Tech Remedies for Regulatory Compliance

How technology eases regulatory burdens, helps providers work smarter, and improves clinical quality.

This article first appeared in the October 2016 issue of HealthLeaders magazine.

Clinical quality measures that are being scrutinized by the Centers for Medicare & Medicaid Services and The Joint Commission are driving providers to work smarter, not just harder, to meet ever-increasing regulatory burdens, and technology is playing its part.

Those regulatory burdens also include reporting data breaches, a category recently clarified by CMS to include ransomware attacks; meaningful use stage 3, which takes effect for some healthcare systems in 2017 and others in 2018; and the Medicare Access and CHIP Reauthorization Act (MACRA), which is also scheduled to commence in 2017 and is CMS' main vehicle for moving healthcare from volume-based to value-based reimbursement.

Quality rules
At Halifax Health, whose main 678-bed medical center is based in Daytona Beach, Florida, director of quality improvement Suzanne Lovelady has turned to technology to automate manual paper rounding, as well as to meet Joint Commission survey readiness objectives.

"We are definitely measuring more," Lovelady says. "When I first went into quality improvement 15 years ago, I could count on one hand the projects that were ongoing. Now it fills up a couple of whiteboards. So the number of projects has grown, and also the scope of those projects is much greater."

Key drivers of these quality reports include patient safety and outcomes. Halifax Health replaced paper-based written observations with software from ReadyPoint to speed preparation of these observation findings and facilitate dissemination of these among its staff through a system replacing numerous, time-consuming meetings or face-to-face conversations.

Technology is a necessary but not sufficient part of making such a transition work, Lovelady says.

"The team that is doing these rounds still has to be familiar enough with the standards to know how to interpret them, any of the regulatory guidelines they're monitoring," she says. "Having some sort of electronic tool that will also allow that team to have those standards at their fingertips as they're rounding is key. If a staff member approaches me [with a question about] how come something isn't compliant—maybe having a cart in a hallway is the issue from a safety perspective—the team can pull up that standard on the spot and show it to them, exactly why we're saying it's not compliant, which is key." The software also utilizes mobile devices carried by the compliance team to capture and present photos documenting noncompliant practices.

Immediately following noncompliant incidents, the software allows Lovelady's team to push out emails to staff leaders, who can then work on corrective action plans even before the compliance team has left the scene, she says. "Once we're done with our rounds, there's no more hours spent on my team's end to come up with our findings, and put it into some sort of understandable format for the rest of the organization. So that's how realtime our compliance efforts and our improvement efforts can be."

Since the initiative has only been in place for three months, it is still too early to tell precisely how much better overall staff compliance is, Lovelady says.

As CMS increases the amount of electronic reporting of clinical quality measures (eCQMs), Lovelady admits that, at times, she and other providers are at the mercy of the electronic health record software vendors to implement this new compliance mandate.

"I believe, and I hear from some of my colleagues in other hospitals that have different platforms, that all EHRs have their shortcomings" in reporting eCQMs, Lovelady says. In addition, EHRs still struggle to pull information from these measurements into clinical decision support workflows, she adds.

Another technology component Halifax uses helps with reporting to The Joint Commission's ongoing professional practice evaluation (OPPE). Since the reporting pulls from four different EHR systems, Halifax recently adopted technology from Acmeware to pull data from data registries in each EHR, Lovelady says.

Clinical decision support and analytics help
"We're being faced with more and more regulatory requirements," says Mary Beth Mitchell, chief nursing informatics officer at Texas Health Resources, a 29-hospital system headquartered in Arlington, Texas. "One of our first challenges is that they don't always align. So you might be reporting the same measure to multiple agencies, but not in the same way. I can think of a couple of agencies that don't always look at things the same way. They try, and they're working at getting more aligned, but still today we're faced with reporting the same data in more than one way."

At Texas Health, a public dashboard shows all key CMS-related quality measures and how they compare to other hospitals across Texas and the United States, Mitchell says. But even here, there may be slight variances in how measures are reported, which could explain why a competitor might score higher or lower than Texas Health, she adds.

"Even more fundamental than that, technology is a critical necessary component to this," Mitchell says. "We absolutely could not keep up with everything if we did not have technology to support it, and if we did not have clinical decision support to help monitor, provide reminders, and to do alerts and comparisons."

A major direction is to enable more and more of these technology-driven processes, and the predictive analytics they can enable, to run in the background and present themselves at appropriate times, yet not force clinicians to constantly read alerts, "though there is still a lot of that," Mitchell says. "When you get a stroke patient in, or a cardiac patient, I believe you need those reminders."

Now, like other providers, Texas Health must also pivot from volume to value. To meet the many new compliance requirements as part of that change, Texas Health created its Reliable Care Blueprinting initiative, "where we are creating standards for different types of care and making sure everything is done the same way for every patient every time," Mitchell says. As part of this initiative, quality efforts must align with compliance mandates such as what we've done with our bundle care program for joint replacement (the Comprehensive Care for Joint Replacement model), she adds.

Leadership remains challenged by the overwhelming amount of change compliance represents to nurses and other clinicians.

"Within the staff nursing area, it's just seen as a lot of change coming at them too fast, and I agree it's becoming a real issue for them," Mitchell says. "I think technology can help, if we can start doing more things that run in the background that take less intervention on the part of the nurse."

For example, Mitchell says she would like to replace nurse requirements to take patient vital signs every four hours with wearable devices that can continuously monitor heart rate and respiratory rate, in order to detect conditions such as sepsis, and bring this to the attention of nurses earlier. "It's something I'm just starting to work on, and it is a challenge and somewhat risky to try unproven technology," she says.

Giving radiologists the compliance value proposition
For far too many clinicians, the many compliance initiatives already in place and those being added to the workload just seem a never-ending grind of checking boxes, even though the original intentions of CMS, The Joint Commission, and others to improve clinical quality seem far removed from that box-checking.

Executives push forward anyway, and realize that communicating the why of compliance is just as important, if not more so, than the what.

"At least for our company, what we're most concerned about is the new legislation that is going to tie our pay to performance, so what we're trying to wrap our heads around is how can we position ourselves so that we can maximize our reimbursement from the Merit-Based Incentive Payment System," says Stephen Holtzman, MD, CEO of the 100-employee Radiology Associates of San Luis Obispo in California, and providing imaging services in two area hospitals and four imaging centers.

"One of the changes we've made recently is for all needle-based procedures—whether it's inpatient or outpatient—we follow a detailed safety checklist," Holtzman says. "The concept is that you really want to prevent even the smallest adverse effects. So The Joint Commission really is out there trying to do things to improve quality and patient safety.

"The disconnect is that it's not explained why this needs to happen. It's just a box that you need to check. It's seen as a waste from the perspective of the provider, and they feel that it's taking them away from doing their care. I think The Joint Commission could do themselves, their patients, and their providers a huge favor if they've really invested upfront in explaining the why."

That said, Holtzman says he is "a huge believer in continuous quality improvement." Using technology from Merge Healthcare, the organization's seven radiologists are able to suggest improvements to quality and safety on a daily basis, he says.

These improvements manifest themselves when radiologists, in the midst of reading a case within Radiology Associates' picture archiving and communication system, make suggestions that find their way into the pop-up templates that guide radiologists through the radiology reporting process, Holtzman says.

"There is no such thing as 100% compliance or 100% security, but prudent organizations and people put forth ongoing good-faith effort to be on top of both. The changing and dynamic threat landscape demands it."

"Our target is to implement 10 improvements on our templates every single day," he says. "One of the current PQRS measures that's going to be converted to MIPS is documenting the number of images you take. It's a surrogate for how much radiation exposure the patient receives. You can't sign off on the report unless you've documented the number of images. The requirement is basically to get people thinking about radiation exposure."

Security compliance remains a challenge
One area where mere compliance with regulations falls short of the ultimate goal of any healthcare organization has to be security and privacy of electronic patient information.

"Oftentimes people feel that if you're compliant, you must be, by definition, secure," says Bob Chaput, founder and CEO of Clearwater Compliance, a Nashville supplier of compliance and cyber-risk services. "It's not true. Similarly, you can be very secure but not compliant with certain regulations. So we encourage organizations to think about not only those two risks, which are inextricably linked, but also about other risks with which they're linked or they may trigger. For example, financial risk or reputational risk, or the risk if you don't have the ability to attract and retain talented people."

"There is no such thing as 100% compliance or 100% security, but prudent organizations and people put forth ongoing good-faith effort to be on top of both," Chaput says. "The changing and dynamic threat landscape demands it."