OCR Takes Enforcement Action Against Puerto Rican Hospital. The HHS Office for Civil Rights (OCR) issued a notice of violation to a psychiatric hospital located in Puerto Rico for failure to comply with federal civil rights laws on disability. Following an investigation, OCR found that the hospital violated disability civil rights laws when it failed to provide a patient with a sign language interpreter, under Section 504 of the Rehabilitation Act (Section 504) and Section 1557 of the Affordable Care Act (Section 1557), laws which prohibit discrimination on the basis of disability. Section 504 prohibits discrimination based on disability in any program or activity receiving federal financial assistance from HHS, while Section 1557 does the same with respect to certain health programs and activities. Collectively, Section 504 and Section 1557 prohibit any entity that receives Federal financial assistance from discriminating against qualified individuals with disabilities and requires an entity to take steps to ensure that communication with individuals with disabilities using appropriate auxiliary aids and services is as effective as communication with others. OCR finalized important updates to the rules implementing Section 504 and Section 1557 this past spring.
OCR received a complaint alleging the hospital discriminated against a patient on the basis of disability by failing to provide a sign language interpreter for a court-ordered psychiatric evaluation at the hospital, which denied the patient an equal opportunity to participate in or benefit from the hospital’s programs and services because of the disability. As a result of its investigation, OCR determined that: (i) The patient was a qualified individual with a disability who used sign language as her primary form of communication; (ii) The patient needed a sign language interpreter to communicate effectively with others; (iii) The hospital’s use of handwritten notes, gestures, and lip reading was insufficient given the complexity of the communications required to perform a psychiatric evaluation and the centrality of communication to such an evaluation; (iv) The hospital failed to take appropriate steps to ensure that communication with the patient was as effective as communication with persons who are not deaf or hard-of-hearing; and (v) The hospital failed to provide auxiliary aids and services where necessary to provide effective communication and afford the patient an equal opportunity to participate in and benefit from the Hospital’s services.
OCR’s determination advises the hospital to contact OCR within thirty days and enter into a Settlement Agreement within sixty days. The Settlement Agreement outlines the actions that the hospital must take to remedy the violations. If compliance has not been secured through a Settlement Agreement negotiation, the HHS division that has disbursed federal funding to the hospital may take potential action. This action may ultimately result in limitations on continued receipt of HHS funds. Go here to read the Letter of Finding / Notice of Violation.
CISA Issues Guidance on Best Practices for Event Logging and Cyberthreat Detection. The Cybersecurity and Infrastructure Security Agency (CISA) issued guidance identifying best practices for event logging to mitigate cyberthreats. The guidance was developed in concert with the Federal Bureau of Investigation, the National Security Agency and several cybersecurity agencies from other nations. The guide provides recommendations designed to improve organizational resilience in the current cyberthreat environment. Event logging supports the continued delivery of operations and improves the security and resilience of critical systems by enabling network visibility. This guidance makes recommendations that improve an organization’s resilience in the current cyber threat environment, with regard for resourcing constraints. The guidance is of moderate technical complexity and assumes a basic understanding of event logging.
CMS Publishes its Data Sharing Strategy. The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation published a blog in Health Affairs entitled ”Improving Participation In Value-Based Care—The CMS Innovation Center’s Data-Sharing Strategy Initiative.” The blog addresses the agency’s data sharing strategy stating that, given the role and importance of data to the work they do and to model participants, the agency is advancing its data-sharing strategy with a primary goal of identifying additional data-sharing needs across CMS Innovation Center models that ensures proper security, risk management, and privacy obligations are employed in tandem with sharing goals.
HC3 Issues Threat Actor Profile on Everest Ransomware. The Health Sector Cybersecurity Coordination Center (HC3) released a Threat Actor Profile on Everest Ransomware. According to HC3, the Everest ransomware group has been active since 2020, and has engaged in data extortion and ransomware operations, along with initial access broker (IAB) activity. The group has increasingly targeted the healthcare industry since 2021 and claimed responsibility for a recent incident impacting a surgical facility in the United States. The group leverages a variety of common publicly available tools in its attacks and is known to obtain initial access via various remote access tools and methods. The ransomware strain was previously linked to a Russia-based ransomware operation.
CMS OIT to Host Information Technology Call. The CMS Office of Information Technology (OIT) will host a webinar to provide the latest update on the following topics: (i) Interoperability Matters to YOU!; and (ii) CMS Enterprise End-User Access Management System (CEEAMS) and Enterprise User Administration (EUA) Transformation. The webinar will take place Sept. 26 from 10 am to 12 noon ET. Here is the zoom link. To access the call-in option, dial: 833 568 8864 US Toll Free. The passcode is 007971.
CMS to Hold Office Hour Session on Promoting Interoperability Program. CMS will hold an “Office Hour” session to discuss the Antibiotic Use and Antibiotic Resistance Surveillance measure(s) of the Public Health and Clinical Data Exchange Objective for the Medicare Promoting Interoperability Program. The session will be in conjunction with the Centers for Disease Control and Prevention and the Assistant Secretary for Technology Policy and Office of the National Coordinator for Health Information Technology. The session will take place on October 4, 2024, at 2:00 PM ET. CMS will discuss the requirements for CY 2024 and CY 2025.
To attend the session or if you have a question related to the Antibiotic Use and Antibiotic Resistance Surveillance measure(s), please email Elizabeth.Holland@cms.hhs.gov.
Save the Date: CMS Announces Date for its Optimizing Healthcare Delivery Conference. CMS announced that its 2024 CMS Optimizing Healthcare Delivery to Improve Patient Lives Conference will take place on December 12, 2024. This free, virtual conference will convene the health care community and federal government to share new ideas, lessons learned, and best practices to reduce administrative burden and strengthen access to quality care. CMS will release additional details about this event in the coming months, including session topics, speaker names, and opportunities for engagement.
Study: The Impact of AI on Clinician Documentation Burden. In an article published in JAMA Network Open entitled “AI-Powered Clinical Documentation and Clinicians’ Electronic Health Record Experience: A Nonrandomized Clinical Trial,” researchers studied the impact of artificial intelligence (AI) on clinical documentation in EHRs. The nonrandomized clinical trial included 140 family medicine, internal medicine, and general pediatrics clinicians (physicians and advanced practice practitioners) from all outpatient clinics in North Carolina and Georgia within Atrium Health. In the intervention group, 47.1% reported decreased time on the EHR at home vs 14.5% in the control group and 44.7% reported decreased weekly time on the EHR outside normal work hours vs 20.0% in the control group. Further, 43.5% of intervention respondents reported decreased time on documentation after visits vs 18.2% in the control group. In the intervention group, 44.7% reported less frustration using the EHR vs 14.5% in the control group.