Proposed rule from CMS for Stage 2 Meaningful Use of Certified Electronic Health Records (EHR) Technology

The NPUAP Public Policy Committee would like to make the following comments on the proposed rule from CMS for Stage 2 Meaningful Use of Certified Electronic Health Records (HER) Technology. While we commend the inclusion of the current clinical quality measures proposed for eligible hospital and critical access hospitals (CAHs), we recommend the addition of quality measures of pressure ulcer risk and prevention.

The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research. NPUAP is an independent not-for-profit professional organization dedicated to the prevention and management of pressure ulcers. Formed in 1987, the NPUAP Board of Directors is composed of leading experts from different health care disciplines— all of whom share a commitment to the prevention and management of pressure ulcers. The NPUAP serves as a resource to health care professionals, government, the public and health care agencies, provides educational materials, conducts national conferences, and support of efforts in public policy, education and research.

NPUAP defines prevalence as “a proportion of persons who have a pressure ulcer at a specific point in time”.(1) It is estimated that the prevalence of pressure ulcers varies from 10% to 18% in acute care, 2.3% to 28% in long term care, and 0% to 29% in home care. Approximately 2.5 million patients are treated for pressure ulcers in U.S. acute care facilities each year and as many as 60,000 U.S. hospital patients die each year from pressure ulcer complications.(2) Development of a stage 3 or 4 pressure ulcer during a hospital stay is considered a Serious Reportable Event.(3)

Another serious concern is the increased incidence of pressure ulcers in hospitals. From 1993 to 2006, there was a 78.9% increase in the number of hospital stays during which pressure ulcers were noted. Stays with a secondary diagnosis of pressure ulcers increased by 86.4% during this period, while stays principally for pressure ulcers increased by 27.2%. Adult hospital stays noting a diagnosis of pressure ulcers totaled $11.0 billion in 2006.(4) Since Medicare was the most common payer of adult stays related to pressure ulcers, this represents a great financial burden on the US health care system.

The following initiatives and programs have listed pressure ulcer prevention and treatment as a priority concern:

• Partnership for Patients Areas of Focus(5)
• National Quality Forum’s Serious Reportable Events (SREs)(6)
• Joint Commission Pressure Ulcer Prevention Project(7)
• Center for Medicare and Medicaid serious Hospital Acquired Conditions(HACs)(8)
• Agency for Healthcare Research and Quality: Preventing Pressure Ulcers in Hospitals—A Toolkit for Improving Quality of Care(9)
• HL7 Patient Care Work Group Pressure Ulcer Standards for Assessment and Prevention(10)
• The 2010 National Patient Safety Goals (11) Goal 14: Prevent health-care associated pressure ulcers (decubitus ulcers)
• National Pressure Ulcer Advisory Council(12) Pressure Ulcer Stages
• Academy of Nutrition and Dietetics Evidence Analysis Library: Unintended Weight Loss (UWL) in Older Adults(13)

The Agency for Healthcare Research and Quality (AHRQ) and the National Quality Forum (NQF) have endorsed numerous quality measures relating to pressure ulcer prevention and treatment.(14,15)

Screening for pressure ulcer risk and appropriate intervention for treatment of pressure ulcers are important components in wound healing and maintenance of tissue integrity. It is important that the skin integrity and interventions are communicated as patients move across the continuum of care. Standardization of patient information exchange has the potential for improving patient safety and clinical outcomes

NPUAP recommends the addition of Clinical Quality Measures (CQM) for both prevention and treatment of pressure ulcers in the Stage 2 regulations under the domains of Patient Safety, Care Coordination, Efficient Use of Healthcare Resources and Clinical Process/Effectiveness.

NPUAP requests the following objectives:

1. Inclusion of interdisciplinary assessment and treatment goals for pressure ulcers as mandatory for both Eligible Professionals (EP) and Eligible Hospitals (EH).
2. The EP, EH or CAH that transitions a patient to another setting of care or provider of care or refers that patient to another provider of care should provide summary care records for each transition of care or referral.
3. EP: Provide clinical summaries for patients for each office visit.
4. Generate lists of patients who have documented pressure ulcers on admission to EH or CAH.
5. Documentation of appropriate stage of existing pressure ulcers, at admission and on discharge, using a formal wound classification guideline.
6. Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP or for the EH. Provide patients the ability to view online, download, and transmit information about a hospital admission.
7. Use clinically relevant information from Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient.
8. Document treatment plan of care for patients with existing pressure ulcers and those at high risk for developing pressure ulcers.
9. Document pressure ulcer risk assessment.

In summation, patient care suffers from incomplete, inaccessible and inconsistent use of pressure ulcer assessment and treatment plans. Inclusion of these as a component of the next iteration of EHRs will serve to improve patient care and communication among health care providers. This can also provide transparency and needed information for patients and caregivers once they are given access to the EHR. An additional benefit to the health system is an avenue to develop quality surveillance and initiatives. Thank you for the opportunity to offer comments on the CMS proposed regulations for Stage 2 Meaningful Use of Certified Electronic Health Records (EHR) Technology.