes. Department officials estimate that the efforts to fight fraud and abuse would save $9.9 billion over the next decade.

HHS also expects to squeeze more savings out of the Medicare and Medicaid programs by giving more scrutiny to the provider enrollment process, increasing oversight of claims, improving the data analysis within Medicare, and reducing the overutilization of prescription drugs in Medicaid.

“This budget sends a clear message to those who commit fraud: Stop stealing from seniors and taxpayers or we'll put you behind bars,” Kathleen Sebelius, HHS Secretary, said during a press conference to release the HHS budget proposal.

The FY 2011 budget proposal focuses on fraud prevention, wellness, and building the public health infrastructure. While the budget documents note that the HHS proposal lays the “groundwork” for health reform, it is a stark contrast to last year's proposal, which included a $635 billion “reserve fund” dedicated to health reform over the next decade. With the prospect for passing comprehensive health reform legislation waning, there was a much smaller emphasis on health reform in the current budget proposal.

Ms. Sebelius said that while the current budget proposal tries to increase coverage and curb costs, it would do little to affect the overall trajectory of health care costs if it is not accompanied by health reform legislation. The FY 2011 budget aims to invest in wellness, health information technology, and comparative effectiveness research, but it won't significantly alter the rise in health care costs, fill the coverage gap, or provide security to those with coverage that they can remain insured, she said.

Overall, the Obama administration is seeking $911 billion in funding for HHS in FY 2011, an increase of $51 billion over the current fiscal year. Since the bulk of HHS's funding is tied up in mandatory obligations including Medicare and Medicaid, the budget includes $81 billion in discretionary program spending, an increase of $2.3 billion over last year.

The Obama administration's budget request assumes that Congress will step in to correct the Medicare physician payment formula, known as the Sustainable Growth Rate. At press time, physicians were scheduled to face a 21% across-the-board cut to their Medicare payments as of March 1, unless Congress passes legislation to avert the cut. The budget proposal assumes no growth in Medicare physician payment over the next 10 years, at a cost of $371 billion, Ms. Sebelius said.

The budget request also calls for a $290 million investment in community health centers, bringing their funding to $2.5 billion. The increase should allow the health centers to continue to serve the new patients they began caring for when the centers got an infusion of funding under the American Recovery and Reinvestment Act (stimulus bill) last year. HHS estimates that community health centers will be able to serve more than 20 million patients in FY 2011.

The budget request also calls for nearly $1 billion, an increase of about $33 million, to help shore up the health care workforce. The money will help to expand loan repayment programs for physicians, nurses, and dentists who agree to practice medically underserved areas.

The Obama administration also proposes to spend $4 billion to fund the Food and Drug Administration, with $1.4 billion going toward medical product safety, including drugs, devices, vaccines, and the blood supply. The funding represents an increase of $101 million in FY 2011.

The new money would go toward import safety, high-risk products, and partnerships for patient safety. About $40 million of that new funding is slated to go toward the generic drugs program, including new investments in postmarket drug safety and the establishment of a medical device registry.

BOSTON – Taking a good history and administering a brief cognitive screening test can go a long way toward identifying Alzheimer's disease and other dementias, according to one family physician.

Currently, too many patients with mild to moderate dementia–patients with significant functional impairment–are being missed in the office, according Dr. Kathleen R. Soch, associate professor in the department of family and community medicine at the Texas A&M Health Science Center in Corpus Christi.

But physicians can improve their track records by following a few simple steps: take a complete history, administer the Folstein Mini Mental Status Exam (FMMSE), rule out depression, perform routine laboratory testing, and consider ordering an imaging study, she said at the annual meeting of the American Academy of Family Physicians.

Most physicians know to ask patients and their family members about memory loss, Dr. Soch said, but they do not realize that family members often overlook problems with memory. A family caregiver may think their parent's memory loss is normal for their age and that they are doing well, when in fact the memory impairment could be significant, she said. In those cases, families often come to the office because of the behavioral problems sometimes seen in dementia patients. When taking a history, consider other symptoms such as aphasia, apraxia, agnosia, and problems with executive function.

For patients with symptoms of dementia, Dr. Soch recommends using the FMMSE as a screening tool. The test is one of the most widely used screening tests. It takes less than 10 minutes to complete in the office, and physicians can administer it themselves or train someone else in the office to do it, she said.

The FMMSE is a 30-point test that asks patients to identify where they are, the date and season, repeat words they have heard, recall words, spell a word backward, demonstrate simple language skills, and perform simple tasks. The cut off score is 24, and most people without any cognitive impairment should be able to score 29 or 30 on the test, she said.

The test has a sensitivity of 87% and a specificity of 82%. Most people who have a score of 24 or less will have some form of cognitive impairment, but the test also will miss a lot of people with early dementia, she said. The FMMSE also is less accurate in patients with higher and lower levels of education.

Dr. Soch said if she sees a patient who is very well educated and scores 28 or 29 points, she is more likely to consider a diagnosis of dementia. On the other hand, patients who are unable to read will have trouble with the test regardless of any dementia diagnosis. The test is also less accurate as patients get older. Dr. Soch said she often scores the test more leniently for a patient over age 80 years.

For those patients who score around the 24-point cutoff, Dr. Soch recommends ordering a few simple laboratory screens including CBC, a comprehensive metabolic panel, a test of TSH levels, and a check of the patient's vitamin B₁₂ level to rule out reversible causes. Physicians also should order an imaging test, either a CT scan or MRI, to eliminate other possible conditions such as vascular dementia.

In addition, physicians should screen every patient being assessed for dementia for depression. Depression affects between 30% and 50% of dementia patients. Since depression often presents with fatigue, psychomotor slowing, and apathy, it might be misinterpreted as a worsening of dementia.

Dr. Soch advised physicians to have a high index of suspicion for depression and consider a trial with a selective serotonin reuptake inhibitor. He reported having no conflicts of interest.

BOSTON – Taking a good history and administering a brief cognitive screening test can go a long way toward identifying Alzheimer's disease and other dementias, according to one family physician.

Currently, too many patients with mild to moderate dementia–patients with significant functional impairment–are being missed in the office, according Dr. Kathleen R. Soch, associate professor in the department of family and community medicine at the Texas A&M Health Science Center in Corpus Christi.

But physicians can improve their track records by following a few simple steps: take a complete history, administer the Folstein Mini Mental Status Exam (FMMSE), rule out depression, perform routine laboratory testing, and consider ordering an imaging study, she said at the annual meeting of the American Academy of Family Physicians.

Most physicians know to ask patients and their family members about memory loss, Dr. Soch said, but they do not realize that family members often overlook problems with memory. A family caregiver may think their parent's memory loss is normal for their age and that they are doing well, when in fact the memory impairment could be significant, she said. In those cases, families often come to the office because of the behavioral problems sometimes seen in dementia patients. When taking a history, consider other symptoms such as aphasia, apraxia, agnosia, and problems with executive function.

For patients with symptoms of dementia, Dr. Soch recommends using the FMMSE as a screening tool. The test is one of the most widely used screening tests. It takes less than 10 minutes to complete in the office, and physicians can administer it themselves or train someone else in the office to do it, she said.

The FMMSE is a 30-point test that asks patients to identify where they are, the date and season, repeat words they have heard, recall words, spell a word backward, demonstrate simple language skills, and perform simple tasks. The cut off score is 24, and most people without any cognitive impairment should be able to score 29 or 30 on the test, she said.

The test has a sensitivity of 87% and a specificity of 82%. Most people who have a score of 24 or less will have some form of cognitive impairment, but the test also will miss a lot of people with early dementia, she said. The FMMSE also is less accurate in patients with higher and lower levels of education.

Dr. Soch said if she sees a patient who is very well educated and scores 28 or 29 points, she is more likely to consider a diagnosis of dementia. On the other hand, patients who are unable to read will have trouble with the test regardless of any dementia diagnosis. The test is also less accurate as patients get older. Dr. Soch said she often scores the test more leniently for a patient over age 80 years.

For those patients who score around the 24-point cutoff, Dr. Soch recommends ordering a few simple laboratory screens including CBC, a comprehensive metabolic panel, a test of TSH levels, and a check of the patient's vitamin B₁₂ level to rule out reversible causes. Physicians also should order an imaging test, either a CT scan or MRI, to eliminate other possible conditions such as vascular dementia.

In addition, physicians should screen every patient being assessed for dementia for depression. Depression affects between 30% and 50% of dementia patients. Since depression often presents with fatigue, psychomotor slowing, and apathy, it might be misinterpreted as a worsening of dementia.

Dr. Soch advised physicians to have a high index of suspicion for depression and consider a trial with a selective serotonin reuptake inhibitor. He reported having no conflicts of interest.

BOSTON – Taking a good history and administering a brief cognitive screening test can go a long way toward identifying Alzheimer's disease and other dementias, according to one family physician.

Currently, too many patients with mild to moderate dementia–patients with significant functional impairment–are being missed in the office, according Dr. Kathleen R. Soch, associate professor in the department of family and community medicine at the Texas A&M Health Science Center in Corpus Christi.

But physicians can improve their track records by following a few simple steps: take a complete history, administer the Folstein Mini Mental Status Exam (FMMSE), rule out depression, perform routine laboratory testing, and consider ordering an imaging study, she said at the annual meeting of the American Academy of Family Physicians.

Most physicians know to ask patients and their family members about memory loss, Dr. Soch said, but they do not realize that family members often overlook problems with memory. A family caregiver may think their parent's memory loss is normal for their age and that they are doing well, when in fact the memory impairment could be significant, she said. In those cases, families often come to the office because of the behavioral problems sometimes seen in dementia patients. When taking a history, consider other symptoms such as aphasia, apraxia, agnosia, and problems with executive function.

For patients with symptoms of dementia, Dr. Soch recommends using the FMMSE as a screening tool. The test is one of the most widely used screening tests. It takes less than 10 minutes to complete in the office, and physicians can administer it themselves or train someone else in the office to do it, she said.

The FMMSE is a 30-point test that asks patients to identify where they are, the date and season, repeat words they have heard, recall words, spell a word backward, demonstrate simple language skills, and perform simple tasks. The cut off score is 24, and most people without any cognitive impairment should be able to score 29 or 30 on the test, she said.

The test has a sensitivity of 87% and a specificity of 82%. Most people who have a score of 24 or less will have some form of cognitive impairment, but the test also will miss a lot of people with early dementia, she said. The FMMSE also is less accurate in patients with higher and lower levels of education.

Dr. Soch said if she sees a patient who is very well educated and scores 28 or 29 points, she is more likely to consider a diagnosis of dementia. On the other hand, patients who are unable to read will have trouble with the test regardless of any dementia diagnosis. The test is also less accurate as patients get older. Dr. Soch said she often scores the test more leniently for a patient over age 80 years.

For those patients who score around the 24-point cutoff, Dr. Soch recommends ordering a few simple laboratory screens including CBC, a comprehensive metabolic panel, a test of TSH levels, and a check of the patient's vitamin B₁₂ level to rule out reversible causes. Physicians also should order an imaging test, either a CT scan or MRI, to eliminate other possible conditions such as vascular dementia.

In addition, physicians should screen every patient being assessed for dementia for depression. Depression affects between 30% and 50% of dementia patients. Since depression often presents with fatigue, psychomotor slowing, and apathy, it might be misinterpreted as a worsening of dementia.

Dr. Soch advised physicians to have a high index of suspicion for depression and consider a trial with a selective serotonin reuptake inhibitor. He reported having no conflicts of interest.

Dr. Steve Narang, a pediatric hospitalist in Baton Rouge, La., has a deceptively simple philosophy about delivering care to his patients: He wants them to get the best care available, even if that isn't the latest and supposedly greatest therapy.

Over the last decade, he has worked with his colleagues to apply that philosophy in hospitals in the Baton Rouge area, and he has watched quality of care improve while costs decline. Now he is working with other pediatric hospitalists to spread his quality-improvement approach to hospitals around the country.

“There's a lot of emphasis in our health care system on what is the newest drug, the newest technology,” but very little comparative effectiveness data can be tapped to help physicians judge “what makes something better to use than something else,” said Dr. Narang, who serves as the medical director for quality and safety at Our Lady of the Lake Regional Medical Center in Baton Rouge.

About 2 years ago, Dr. Narang joined forces with four other pediatric hospitalists to launch the Value in Inpatient Pediatrics (VIP) Network. The small, informal steering committee included Dr. Narang, Dr. Matthew D. Garber of the University of South Carolina in Columbia, Dr. Brian M. Pate of the University of Missouri–Kansas City, Dr. Shawn Ralston of the University of Texas Health Science Center in San Antonio, and Dr. Mark Shen of Dell Children's Medical Center of Central Texas in Austin.

The grassroots project had no funding source, but it did have a straightforward goal: “Let's ask people to share their secrets” was how Dr. Narang and the other VIP Network members expressed their intent.

They began by asking hospitals around the country that care for children to report benchmark data on one of the most common diagnoses in hospitalized children—bronchiolitis. They invited the hospitals to provide a mix of process and outcome data about such patients. They sought information on length of stay, utilization of therapies, readmission rates within 72 hours, and variable direct costs for the treatment of children with bronchiolitis. They also asked hospitals to report on the percentage of such patients receiving bronchodilators, steroids, chest x-rays, respiratory syncytial virus antigen testing, and chest physiotherapy.

The project, which is now in its second year, so far has collected data on about 7,000 patients who were treated for bronchiolitis at about 30 hospitals. The hospitals participating in the VIP Network can compare their performance with that of other institutions on a quarterly and annual basis. But the more exciting part, Dr. Narang said, is that hospitals are beginning to form collaboratives within the network, and the best-performing hospitals are sharing how they achieved success.

Dr. Narang said that he hopes that the VIP Network will be able to obtain funding and thereby continue to grow. The network founders are applying for a grant from the Agency for Healthcare Research and Quality, which they would use to hire a paid staff member who could automate and validate the data coming from the hospitals in the network.

Although other organizations are also performing this type of benchmarking work, Dr. Narang said that the VIP Network offers something unique because it does not focus only on freestanding children's hospitals. Approximately 75% of children are cared for outside of freestanding children's hospitals, he noted, so quality data from general hospitals are needed to find the quality gaps.

The other characteristic that makes the VIP Network stand out is that it links process and outcome data, while most databases contain information only on outcomes. “I think the key thing that we're learning in health care is not only do you need outcome measures, you need performance drivers,” Dr. Narang said. “How and why did these things occur?”

'Not only do you need outcome measures, you need performance drivers. How and why did these things occur?'

Dr. Steve Narang, a pediatric hospitalist in Baton Rouge, La., has a deceptively simple philosophy about delivering care to his patients: He wants them to get the best care available, even if that isn't the latest and supposedly greatest therapy.

Over the last decade, he has worked with his colleagues to apply that philosophy in hospitals in the Baton Rouge area, and he has watched quality of care improve while costs decline. Now he is working with other pediatric hospitalists to spread his quality-improvement approach to hospitals around the country.

“There's a lot of emphasis in our health care system on what is the newest drug, the newest technology,” but very little comparative effectiveness data can be tapped to help physicians judge “what makes something better to use than something else,” said Dr. Narang, who serves as the medical director for quality and safety at Our Lady of the Lake Regional Medical Center in Baton Rouge.

About 2 years ago, Dr. Narang joined forces with four other pediatric hospitalists to launch the Value in Inpatient Pediatrics (VIP) Network. The small, informal steering committee included Dr. Narang, Dr. Matthew D. Garber of the University of South Carolina in Columbia, Dr. Brian M. Pate of the University of Missouri–Kansas City, Dr. Shawn Ralston of the University of Texas Health Science Center in San Antonio, and Dr. Mark Shen of Dell Children's Medical Center of Central Texas in Austin.

The grassroots project had no funding source, but it did have a straightforward goal: “Let's ask people to share their secrets” was how Dr. Narang and the other VIP Network members expressed their intent.

They began by asking hospitals around the country that care for children to report benchmark data on one of the most common diagnoses in hospitalized children—bronchiolitis. They invited the hospitals to provide a mix of process and outcome data about such patients. They sought information on length of stay, utilization of therapies, readmission rates within 72 hours, and variable direct costs for the treatment of children with bronchiolitis. They also asked hospitals to report on the percentage of such patients receiving bronchodilators, steroids, chest x-rays, respiratory syncytial virus antigen testing, and chest physiotherapy.

The project, which is now in its second year, so far has collected data on about 7,000 patients who were treated for bronchiolitis at about 30 hospitals. The hospitals participating in the VIP Network can compare their performance with that of other institutions on a quarterly and annual basis. But the more exciting part, Dr. Narang said, is that hospitals are beginning to form collaboratives within the network, and the best-performing hospitals are sharing how they achieved success.

Dr. Narang said that he hopes that the VIP Network will be able to obtain funding and thereby continue to grow. The network founders are applying for a grant from the Agency for Healthcare Research and Quality, which they would use to hire a paid staff member who could automate and validate the data coming from the hospitals in the network.

Although other organizations are also performing this type of benchmarking work, Dr. Narang said that the VIP Network offers something unique because it does not focus only on freestanding children's hospitals. Approximately 75% of children are cared for outside of freestanding children's hospitals, he noted, so quality data from general hospitals are needed to find the quality gaps.

The other characteristic that makes the VIP Network stand out is that it links process and outcome data, while most databases contain information only on outcomes. “I think the key thing that we're learning in health care is not only do you need outcome measures, you need performance drivers,” Dr. Narang said. “How and why did these things occur?”

'Not only do you need outcome measures, you need performance drivers. How and why did these things occur?'

Dr. Steve Narang, a pediatric hospitalist in Baton Rouge, La., has a deceptively simple philosophy about delivering care to his patients: He wants them to get the best care available, even if that isn't the latest and supposedly greatest therapy.

Over the last decade, he has worked with his colleagues to apply that philosophy in hospitals in the Baton Rouge area, and he has watched quality of care improve while costs decline. Now he is working with other pediatric hospitalists to spread his quality-improvement approach to hospitals around the country.

“There's a lot of emphasis in our health care system on what is the newest drug, the newest technology,” but very little comparative effectiveness data can be tapped to help physicians judge “what makes something better to use than something else,” said Dr. Narang, who serves as the medical director for quality and safety at Our Lady of the Lake Regional Medical Center in Baton Rouge.

About 2 years ago, Dr. Narang joined forces with four other pediatric hospitalists to launch the Value in Inpatient Pediatrics (VIP) Network. The small, informal steering committee included Dr. Narang, Dr. Matthew D. Garber of the University of South Carolina in Columbia, Dr. Brian M. Pate of the University of Missouri–Kansas City, Dr. Shawn Ralston of the University of Texas Health Science Center in San Antonio, and Dr. Mark Shen of Dell Children's Medical Center of Central Texas in Austin.

The grassroots project had no funding source, but it did have a straightforward goal: “Let's ask people to share their secrets” was how Dr. Narang and the other VIP Network members expressed their intent.

They began by asking hospitals around the country that care for children to report benchmark data on one of the most common diagnoses in hospitalized children—bronchiolitis. They invited the hospitals to provide a mix of process and outcome data about such patients. They sought information on length of stay, utilization of therapies, readmission rates within 72 hours, and variable direct costs for the treatment of children with bronchiolitis. They also asked hospitals to report on the percentage of such patients receiving bronchodilators, steroids, chest x-rays, respiratory syncytial virus antigen testing, and chest physiotherapy.

The project, which is now in its second year, so far has collected data on about 7,000 patients who were treated for bronchiolitis at about 30 hospitals. The hospitals participating in the VIP Network can compare their performance with that of other institutions on a quarterly and annual basis. But the more exciting part, Dr. Narang said, is that hospitals are beginning to form collaboratives within the network, and the best-performing hospitals are sharing how they achieved success.

Dr. Narang said that he hopes that the VIP Network will be able to obtain funding and thereby continue to grow. The network founders are applying for a grant from the Agency for Healthcare Research and Quality, which they would use to hire a paid staff member who could automate and validate the data coming from the hospitals in the network.

Although other organizations are also performing this type of benchmarking work, Dr. Narang said that the VIP Network offers something unique because it does not focus only on freestanding children's hospitals. Approximately 75% of children are cared for outside of freestanding children's hospitals, he noted, so quality data from general hospitals are needed to find the quality gaps.

The other characteristic that makes the VIP Network stand out is that it links process and outcome data, while most databases contain information only on outcomes. “I think the key thing that we're learning in health care is not only do you need outcome measures, you need performance drivers,” Dr. Narang said. “How and why did these things occur?”

'Not only do you need outcome measures, you need performance drivers. How and why did these things occur?'

Officials at the Centers for Disease Control and Prevention are asking U.S. hospitals to enroll in a new national surveillance system for monitoring adverse events in patients receiving blood transfusions.

The voluntary Hemovigilance Module is the latest addition to the CDC's National Healthcare Safety Network, which allows health care providers to securely submit data on heath care–associated infections via the Internet. Through the network, the CDC provides hospitals with risk-adjusted data to be used for internal comparisons and local quality-improvement activities.

“Health care facilities that join the Hemovigilance Module will now have a yardstick by which to measure their current safety initiatives and their future efforts,” Dr. Dan Pollock, chief of the branch that leads the CDC safety network, said in a statement. “Through this system, health care facilities can also see how their performance stacks up to similar facilities nationwide, with a goal of designing the best processes to protect patients' health and reduce health care costs.”

Previously, hospitals have been left to monitor transfusion-related adverse events on their own, according to the CDC. Hospitals that opt into the new system can submit data confidentially; the CDC, along with some private partners, will use the national data to identify potential strategies to improve transfusion safety.

The CDC is offering the module, training, and user support free of charge.

The module was developed by the CDC and the AABB, an international association representing organizations involved in transfusion and cellular therapies.

The AABB called the launch of the surveillance system an important step forward. “The U.S. is the only developed country that does not have an established method to track and monitor adverse events associated with blood transfusion on a national level,” AABB's CEO Karen Shoos Lipton said in a statement.

More information on the Hemovigilance Module is available online at www.cdc.gov/nhsn/bio.html

Officials at the Centers for Disease Control and Prevention are asking U.S. hospitals to enroll in a new national surveillance system for monitoring adverse events in patients receiving blood transfusions.

The voluntary Hemovigilance Module is the latest addition to the CDC's National Healthcare Safety Network, which allows health care providers to securely submit data on heath care–associated infections via the Internet. Through the network, the CDC provides hospitals with risk-adjusted data to be used for internal comparisons and local quality-improvement activities.

“Health care facilities that join the Hemovigilance Module will now have a yardstick by which to measure their current safety initiatives and their future efforts,” Dr. Dan Pollock, chief of the branch that leads the CDC safety network, said in a statement. “Through this system, health care facilities can also see how their performance stacks up to similar facilities nationwide, with a goal of designing the best processes to protect patients' health and reduce health care costs.”

Previously, hospitals have been left to monitor transfusion-related adverse events on their own, according to the CDC. Hospitals that opt into the new system can submit data confidentially; the CDC, along with some private partners, will use the national data to identify potential strategies to improve transfusion safety.

The CDC is offering the module, training, and user support free of charge.

The module was developed by the CDC and the AABB, an international association representing organizations involved in transfusion and cellular therapies.

The AABB called the launch of the surveillance system an important step forward. “The U.S. is the only developed country that does not have an established method to track and monitor adverse events associated with blood transfusion on a national level,” AABB's CEO Karen Shoos Lipton said in a statement.

More information on the Hemovigilance Module is available online at www.cdc.gov/nhsn/bio.html

Officials at the Centers for Disease Control and Prevention are asking U.S. hospitals to enroll in a new national surveillance system for monitoring adverse events in patients receiving blood transfusions.

The voluntary Hemovigilance Module is the latest addition to the CDC's National Healthcare Safety Network, which allows health care providers to securely submit data on heath care–associated infections via the Internet. Through the network, the CDC provides hospitals with risk-adjusted data to be used for internal comparisons and local quality-improvement activities.

“Health care facilities that join the Hemovigilance Module will now have a yardstick by which to measure their current safety initiatives and their future efforts,” Dr. Dan Pollock, chief of the branch that leads the CDC safety network, said in a statement. “Through this system, health care facilities can also see how their performance stacks up to similar facilities nationwide, with a goal of designing the best processes to protect patients' health and reduce health care costs.”

Previously, hospitals have been left to monitor transfusion-related adverse events on their own, according to the CDC. Hospitals that opt into the new system can submit data confidentially; the CDC, along with some private partners, will use the national data to identify potential strategies to improve transfusion safety.

The CDC is offering the module, training, and user support free of charge.

The module was developed by the CDC and the AABB, an international association representing organizations involved in transfusion and cellular therapies.

The AABB called the launch of the surveillance system an important step forward. “The U.S. is the only developed country that does not have an established method to track and monitor adverse events associated with blood transfusion on a national level,” AABB's CEO Karen Shoos Lipton said in a statement.

More information on the Hemovigilance Module is available online at www.cdc.gov/nhsn/bio.html

The federal government has released its plan to deal with the health consequences associated with major national emergencies such as disease outbreaks, natural disasters, and terrorist attacks.

The newly released National Health Security Strategy (www.hhs.gov/disasters

The plan outlines several objectives including fostering integrated, scalable health care delivery systems; incorporating postincident health recovery into planning and response; maintaining a workforce necessary to respond to health emergencies; and preventing or minimizing emerging threats to health. HHS will update the plan every 2 years to reflect advances in medicine and public health.

Although the National Health Security Strategy was prepared by the federal government, HHS Secretary Kathleen Sebelius said that for the plan to be effective, it requires participation from everyone in the nation.

“As we've learned in the response to the 2009 H1N1 pandemic, responsibility for improving our nation's ability to address existing and emergency health threats must be broadly shared by everyone—governments, communities, families, and individuals,” Ms. Sebelius said in a statement. “The [strategy] is a call to action for each of us so that every community becomes fully prepared and ready to recover quickly after an emergency.”

The new plan provides a framework for physicians, in particular, to begin planning for their response to an emergency, Dr. Georges C. Benjamin, executive director of the American Public Health Association, said in an interview. Looking back at the challenges that physicians faced after Hurricane Katrina, Dr. Benjamin said that many of those obstacles could have been addressed in a systemic way if a strategy such as this one had existed at the time.

This year, HHS officials, with the help of government and external partners, plan to analyze health care workforce levels to identify areas in which there is a shortage when it comes to health security readiness. For example, shortages have already been identified in the number of public health nurses, epidemiologists, and laboratory personnel, according to HHS.

Dr. Benjamin said that workforce shortfalls are a major issue. Although part of the solution will likely involve recruiting more people to the health care field, it will also involve asking clinicians to expand their traditional scope of practice.

Emergency skills also must be taught so that health care providers are ready for the long term, Dr. Benjamin said. That means reexamining graduate medical education to ensure that the full range of practitioners—physicians, nurses, physician assistants, and nurse practitioners—are competent in emergencies, he said. “We've never done that in a comprehensive way in our country. We've been very specialized and silo-based in most of what we do.”

In addition to staying current on emergency skills, physicians also need to consider how a major crisis would affect their practice, Dr. Benjamin advised, adding they should identify the most likely emergency scenarios in their area and think through their role in an emergency. That should include examining employment policies and ensuring safe storage of medical records. They should also plan for the recovery from an emergency, he said. Have a plan for how to get rapidly recredentialed in another hospital or state.

“Good planning for [such] emergencies, for your own needs as well as your family's and your patients' needs, is probably a good thing to do,” he said.

The federal government has released its plan to deal with the health consequences associated with major national emergencies such as disease outbreaks, natural disasters, and terrorist attacks.

The newly released National Health Security Strategy (www.hhs.gov/disasters

The plan outlines several objectives including fostering integrated, scalable health care delivery systems; incorporating postincident health recovery into planning and response; maintaining a workforce necessary to respond to health emergencies; and preventing or minimizing emerging threats to health. HHS will update the plan every 2 years to reflect advances in medicine and public health.

Although the National Health Security Strategy was prepared by the federal government, HHS Secretary Kathleen Sebelius said that for the plan to be effective, it requires participation from everyone in the nation.

“As we've learned in the response to the 2009 H1N1 pandemic, responsibility for improving our nation's ability to address existing and emergency health threats must be broadly shared by everyone—governments, communities, families, and individuals,” Ms. Sebelius said in a statement. “The [strategy] is a call to action for each of us so that every community becomes fully prepared and ready to recover quickly after an emergency.”

The new plan provides a framework for physicians, in particular, to begin planning for their response to an emergency, Dr. Georges C. Benjamin, executive director of the American Public Health Association, said in an interview. Looking back at the challenges that physicians faced after Hurricane Katrina, Dr. Benjamin said that many of those obstacles could have been addressed in a systemic way if a strategy such as this one had existed at the time.

This year, HHS officials, with the help of government and external partners, plan to analyze health care workforce levels to identify areas in which there is a shortage when it comes to health security readiness. For example, shortages have already been identified in the number of public health nurses, epidemiologists, and laboratory personnel, according to HHS.

Dr. Benjamin said that workforce shortfalls are a major issue. Although part of the solution will likely involve recruiting more people to the health care field, it will also involve asking clinicians to expand their traditional scope of practice.

Emergency skills also must be taught so that health care providers are ready for the long term, Dr. Benjamin said. That means reexamining graduate medical education to ensure that the full range of practitioners—physicians, nurses, physician assistants, and nurse practitioners—are competent in emergencies, he said. “We've never done that in a comprehensive way in our country. We've been very specialized and silo-based in most of what we do.”

In addition to staying current on emergency skills, physicians also need to consider how a major crisis would affect their practice, Dr. Benjamin advised, adding they should identify the most likely emergency scenarios in their area and think through their role in an emergency. That should include examining employment policies and ensuring safe storage of medical records. They should also plan for the recovery from an emergency, he said. Have a plan for how to get rapidly recredentialed in another hospital or state.

“Good planning for [such] emergencies, for your own needs as well as your family's and your patients' needs, is probably a good thing to do,” he said.

The federal government has released its plan to deal with the health consequences associated with major national emergencies such as disease outbreaks, natural disasters, and terrorist attacks.

The newly released National Health Security Strategy (www.hhs.gov/disasters

The plan outlines several objectives including fostering integrated, scalable health care delivery systems; incorporating postincident health recovery into planning and response; maintaining a workforce necessary to respond to health emergencies; and preventing or minimizing emerging threats to health. HHS will update the plan every 2 years to reflect advances in medicine and public health.

Although the National Health Security Strategy was prepared by the federal government, HHS Secretary Kathleen Sebelius said that for the plan to be effective, it requires participation from everyone in the nation.

“As we've learned in the response to the 2009 H1N1 pandemic, responsibility for improving our nation's ability to address existing and emergency health threats must be broadly shared by everyone—governments, communities, families, and individuals,” Ms. Sebelius said in a statement. “The [strategy] is a call to action for each of us so that every community becomes fully prepared and ready to recover quickly after an emergency.”

The new plan provides a framework for physicians, in particular, to begin planning for their response to an emergency, Dr. Georges C. Benjamin, executive director of the American Public Health Association, said in an interview. Looking back at the challenges that physicians faced after Hurricane Katrina, Dr. Benjamin said that many of those obstacles could have been addressed in a systemic way if a strategy such as this one had existed at the time.

This year, HHS officials, with the help of government and external partners, plan to analyze health care workforce levels to identify areas in which there is a shortage when it comes to health security readiness. For example, shortages have already been identified in the number of public health nurses, epidemiologists, and laboratory personnel, according to HHS.

Dr. Benjamin said that workforce shortfalls are a major issue. Although part of the solution will likely involve recruiting more people to the health care field, it will also involve asking clinicians to expand their traditional scope of practice.

Emergency skills also must be taught so that health care providers are ready for the long term, Dr. Benjamin said. That means reexamining graduate medical education to ensure that the full range of practitioners—physicians, nurses, physician assistants, and nurse practitioners—are competent in emergencies, he said. “We've never done that in a comprehensive way in our country. We've been very specialized and silo-based in most of what we do.”

In addition to staying current on emergency skills, physicians also need to consider how a major crisis would affect their practice, Dr. Benjamin advised, adding they should identify the most likely emergency scenarios in their area and think through their role in an emergency. That should include examining employment policies and ensuring safe storage of medical records. They should also plan for the recovery from an emergency, he said. Have a plan for how to get rapidly recredentialed in another hospital or state.

“Good planning for [such] emergencies, for your own needs as well as your family's and your patients' needs, is probably a good thing to do,” he said.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders could significantly change the way in which physicians diagnose psychiatric illness by placing a greater emphasis on the severity of patients' symptoms as well as those symptoms that crosscut different disorders.

The current edition of the DSM does not have a good way to account for symptoms that do not fit discretely into a single diagnosis, so the American Psychiatric Association is proposing to add “dimensional assessments” to the standard diagnostic evaluations of mental disorders. This dimensional approach is aimed at helping clinicians take into account symptoms that exist across several diagnoses, such as insomnia or anxiety. APA officials also are hopeful that it could help assess whether a patient is improving with treatment or even provide effective treatment earlier when symptoms are not yet severe.

“One of the challenges we have in accurately diagnosing mental disorders is having an ability to evaluate the full range of symptoms that a given patient presents with,” Dr. Darrel A. Regier, vice chair of the DSM-5 Task Force and director of the division of research at the APA, said during a press briefing to announce the proposed changes.

“A person with schizophrenia may also present with insomnia or symptoms of depression and anxiety, and these aren't a part of the diagnostic criteria for this diagnosis. But they still can affect the patients' lives and affect the treatment planning.”

The APA, which publishes the DSM, released the draft diagnostic criteria on Feb. 10. The proposed revisions were also posted online at www.DSM5.org

This is the first time the DSM has been revised since 1994.

The fifth edition of the DSM also is likely to include numerous changes to specific diagnoses. For the first time, “autism spectrum disorders” will be grouped together into a single diagnostic category. The new category will include the current diagnoses of autistic disorder, Asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified).

“This was done because the work group recognized that the symptoms of these disorders represent a continuum from mild to severe, rather than being distinct disorders,” said Dr. Edwin Cook, a member of the DSM-5 Neurodevelopmental Disorders Work Group and professor of psychiatry and director of Autism and Genetics at the University of Illinois at Chicago.

The proposed criteria for autism spectrum disorders also include a new assessment of symptom severity that is related to the person's degree of impairment. In addition, rather than having the three domains of social impairment, communication impairment, restrictive and repetitive behavior, the draft criteria calls for only two domains: social interaction and communication, and the presence of repetitive behaviors and fixated interests and behaviors. The change was necessary, Dr. Cook said, because the issues of social and communication impairment are so closely related.

Under the proposal, the DSM-5 would remove the term “mental retardation” and instead use the term “intellectual disability,” which is used in other disciplines and by the Department of Education. The proposed DSM also would include only one diagnosis of intellectual disabilities, with severity defined by both IQ and impairments in adaptive functioning.

The DSM-5, as currently proposed, also would eliminate the separate diagnostic categories for substance abuse and dependence, and replace them with a new category called “Addiction and Related Disorders.” Removing the dependence category should help clinicians better differentiate between compulsive drug-seeking behavior, and the normal responses of tolerance and withdrawal when using prescribed medications, according to members of the DSM-5 Task Force.

The DSM-5 proposal also includes a new category for “behavioral addictions.” Currently, gambling is the only disorder included in the category. The work group on Substance-Related Disorders had considered adding “Internet Addiction” to the category but decided that research data were insufficient. Instead, Internet Addiction will be included in the appendix.

Another new category being proposed for the DSM-5 is temper dysregulation with dysphoria (TDD). This would be included in the Mood Disorders section of the DSM. The proposed diagnosis of TDD would include severe, recurrent outbursts of temper that occur three or more times a week, and are grossly out of proportion to the situation and interfere with functioning. The criteria also would include extreme verbal and physical displays of aggression when facing minor demands or stress. Between outbursts, the individual's mood is persistently negative, according to the proposed criteria. Only children over age 6 can be assigned the diagnosis, and symptoms must have begun before age 10.

By adding this new category, clinicians might be able to better differentiate children with TDD symptoms from those with bipolar disorder or oppositional defiant disorder, task force members said.

The DSM-5 Task Force also is considering creating a new category called “Risk Syndromes” aimed at helping clinicians identify people who are higher risk for later developing a serious mental disorder. If the risk syndromes category is included in the final DSM-5, it initially would include two new diagnoses: psychosis risk syndrome (a precursor to psychosis) and minor neurocognitive disorder (a precursor to major neurocognitive disorder or dementia).

The DSM-5 also includes greater recognition for binge-eating disorder. The current proposal would take the disorder out of the appendix, as it is in the current edition, and include it as a specific disorder in the new manual. Since the last edition of the DSM, hundreds of studies have been published on binge-eating disorder, and it's now clear that compared with other individuals with weight problems, those with binge-eating disorder are more distressed and have a lower quality of life, said Dr. B. Timothy Walsh, chair of the Eating Disorders Work Group and a professor of pediatric psychopharmacology at the New York State Psychiatric Institute.

There are also two new suicide scales in the proposed DSM-5, one for adults and one for adolescents.

These scales are designed to be used when evaluating anyone for a mental disorder, regardless of whether thoughts of suicide are one of the symptoms of their condition.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders could significantly change the way in which physicians diagnose psychiatric illness by placing a greater emphasis on the severity of patients' symptoms as well as those symptoms that crosscut different disorders.

The current edition of the DSM does not have a good way to account for symptoms that do not fit discretely into a single diagnosis, so the American Psychiatric Association is proposing to add “dimensional assessments” to the standard diagnostic evaluations of mental disorders. This dimensional approach is aimed at helping clinicians take into account symptoms that exist across several diagnoses, such as insomnia or anxiety. APA officials also are hopeful that it could help assess whether a patient is improving with treatment or even provide effective treatment earlier when symptoms are not yet severe.

“One of the challenges we have in accurately diagnosing mental disorders is having an ability to evaluate the full range of symptoms that a given patient presents with,” Dr. Darrel A. Regier, vice chair of the DSM-5 Task Force and director of the division of research at the APA, said during a press briefing to announce the proposed changes.

“A person with schizophrenia may also present with insomnia or symptoms of depression and anxiety, and these aren't a part of the diagnostic criteria for this diagnosis. But they still can affect the patients' lives and affect the treatment planning.”

The APA, which publishes the DSM, released the draft diagnostic criteria on Feb. 10. The proposed revisions were also posted online at www.DSM5.org

This is the first time the DSM has been revised since 1994.

The fifth edition of the DSM also is likely to include numerous changes to specific diagnoses. For the first time, “autism spectrum disorders” will be grouped together into a single diagnostic category. The new category will include the current diagnoses of autistic disorder, Asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified).

“This was done because the work group recognized that the symptoms of these disorders represent a continuum from mild to severe, rather than being distinct disorders,” said Dr. Edwin Cook, a member of the DSM-5 Neurodevelopmental Disorders Work Group and professor of psychiatry and director of Autism and Genetics at the University of Illinois at Chicago.

The proposed criteria for autism spectrum disorders also include a new assessment of symptom severity that is related to the person's degree of impairment. In addition, rather than having the three domains of social impairment, communication impairment, restrictive and repetitive behavior, the draft criteria calls for only two domains: social interaction and communication, and the presence of repetitive behaviors and fixated interests and behaviors. The change was necessary, Dr. Cook said, because the issues of social and communication impairment are so closely related.

Under the proposal, the DSM-5 would remove the term “mental retardation” and instead use the term “intellectual disability,” which is used in other disciplines and by the Department of Education. The proposed DSM also would include only one diagnosis of intellectual disabilities, with severity defined by both IQ and impairments in adaptive functioning.

The DSM-5, as currently proposed, also would eliminate the separate diagnostic categories for substance abuse and dependence, and replace them with a new category called “Addiction and Related Disorders.” Removing the dependence category should help clinicians better differentiate between compulsive drug-seeking behavior, and the normal responses of tolerance and withdrawal when using prescribed medications, according to members of the DSM-5 Task Force.

The DSM-5 proposal also includes a new category for “behavioral addictions.” Currently, gambling is the only disorder included in the category. The work group on Substance-Related Disorders had considered adding “Internet Addiction” to the category but decided that research data were insufficient. Instead, Internet Addiction will be included in the appendix.

Another new category being proposed for the DSM-5 is temper dysregulation with dysphoria (TDD). This would be included in the Mood Disorders section of the DSM. The proposed diagnosis of TDD would include severe, recurrent outbursts of temper that occur three or more times a week, and are grossly out of proportion to the situation and interfere with functioning. The criteria also would include extreme verbal and physical displays of aggression when facing minor demands or stress. Between outbursts, the individual's mood is persistently negative, according to the proposed criteria. Only children over age 6 can be assigned the diagnosis, and symptoms must have begun before age 10.

By adding this new category, clinicians might be able to better differentiate children with TDD symptoms from those with bipolar disorder or oppositional defiant disorder, task force members said.

The DSM-5 Task Force also is considering creating a new category called “Risk Syndromes” aimed at helping clinicians identify people who are higher risk for later developing a serious mental disorder. If the risk syndromes category is included in the final DSM-5, it initially would include two new diagnoses: psychosis risk syndrome (a precursor to psychosis) and minor neurocognitive disorder (a precursor to major neurocognitive disorder or dementia).

The DSM-5 also includes greater recognition for binge-eating disorder. The current proposal would take the disorder out of the appendix, as it is in the current edition, and include it as a specific disorder in the new manual. Since the last edition of the DSM, hundreds of studies have been published on binge-eating disorder, and it's now clear that compared with other individuals with weight problems, those with binge-eating disorder are more distressed and have a lower quality of life, said Dr. B. Timothy Walsh, chair of the Eating Disorders Work Group and a professor of pediatric psychopharmacology at the New York State Psychiatric Institute.

There are also two new suicide scales in the proposed DSM-5, one for adults and one for adolescents.

These scales are designed to be used when evaluating anyone for a mental disorder, regardless of whether thoughts of suicide are one of the symptoms of their condition.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders could significantly change the way in which physicians diagnose psychiatric illness by placing a greater emphasis on the severity of patients' symptoms as well as those symptoms that crosscut different disorders.

The current edition of the DSM does not have a good way to account for symptoms that do not fit discretely into a single diagnosis, so the American Psychiatric Association is proposing to add “dimensional assessments” to the standard diagnostic evaluations of mental disorders. This dimensional approach is aimed at helping clinicians take into account symptoms that exist across several diagnoses, such as insomnia or anxiety. APA officials also are hopeful that it could help assess whether a patient is improving with treatment or even provide effective treatment earlier when symptoms are not yet severe.

“One of the challenges we have in accurately diagnosing mental disorders is having an ability to evaluate the full range of symptoms that a given patient presents with,” Dr. Darrel A. Regier, vice chair of the DSM-5 Task Force and director of the division of research at the APA, said during a press briefing to announce the proposed changes.

“A person with schizophrenia may also present with insomnia or symptoms of depression and anxiety, and these aren't a part of the diagnostic criteria for this diagnosis. But they still can affect the patients' lives and affect the treatment planning.”

The APA, which publishes the DSM, released the draft diagnostic criteria on Feb. 10. The proposed revisions were also posted online at www.DSM5.org

This is the first time the DSM has been revised since 1994.

The fifth edition of the DSM also is likely to include numerous changes to specific diagnoses. For the first time, “autism spectrum disorders” will be grouped together into a single diagnostic category. The new category will include the current diagnoses of autistic disorder, Asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified).

“This was done because the work group recognized that the symptoms of these disorders represent a continuum from mild to severe, rather than being distinct disorders,” said Dr. Edwin Cook, a member of the DSM-5 Neurodevelopmental Disorders Work Group and professor of psychiatry and director of Autism and Genetics at the University of Illinois at Chicago.

The proposed criteria for autism spectrum disorders also include a new assessment of symptom severity that is related to the person's degree of impairment. In addition, rather than having the three domains of social impairment, communication impairment, restrictive and repetitive behavior, the draft criteria calls for only two domains: social interaction and communication, and the presence of repetitive behaviors and fixated interests and behaviors. The change was necessary, Dr. Cook said, because the issues of social and communication impairment are so closely related.

Under the proposal, the DSM-5 would remove the term “mental retardation” and instead use the term “intellectual disability,” which is used in other disciplines and by the Department of Education. The proposed DSM also would include only one diagnosis of intellectual disabilities, with severity defined by both IQ and impairments in adaptive functioning.

The DSM-5, as currently proposed, also would eliminate the separate diagnostic categories for substance abuse and dependence, and replace them with a new category called “Addiction and Related Disorders.” Removing the dependence category should help clinicians better differentiate between compulsive drug-seeking behavior, and the normal responses of tolerance and withdrawal when using prescribed medications, according to members of the DSM-5 Task Force.

The DSM-5 proposal also includes a new category for “behavioral addictions.” Currently, gambling is the only disorder included in the category. The work group on Substance-Related Disorders had considered adding “Internet Addiction” to the category but decided that research data were insufficient. Instead, Internet Addiction will be included in the appendix.

Another new category being proposed for the DSM-5 is temper dysregulation with dysphoria (TDD). This would be included in the Mood Disorders section of the DSM. The proposed diagnosis of TDD would include severe, recurrent outbursts of temper that occur three or more times a week, and are grossly out of proportion to the situation and interfere with functioning. The criteria also would include extreme verbal and physical displays of aggression when facing minor demands or stress. Between outbursts, the individual's mood is persistently negative, according to the proposed criteria. Only children over age 6 can be assigned the diagnosis, and symptoms must have begun before age 10.

By adding this new category, clinicians might be able to better differentiate children with TDD symptoms from those with bipolar disorder or oppositional defiant disorder, task force members said.

The DSM-5 Task Force also is considering creating a new category called “Risk Syndromes” aimed at helping clinicians identify people who are higher risk for later developing a serious mental disorder. If the risk syndromes category is included in the final DSM-5, it initially would include two new diagnoses: psychosis risk syndrome (a precursor to psychosis) and minor neurocognitive disorder (a precursor to major neurocognitive disorder or dementia).

The DSM-5 also includes greater recognition for binge-eating disorder. The current proposal would take the disorder out of the appendix, as it is in the current edition, and include it as a specific disorder in the new manual. Since the last edition of the DSM, hundreds of studies have been published on binge-eating disorder, and it's now clear that compared with other individuals with weight problems, those with binge-eating disorder are more distressed and have a lower quality of life, said Dr. B. Timothy Walsh, chair of the Eating Disorders Work Group and a professor of pediatric psychopharmacology at the New York State Psychiatric Institute.

There are also two new suicide scales in the proposed DSM-5, one for adults and one for adolescents.

These scales are designed to be used when evaluating anyone for a mental disorder, regardless of whether thoughts of suicide are one of the symptoms of their condition.

U.S. hospitals have significantly improved the care they provide for patients with myocardial infarction, heart failure, and pneumonia, according to a report from the Joint Commission.

Hospitals accredited by the commission are adhering to quality measures for MI patients 96.7% of the time, up from 86.9% just 7 years earlier. The results are part of the Joint Commission's annual report on quality and safety.

The report also highlights major improvements in heart failure and pneumonia. In 2008, hospitals provided evidence-based heart failure care 91.6% of the time, up from 59.7% in 2002. Evidence-based pneumonia care was provided 92.9% of the time in 2008, up from 72.3% in 2002. (See box.)

These national findings are based on aggregated data drawn from all Joint Commission–accredited hospitals between 2002 and 2008. Scores for care for heart failure, for example, are composite scores based on a set of specific quality measures in that area. There is no composite score for surgical care, which is measured according to several subcategories, including antibiotic use. Children's asthma care was surveyed for the first time in 2008, with both subcategories scoring over 99%.

The findings are cause for celebration, according to Jerod M. Loeb, Ph.D., executive vice president for quality measurement and research at the Joint Commission in Oakbrook Terrace, Ill. “This improvement translates into significant enhancements in terms of morbidity and mortality across the conditions that we're measuring,” he said in an interview.

In addition to improvements on several measure sets over time, the report also found that hospitals are getting more consistent. For 8 of the 28 measures that the Joint Commission tracked in 2008, hospitals had consistently high performance. Approximately 90% of hospitals scored 90% or more on those eight measures in 2008.

Despite the successes documented in the report, hospitals are still struggling on a few measures. For example, in 2008, hospitals scored only 52.4% on providing fibrinolytic therapy to heart attack patients within 30 minutes of arrival. Similarly, in 2008, hospitals scored only 60.3% on providing antibiotics to ICU pneumonia patients within 24 hours of arrival. Both of the measures were first introduced in 2005.

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009 is available online at www.jointcommission.org

Vitals

Source Elsevier Global Medical News

U.S. hospitals have significantly improved the care they provide for patients with myocardial infarction, heart failure, and pneumonia, according to a report from the Joint Commission.

Hospitals accredited by the commission are adhering to quality measures for MI patients 96.7% of the time, up from 86.9% just 7 years earlier. The results are part of the Joint Commission's annual report on quality and safety.

The report also highlights major improvements in heart failure and pneumonia. In 2008, hospitals provided evidence-based heart failure care 91.6% of the time, up from 59.7% in 2002. Evidence-based pneumonia care was provided 92.9% of the time in 2008, up from 72.3% in 2002. (See box.)

These national findings are based on aggregated data drawn from all Joint Commission–accredited hospitals between 2002 and 2008. Scores for care for heart failure, for example, are composite scores based on a set of specific quality measures in that area. There is no composite score for surgical care, which is measured according to several subcategories, including antibiotic use. Children's asthma care was surveyed for the first time in 2008, with both subcategories scoring over 99%.

The findings are cause for celebration, according to Jerod M. Loeb, Ph.D., executive vice president for quality measurement and research at the Joint Commission in Oakbrook Terrace, Ill. “This improvement translates into significant enhancements in terms of morbidity and mortality across the conditions that we're measuring,” he said in an interview.

In addition to improvements on several measure sets over time, the report also found that hospitals are getting more consistent. For 8 of the 28 measures that the Joint Commission tracked in 2008, hospitals had consistently high performance. Approximately 90% of hospitals scored 90% or more on those eight measures in 2008.

Despite the successes documented in the report, hospitals are still struggling on a few measures. For example, in 2008, hospitals scored only 52.4% on providing fibrinolytic therapy to heart attack patients within 30 minutes of arrival. Similarly, in 2008, hospitals scored only 60.3% on providing antibiotics to ICU pneumonia patients within 24 hours of arrival. Both of the measures were first introduced in 2005.

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009 is available online at www.jointcommission.org

Vitals

Source Elsevier Global Medical News

U.S. hospitals have significantly improved the care they provide for patients with myocardial infarction, heart failure, and pneumonia, according to a report from the Joint Commission.

Hospitals accredited by the commission are adhering to quality measures for MI patients 96.7% of the time, up from 86.9% just 7 years earlier. The results are part of the Joint Commission's annual report on quality and safety.

The report also highlights major improvements in heart failure and pneumonia. In 2008, hospitals provided evidence-based heart failure care 91.6% of the time, up from 59.7% in 2002. Evidence-based pneumonia care was provided 92.9% of the time in 2008, up from 72.3% in 2002. (See box.)

These national findings are based on aggregated data drawn from all Joint Commission–accredited hospitals between 2002 and 2008. Scores for care for heart failure, for example, are composite scores based on a set of specific quality measures in that area. There is no composite score for surgical care, which is measured according to several subcategories, including antibiotic use. Children's asthma care was surveyed for the first time in 2008, with both subcategories scoring over 99%.

The findings are cause for celebration, according to Jerod M. Loeb, Ph.D., executive vice president for quality measurement and research at the Joint Commission in Oakbrook Terrace, Ill. “This improvement translates into significant enhancements in terms of morbidity and mortality across the conditions that we're measuring,” he said in an interview.

In addition to improvements on several measure sets over time, the report also found that hospitals are getting more consistent. For 8 of the 28 measures that the Joint Commission tracked in 2008, hospitals had consistently high performance. Approximately 90% of hospitals scored 90% or more on those eight measures in 2008.

Despite the successes documented in the report, hospitals are still struggling on a few measures. For example, in 2008, hospitals scored only 52.4% on providing fibrinolytic therapy to heart attack patients within 30 minutes of arrival. Similarly, in 2008, hospitals scored only 60.3% on providing antibiotics to ICU pneumonia patients within 24 hours of arrival. Both of the measures were first introduced in 2005.

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009 is available online at www.jointcommission.org

Vitals

Source Elsevier Global Medical News

Officials at the Centers for Medicare and Medicaid Services recently released an initial set of pediatric quality measures that states can choose to use as part of their Medicaid and the Children's Health Insurance Programs.

The set of 24 measures focuses on prevention and health promotion, immunizations, screening, well-child visits, management of acute and chronic conditions, family experiences with care, and access to services. For example, one of the measures calls for annual hemoglobin A_1c testing in all children and adolescents diagnosed with diabetes.

The measures will be familiar to pediatricians since 14 of the 24 are current NCQA Healthcare Effectiveness Data and Information Set (HEDIS) measures reported by Medicaid managed care plans.

The measures are part of an effort by the federal government to encourage quality reporting within Medicaid and the state Children's Health Insurance Programs (CHIP), but they will be voluntary and the requirements of the program would be up to individual states to determine.

The new measures program was established as part of the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009, which required the federal government to identify a core set of child health quality measures for voluntary use by state programs. The government's charge was to identify existing pediatric measures that are in use by public and private health plans. The initial measure set was developed in consultation with child health care providers, according to CMS.

CMS is seeking public comments on which measures should remain part of the core set, which measures need further development, and what type of technical assistance physicians and other health care providers would need to report on these measures. Comments are due by March 1. Under statute, CMS must make the final measure set available to states by Jan. 1, 2013.

Currently, there is no funding set aside by the federal government to provide financial incentives for successfully reporting on these measures, but CMS and the states are exploring ways that they could encourage voluntary reporting, such as provider incentive payments provided under the American Recovery and Reinvestment Act, according to CMS.

The move to develop pediatric-specific quality measures was praised by the American Academy of Pediatrics. The organization was involved in the creation of the initial measure set and encouraged Congress to invest in the development of measures appropriate for children.

That's definitely an area where pediatrics has fallen behind, said Dr. Stuart A. Cohen, a pediatrician in San Diego and an AAP delegate to the American Medical Association. Right now, pediatric quality measures are mostly built off measures from adult medicine, he said.

There is also a lack of research into what measures would have the greatest impact on quality. Dr. Cohen said that current measurement in pediatrics focuses on areas like immunizations and antibiotic usage, but it's unclear on whether those are the best measures of high-quality pediatric care. He speculated that future research could begin with outcomes of care and work backward to determine what kind of care was given. “We don't have those measures,” he said.

Although details about how the measurement program would be set up by the states are still a ways off, Dr. Cohen said he would like to see an appeals process put in place to ensure that physicians have the opportunity to dispute inaccurate data, a safeguard that is in place in most private pay-for-performance programs.

CMS officials are working on ways to coordinate the measurement program with health information technology activities at the state and federal levels. Under the CHIPRA law that created the quality measures program, CMS was also tasked with developing an electronic health record format specifically for children. CMS officials are working to coordinate that effort, as well as work on the meaningful-use criteria for EHRs, with the quality-measurement program.

Officials at the Centers for Medicare and Medicaid Services recently released an initial set of pediatric quality measures that states can choose to use as part of their Medicaid and the Children's Health Insurance Programs.

The set of 24 measures focuses on prevention and health promotion, immunizations, screening, well-child visits, management of acute and chronic conditions, family experiences with care, and access to services. For example, one of the measures calls for annual hemoglobin A_1c testing in all children and adolescents diagnosed with diabetes.

The measures will be familiar to pediatricians since 14 of the 24 are current NCQA Healthcare Effectiveness Data and Information Set (HEDIS) measures reported by Medicaid managed care plans.

The measures are part of an effort by the federal government to encourage quality reporting within Medicaid and the state Children's Health Insurance Programs (CHIP), but they will be voluntary and the requirements of the program would be up to individual states to determine.

The new measures program was established as part of the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009, which required the federal government to identify a core set of child health quality measures for voluntary use by state programs. The government's charge was to identify existing pediatric measures that are in use by public and private health plans. The initial measure set was developed in consultation with child health care providers, according to CMS.

CMS is seeking public comments on which measures should remain part of the core set, which measures need further development, and what type of technical assistance physicians and other health care providers would need to report on these measures. Comments are due by March 1. Under statute, CMS must make the final measure set available to states by Jan. 1, 2013.

Currently, there is no funding set aside by the federal government to provide financial incentives for successfully reporting on these measures, but CMS and the states are exploring ways that they could encourage voluntary reporting, such as provider incentive payments provided under the American Recovery and Reinvestment Act, according to CMS.

The move to develop pediatric-specific quality measures was praised by the American Academy of Pediatrics. The organization was involved in the creation of the initial measure set and encouraged Congress to invest in the development of measures appropriate for children.

That's definitely an area where pediatrics has fallen behind, said Dr. Stuart A. Cohen, a pediatrician in San Diego and an AAP delegate to the American Medical Association. Right now, pediatric quality measures are mostly built off measures from adult medicine, he said.

There is also a lack of research into what measures would have the greatest impact on quality. Dr. Cohen said that current measurement in pediatrics focuses on areas like immunizations and antibiotic usage, but it's unclear on whether those are the best measures of high-quality pediatric care. He speculated that future research could begin with outcomes of care and work backward to determine what kind of care was given. “We don't have those measures,” he said.

Although details about how the measurement program would be set up by the states are still a ways off, Dr. Cohen said he would like to see an appeals process put in place to ensure that physicians have the opportunity to dispute inaccurate data, a safeguard that is in place in most private pay-for-performance programs.

CMS officials are working on ways to coordinate the measurement program with health information technology activities at the state and federal levels. Under the CHIPRA law that created the quality measures program, CMS was also tasked with developing an electronic health record format specifically for children. CMS officials are working to coordinate that effort, as well as work on the meaningful-use criteria for EHRs, with the quality-measurement program.

Officials at the Centers for Medicare and Medicaid Services recently released an initial set of pediatric quality measures that states can choose to use as part of their Medicaid and the Children's Health Insurance Programs.

The set of 24 measures focuses on prevention and health promotion, immunizations, screening, well-child visits, management of acute and chronic conditions, family experiences with care, and access to services. For example, one of the measures calls for annual hemoglobin A_1c testing in all children and adolescents diagnosed with diabetes.

The measures will be familiar to pediatricians since 14 of the 24 are current NCQA Healthcare Effectiveness Data and Information Set (HEDIS) measures reported by Medicaid managed care plans.

The measures are part of an effort by the federal government to encourage quality reporting within Medicaid and the state Children's Health Insurance Programs (CHIP), but they will be voluntary and the requirements of the program would be up to individual states to determine.

The new measures program was established as part of the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009, which required the federal government to identify a core set of child health quality measures for voluntary use by state programs. The government's charge was to identify existing pediatric measures that are in use by public and private health plans. The initial measure set was developed in consultation with child health care providers, according to CMS.

CMS is seeking public comments on which measures should remain part of the core set, which measures need further development, and what type of technical assistance physicians and other health care providers would need to report on these measures. Comments are due by March 1. Under statute, CMS must make the final measure set available to states by Jan. 1, 2013.

Currently, there is no funding set aside by the federal government to provide financial incentives for successfully reporting on these measures, but CMS and the states are exploring ways that they could encourage voluntary reporting, such as provider incentive payments provided under the American Recovery and Reinvestment Act, according to CMS.

The move to develop pediatric-specific quality measures was praised by the American Academy of Pediatrics. The organization was involved in the creation of the initial measure set and encouraged Congress to invest in the development of measures appropriate for children.

That's definitely an area where pediatrics has fallen behind, said Dr. Stuart A. Cohen, a pediatrician in San Diego and an AAP delegate to the American Medical Association. Right now, pediatric quality measures are mostly built off measures from adult medicine, he said.

There is also a lack of research into what measures would have the greatest impact on quality. Dr. Cohen said that current measurement in pediatrics focuses on areas like immunizations and antibiotic usage, but it's unclear on whether those are the best measures of high-quality pediatric care. He speculated that future research could begin with outcomes of care and work backward to determine what kind of care was given. “We don't have those measures,” he said.

Although details about how the measurement program would be set up by the states are still a ways off, Dr. Cohen said he would like to see an appeals process put in place to ensure that physicians have the opportunity to dispute inaccurate data, a safeguard that is in place in most private pay-for-performance programs.

CMS officials are working on ways to coordinate the measurement program with health information technology activities at the state and federal levels. Under the CHIPRA law that created the quality measures program, CMS was also tasked with developing an electronic health record format specifically for children. CMS officials are working to coordinate that effort, as well as work on the meaningful-use criteria for EHRs, with the quality-measurement program.