These comments on the proposed rule to revise the requirements that hospitals and critical access hospitals must meet to participate in the Medicare and Medicaid programs are submitted on behalf of the Medical Library Association (MLA).
MLA’s Strategic Plan calls for the association and its members to serve society by promoting the use of scientific evidence in making healthcare decisions and improving the public’s awareness of, access to, and use of quality health information. Accordingly, the association believes that health sciences librarians have a key role to play in supporting the provisions of the proposed regulations in the effort “to reduce burden, maximize patient safety, and reflect current industry standards.”
MLA’s comments address proposed changes to the CoP section and medical records services CoP that would allow hospitals to use standing orders as long as certain provisions were met. Specifically, we address the proposed “new provisions to Section 482.24(c) (3) that would allow a hospital to use pre-printed and electronic standing orders, order sets, and protocols for patient orders only if the hospital:… (2) demonstrates that such orders and protocols are consistent with nationally recognized and evidence-based guidelines; (3) ensures that the periodic and regular review of such orders and protocols is conducted by the medical staff, in consultation with the hospital’s nursing and pharmacy leadership, to determine the continuing usefulness and safety of the orders and protocols…”
MLA supports these proposed changes in principle and agrees that implementing these “would do much to advance the practice of evidence-based medicine and would ensure more consistent care for all patients.” However, we believe it is important to raise these questions—what qualifies as the best available evidence, and how do we ensure that health professionals have access to the most timely, relevant, accurate, health information to support quality patient care and safety?
MLA strongly supports criteria calling for the use of “evidence-based protocols to enhance the quality for care provided to hospital patients” as addressed in the proposed rule and also in CMS’ October 24, 2008 Memorandum [Ref: S&C-09-10]. The association maintains that health sciences librarians have key roles to play in support of the development of these protocols, particularly during the systematic review process as well as being involved in the periodic and regular review of standing orders and protocols related to the determination of the continuing safety of these orders and protocols.
A recent case study found that the librarian’s multiple roles as an expert searcher, organizer, and analyzer are integral to conducting systematic reviews (Harris, JMLA 93(1) Jan 2005). This finding was further supported in the March 2011 Institute of Medicine (IOM) Report, “Finding What Works in Health Care: Standards for Systematic Reviews.” The IOM Report notes that clinicians and other healthcare providers are increasingly turning to systematic reviews for reliable, evidence-based comparisons for health interventions, and recommend standards for including librarians on the multidisciplinary team involved in the Systematic Review Process [Standard 3.1]. The IOM Report also highlights that the Agency for Healthcare Research and Quality (AHRQ) Effective Health Care Program, the Centre for Reviews and Dissemination (CRD), and The Cochrane Collaboration also provide criteria for working with librarians and information specialists in the conduct of systematic reviews of comparative effectiveness research (Tables D-1 and E-1, page 250, 266).
Evidence supports the claim that medical librarians have the unique education, skills and expertise to provide information and resources that supports high quality patient care and safety, education, and research. Studies in the biomedical literature show that the majority of health professionals and researchers lack the time to seek information, the training to use the databases efficiently and the knowledge of multiple information resources. Health care professionals who conduct their own searches are able to find what they need less than 50 percent of the time. Yet studies also show that when current information is readily available to clinicians, it can change their decisions about patient management at least 47% of the time. Further, when recognized as members of the health care team, librarians can facilitate access to knowledge-based resources via electronic medical record systems and enable improved access to information at the point of care, thereby reducing the organization’s risk for malpractice suits.
Results from a July 2007 Magnet Coordinator Survey show that 94% of the nurses in Magnet facilities have onsite access to a nursing/medical library. The survey also found that 96.3% of the facilities with a medical librarian perceived that this provided added value for the institution and its employees thereby documenting the vital need for nurses as well as other health professionals, to have access to a medical library and the services of a professional medical librarian.
MLA commends the Centers for Medicare and Medicaid Services, for its efforts to improve regulation and regulatory review through this proposed rule. We believe this is a good first step in the process. We maintain, however, that in order to successfully advance the practice of evidence-based medicine and to ensure more consistent care for all patients that librarians and library services must be part of the process. Toward that goal, MLA recommends that Section 482.24 (c) (3) be revised to include a professional health sciences librarian on the team of personnel as follows: