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Ask the Expert
| Author: Dr. Sheila Dunn |
| Article Date: 3/15/2008 |
CLIA-waived CBC?
Q. Did a CLIA-waived CBC ever materialize?
A. The Complete Blood Count group of hematology tests have never achieved the coveted CLIA-waived status. At this writing, a WBC test is currently under FDA consideration for CLIA- waiver. The HemoCue¨ White Blood Cell (WBC) Analyzer is a whole-blood test performed on finger-stick samples which provides a WBC count, s a small part of a CBC often indicating infection. The analyzer was recently purchased by Quest Diagnostics, Inc. (Madison, NJ).
Physician Fee Schedule
Q. Physicians were supposed to get a 10% pay cut in 2008. Did it go into effect, and if so, when? Does it include in-house lab testing payments too?
A. Every year, physicians are slated for Medicare payment slashes but always at the eleventh hour, Congress rides in with their white hats and rolls back the pay cuts for another year.
Unlike previous years, this time Congress gave physicians only a 6-month reprieve, keeping the entire healthcare industry in suspense until June 30, 2008. Perhaps it had something to do with a recent New York Times article blaming physician salaries for the nation's rising healthcare costs. U.S. doctors earn two to three times more than doctors from other industrialized countries, the Times reported.
The Times also blamed physician payment systems for spiraling healthcare costs; instead of a flat rate for services rendered as in many other countries, doctors are paid based on the amount of services that they provide, leading to unnecessary procedures performed Òfor financial incentives.Ó (EditorÕs Note: I wonder if overseas physicians have 6 figure tuition bills or whether TV Òdirect to consumerÓ ads urge patients to ÒAsk your doctorÓ about some obscure disease that they may need treatment forÉ..donÕt get me started!)
It remains to be seen whether Congress will forestall the slated 2008 pay cut in June. My guess is that Congress will grant physicians another reprieve from pay cuts until the end of the year, so that itÕs fresh in their minds at election time.
Luckily, lab tests performed in physician offices are billed under a totally separate fee schedule and payments have remained flat for years.
Disinfecting Equipment
Q. What should we use to disinfect equipment, such as electrocardiographs?
A. If the equipment is in an area where it could be splashed or sprayed with patient body fluids, then clean it with an EPA-approved hospital level disinfectant. If not, then clean it to remove dust and surface dirt with any type of cleanser after consulting the manufacturerÕs instructions.
Heed the advice, though, from an Oct. 31, 2007 warning from OSHA, FDA, CDC, and the EPA about disinfectants used with electronic medical equipment: Using excessive cleaning and disinfectant liquids on certain electronic medical equipment may cause equipment fires and other damage, equipment malfunctions, and healthcare worker burns. The warning is for equipment with unsealed electronic circuitry or components, including computer workstations, handheld devices, and other monitoring equipment. Here are some tips to stay safe when disinfecting electronic medical equipment:
Identify unsealed equipment. Review the labeling for any cautions, precautions, or warnings about wetting, immersing, or soaking the equipment.
Ensure all staff are trained and will follow the manufacturerÕs cleaning and maintenance instructions.
Protect equipment from contamination whenever possible. Position equipment to minimize contamination. Use barriers on equipment surfaces that are touched with contaminated gloved hands or when contact with spatter canÕt be avoided.
If equipment contamination is suspected, clean equipment surfaces in accordance with instructions from both the equipment manufacturer and the cleaning chemical manufacturer. Adhere strictly to all the chemical manufacturerÕs warnings, precautions, and cautions, and carefully follow all directions for use. ItÕs actually illegal to use a disinfectant in a manner inconsistent with its labeling. When a disinfectant labeled for immersion is applied by wiping or spraying, disinfection may not result, especially if the product doesnÕt remain wet for the required contact time.
Source: www.fda.gov/cdrh/safety/103107-cleaners.html
Is a rapid HIV test required after exposure?
Q. WeÕve never had a needlestick and donÕt perform rapid HIV tests for other reasons. Our management says having kits expire is wasting too much money. Do we actually have to perform a rapid HIV test on a source patient after an exposure incident?
A. Yes, you do need to perform rapid HIV tests after an employee exposure (Bloodborne Pathogens Standard, 1910.1030(f)(3)(ii)(A)). But in your setting, it makes sense to send blood samples to a referral laboratory in your vicinity that performs STAT HIV tests, such as the local health department or hospital lab.
Flu test survey
Q. I understand that the government will soon survey physician offices about flu testing. What do they want to know?
A. CDC wants to know the current extent and quality of rapid flu tests performed outside the clinical laboratory, since influenza kills about 36,000 people in the US each year. So, the Agency funded the Joint Commission to survey 5,000 outpatient settings to find:
* Types of tests in use
* How the tests are selected
* Training/competency of those that perform tests
* How closely laboratory practices and testing guidelines are followed
* Impact on antibiotic/antiviral prescribing
* Advantages and disadvantages of rapid testing
Previous Joint Commission surveys found that test controls are not always used; test kits are improperly stored and sometimes used past their expiration date; individuals conducting the tests are not always trained or evaluated and deemed to be competent to conduct or interpret the test; staff within organizations are confused about the use of confirmatory tests and whether the flu test is done for screening purposes or for definitive diagnosis; and there were insufficient policies and procedures in place to support conducting the tests.Ê
CDC is also interested in evaluating the extent to which outpatient testing sites are linked to their local public health system.
Physicians and EMRs
Q. Do you know the percent of office-based physicians who have purchased electronic medical records?
A. The latest published data that I could find is from the National Ambulatory Medical Care Survey (NAMCS) and it indicates that one-quarter of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2005. The only caveat is that if EMR features that experts consider to be the minimal requirements of a complete EMR are considered, such as computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes, though, only one in ten of the physicians surveyed was considered to be using EMRs.
In physicianÕs offices, the most common use of IT is electronic billing (73%), followed by EMRÕs (17%). Only 8% of physiciansÕ offices have adopted computerized order entry systems (CPOE). Earlier studies indicated that physicians younger than 50 were more likely to adopt IT systems in their offices than their older colleagues, but the most recent study (2007, unpublished results) found no correlation between EMR use and physician age. In this survey of 1600 physicians, solo practitioners were the least likely to use EMRs. Overall, this survey found that 22% of MDÕs use a full EMR, 17% a partial EMR and 61% use no EMR.
The main objections physicians have to purchasing IT systems are:
* Cost of acquire
* Time and cost to train staff
* Changes in work flow
Differences in technical standards and features among more than 100 software vendors hamper doctors' ability to exchange patient data with other physicians and hospitals. (Uncle Sam encourages the IT industry to settle on software standards and features so the data can be easily exchanged, but this hasnÕt happened yet).
Physicians are data-driven and conservative, and when WellPoint Inc. offered 25,000 of its high-volume physicians in California, Georgia, Missouri and Wisconsin a choice of either free computers to submit claims electronically or PDAs for writing e-prescriptions, one quarter passed up the offer! One physician said: ÓGetting to electronic medical records is like going to paradise, but you have to walk through a bed of hot coals to get thereÓ.
Q. Did a CLIA-waived CBC ever materialize?
A. The Complete Blood Count group of hematology tests have never achieved the coveted CLIA-waived status. At this writing, a WBC test is currently under FDA consideration for CLIA- waiver. The HemoCue¨ White Blood Cell (WBC) Analyzer is a whole-blood test performed on finger-stick samples which provides a WBC count, s a small part of a CBC often indicating infection. The analyzer was recently purchased by Quest Diagnostics, Inc. (Madison, NJ).
Physician Fee Schedule
Q. Physicians were supposed to get a 10% pay cut in 2008. Did it go into effect, and if so, when? Does it include in-house lab testing payments too?
A. Every year, physicians are slated for Medicare payment slashes but always at the eleventh hour, Congress rides in with their white hats and rolls back the pay cuts for another year.
Unlike previous years, this time Congress gave physicians only a 6-month reprieve, keeping the entire healthcare industry in suspense until June 30, 2008. Perhaps it had something to do with a recent New York Times article blaming physician salaries for the nation's rising healthcare costs. U.S. doctors earn two to three times more than doctors from other industrialized countries, the Times reported.
The Times also blamed physician payment systems for spiraling healthcare costs; instead of a flat rate for services rendered as in many other countries, doctors are paid based on the amount of services that they provide, leading to unnecessary procedures performed Òfor financial incentives.Ó (EditorÕs Note: I wonder if overseas physicians have 6 figure tuition bills or whether TV Òdirect to consumerÓ ads urge patients to ÒAsk your doctorÓ about some obscure disease that they may need treatment forÉ..donÕt get me started!)
It remains to be seen whether Congress will forestall the slated 2008 pay cut in June. My guess is that Congress will grant physicians another reprieve from pay cuts until the end of the year, so that itÕs fresh in their minds at election time.
Luckily, lab tests performed in physician offices are billed under a totally separate fee schedule and payments have remained flat for years.
Disinfecting Equipment
Q. What should we use to disinfect equipment, such as electrocardiographs?
A. If the equipment is in an area where it could be splashed or sprayed with patient body fluids, then clean it with an EPA-approved hospital level disinfectant. If not, then clean it to remove dust and surface dirt with any type of cleanser after consulting the manufacturerÕs instructions.
Heed the advice, though, from an Oct. 31, 2007 warning from OSHA, FDA, CDC, and the EPA about disinfectants used with electronic medical equipment: Using excessive cleaning and disinfectant liquids on certain electronic medical equipment may cause equipment fires and other damage, equipment malfunctions, and healthcare worker burns. The warning is for equipment with unsealed electronic circuitry or components, including computer workstations, handheld devices, and other monitoring equipment. Here are some tips to stay safe when disinfecting electronic medical equipment:
Identify unsealed equipment. Review the labeling for any cautions, precautions, or warnings about wetting, immersing, or soaking the equipment.
Ensure all staff are trained and will follow the manufacturerÕs cleaning and maintenance instructions.
Protect equipment from contamination whenever possible. Position equipment to minimize contamination. Use barriers on equipment surfaces that are touched with contaminated gloved hands or when contact with spatter canÕt be avoided.
If equipment contamination is suspected, clean equipment surfaces in accordance with instructions from both the equipment manufacturer and the cleaning chemical manufacturer. Adhere strictly to all the chemical manufacturerÕs warnings, precautions, and cautions, and carefully follow all directions for use. ItÕs actually illegal to use a disinfectant in a manner inconsistent with its labeling. When a disinfectant labeled for immersion is applied by wiping or spraying, disinfection may not result, especially if the product doesnÕt remain wet for the required contact time.
Source: www.fda.gov/cdrh/safety/103107-cleaners.html
Is a rapid HIV test required after exposure?
Q. WeÕve never had a needlestick and donÕt perform rapid HIV tests for other reasons. Our management says having kits expire is wasting too much money. Do we actually have to perform a rapid HIV test on a source patient after an exposure incident?
A. Yes, you do need to perform rapid HIV tests after an employee exposure (Bloodborne Pathogens Standard, 1910.1030(f)(3)(ii)(A)). But in your setting, it makes sense to send blood samples to a referral laboratory in your vicinity that performs STAT HIV tests, such as the local health department or hospital lab.
Flu test survey
Q. I understand that the government will soon survey physician offices about flu testing. What do they want to know?
A. CDC wants to know the current extent and quality of rapid flu tests performed outside the clinical laboratory, since influenza kills about 36,000 people in the US each year. So, the Agency funded the Joint Commission to survey 5,000 outpatient settings to find:
* Types of tests in use
* How the tests are selected
* Training/competency of those that perform tests
* How closely laboratory practices and testing guidelines are followed
* Impact on antibiotic/antiviral prescribing
* Advantages and disadvantages of rapid testing
Previous Joint Commission surveys found that test controls are not always used; test kits are improperly stored and sometimes used past their expiration date; individuals conducting the tests are not always trained or evaluated and deemed to be competent to conduct or interpret the test; staff within organizations are confused about the use of confirmatory tests and whether the flu test is done for screening purposes or for definitive diagnosis; and there were insufficient policies and procedures in place to support conducting the tests.Ê
CDC is also interested in evaluating the extent to which outpatient testing sites are linked to their local public health system.
Physicians and EMRs
Q. Do you know the percent of office-based physicians who have purchased electronic medical records?
A. The latest published data that I could find is from the National Ambulatory Medical Care Survey (NAMCS) and it indicates that one-quarter of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2005. The only caveat is that if EMR features that experts consider to be the minimal requirements of a complete EMR are considered, such as computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes, though, only one in ten of the physicians surveyed was considered to be using EMRs.
In physicianÕs offices, the most common use of IT is electronic billing (73%), followed by EMRÕs (17%). Only 8% of physiciansÕ offices have adopted computerized order entry systems (CPOE). Earlier studies indicated that physicians younger than 50 were more likely to adopt IT systems in their offices than their older colleagues, but the most recent study (2007, unpublished results) found no correlation between EMR use and physician age. In this survey of 1600 physicians, solo practitioners were the least likely to use EMRs. Overall, this survey found that 22% of MDÕs use a full EMR, 17% a partial EMR and 61% use no EMR.
The main objections physicians have to purchasing IT systems are:
* Cost of acquire
* Time and cost to train staff
* Changes in work flow
Differences in technical standards and features among more than 100 software vendors hamper doctors' ability to exchange patient data with other physicians and hospitals. (Uncle Sam encourages the IT industry to settle on software standards and features so the data can be easily exchanged, but this hasnÕt happened yet).
Physicians are data-driven and conservative, and when WellPoint Inc. offered 25,000 of its high-volume physicians in California, Georgia, Missouri and Wisconsin a choice of either free computers to submit claims electronically or PDAs for writing e-prescriptions, one quarter passed up the offer! One physician said: ÓGetting to electronic medical records is like going to paradise, but you have to walk through a bed of hot coals to get thereÓ.