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About This TrackerThis tracker provides current data on the share of the population having received at least one erectile dysfunction treatment dose by country, income-level, region, and globally levitra discount prices. Additionally, this levitra discount prices tool estimates future treatment coverage levels if the current rate of first dose administration is maintained going forward and compares these coverage levels to global vaccination targets. These targets include 40% by the end of 2021 (set by the World Health Organization), 70% by mid-2022 (set by the WHO), and 70% by the United Nations General Assembly in 2022 (set by the U.S.). This tracker will be updated levitra discount prices regularly as new data are available.Related Content:The Henry J.

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Overview (see this CMS Fact helpful hints Sheet for more information) What levitra 10mg bayer preisvergleich is a “Surprise Bill”?. Generally speaking, a Surprise Bill is a bill a patient receives from an out-of-network (OON) provider when the patient believed the service received was provided by an in-network (INN) provider and therefore covered at a greater rate by their health insurance. NY FIN SERV § 603(h). What does it mean to be “balance billed”? levitra 10mg bayer preisvergleich.

A patient is balance billed when they are billed by their medical provider for the balance remaining on a bill after the patient paid their expected cost-sharing (co-pay, coinsurance, and/or deductibles), and the patient’s insurance paid the most the plan agreed to pay for services the patient received. If you get health coverage through your employer, a Health Insurance Marketplace, or an individual health insurance plan you purchase directly from an insurance company, these new rules will. Ban surprise bills for levitra 10mg bayer preisvergleich most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization). Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services.

You can’t be charged more than in-network cost-sharing for these services. Ban out-of-network charges and balance bills levitra 10mg bayer preisvergleich for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility. Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider). If you don’t have insurance or you self-pay for care, in most cases, these new rules make sure you can get a good faith estimate of how much your care will cost before you receive it.

For services provided in 2022, you can dispute a medical bill if your final charges are at least $400 higher than your good faith estimate and you file your dispute claim within 120 days of levitra 10mg bayer preisvergleich the date on your bill. What if my state has a surprise billing law?. The No Surprises Act supplements state surprise billing laws. It does levitra 10mg bayer preisvergleich not supplant them.

The No Surprises Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibility for patients. So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law generally will apply. For example, if your state operates its own patient-provider dispute resolution process that levitra 10mg bayer preisvergleich determines appropriate payment rates for self-pay consumers and Health and Human Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements under the federal patient-provider dispute resolution process, then HHS will defer to the state process and would not accept such disputes into the federal process. As another example, if your state has an All-payer Model Agreement or another state law that determines payment amounts to out-of-network providers and facilities for a service, the All-payer Model Agreement or other state law will generally determine your cost-sharing amount and the out-of-network payment rate.

Other Protections -- consumers already benefit from the following protections. The No Surprises Act and The New York Surprise Bill Law The New York Surprise Bill levitra 10mg bayer preisvergleich Law and the NSA provide further protections for NY consumers, including those with private health insurance. The NSA sets a floor for consumer protections and will work in coordination with New York State’s existing health care consumer billing protections that became effective March 31, 2015 via the New York Surprise Bill Law, NY PUB HEALTH § 24;passed along with NY FIN SERV § 606. The Department of Health (DOH) and the Department of Financial Services (DFS) will both be charged with ensuring consumers in NYS benefit from elements of the NSA that NYS’s laws do not already address.

Prior to the NSA, levitra 10mg bayer preisvergleich the New York Surprise Bill law applied to consumers with “fully insured” plans that were therefore subject to NYS insurance law. Consumers with “self-insured” plans did not fully benefit from NYS insurance protections because self-insured plans are regulated by and subject to federal law, such as ERISA. Now consumers with both types of coverage are protected from most surprise bills. If a consumer receives a surprise bill in the following situations the consumer will only be responsible for their levitra 10mg bayer preisvergleich in-network cost-sharing obligations.

Treatment for Emergency Services and post-stabilization care Treatment by an out-of-network provider at an in-network hospital or ambulatory surgical center. A consumer was treated by an out-of-network provider at an in-network hospital or ambulatory surgical center if an in-network provider was not available. Or an out-of-network provider provided services without the consumer’s knowledge. Or there were unforeseen medical services provided levitra cost and done so by levitra 10mg bayer preisvergleich an out-of-network provider.

The NSA expanded the types of out-of-network provider services this protection applies to beyond only physicians. It now also applies to services provided by emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalists, or intensivist services. Referral to an out-of-network provider levitra 10mg bayer preisvergleich by one’s in-network provider. A consumer did not sign a consent acknowledging that the services were out-of-network AND.

An out-of-network provider treats the consumer during their visit with an in-network provider. OR a consumer’s in-network provider sends levitra 10mg bayer preisvergleich a specimen to an out-of-network lab or pathologist. OR any other referrals by an in-network provider to an out-of-network provider when referrals are required by the insurer. Out-of-network air ambulance services NSA additional protections Continuity of Care.

If an in-network provider leaves the consumer’s insurance network, consumers are entitled to 90 days of continued care from the provider levitra 10mg bayer preisvergleich at the in-network cost. Health insurance identification card requirements. DFS implemented regulations in April 2021 that require NYS health insurance plans to print specific information on their consumer’s health insurance ID cards, such as plan name, consumer name and ID, coverage type, plan contact information, and specific cost-sharing amounts for primary care, specialists, urgent care, emergency care, and prescription drugs for 30-day supply. NSA requirements levitra 10mg bayer preisvergleich also include listing on the card the consumer’s annual deductible and annual maximum out of pocket expense.

Up-to-date In-Network Provider Directories. Providers are required under the NSA to keep health plans informed as to their network status and current provider directory information. Consumers who relied upon network misinformation from the provider directory or through phone queries, including when not receiving a response from the plan within 1 business day of reaching out for network information, must be reimbursed by the provider for any amount the consumer paid above their levitra 10mg bayer preisvergleich in-network cost-sharing. NYS law requires health plans to maintain provider directories with specific enumerated provider information, with the written directory to be updated annually, and the online directory to be updated within 15 days of a provider changing a network or changing a hospital affiliation.

The NSA provisions requiring directory updates are more stringent, but DFS is still evaluating whether changes might need to be made to current regulation https://www.dfs.ny.gov/industry_guidance/circular_letters/cl2021_12 Providers are required to ask consumers scheduling an appointment whether they have insurance, what kind, and if they do, whether they will be using their insurance for the appointment. When is levitra 10mg bayer preisvergleich a bill not a surprise bill?. Consumers have the right to choose out-of-network providers. If a consumer agrees to see an out-of-network provider, then the consumer’s bill will not be a Surprise Bill.

The NSA allows for consumers to agree, usually 3 days in advance and levitra 10mg bayer preisvergleich in writing, to balance billing in certain circumstances although consumers can never agree to out-of-pocket costs for certain specialists (i.e., emergency medicine, anesthesiology, laboratory, etc.). The provider must provide a list of alternative in-network providers, and a “good faith estimate” of the service. An “advanced explanation of benefits”, as in advance of the service, will follow. If the fee ends up being $400 or more in excess of the good faith estimate, the consumer may dispute the bill.

Complaints may also be filed with CMS within 120 days of the date of your first bill. Https://www.cms.gov/nosurprises/consumers/complaints-about-medical-billing or by calling 1-800-985-3059. Providers are prohibited from assessing late fees or pursuing collections until the complaint is resolved. Consumers who are uninsured or who choose self-pay are entitled to receive a “good faith estimate” of the charges within a certain timeframe prior to the appointment.

What if a consumer receives a surprise bill?. Still to be determined The NSA requires that numerous regulations must be issued by several federal agencies.

If you have private health insurance, these new protections ban the most common types of surprise levitra discount prices bills. If you’re uninsured or you decide not to use your health insurance for a service, under these protections, you can often get a good faith estimate of the cost of your care up front, before your visit. If you disagree with your bill, you may be able to dispute the charges. Overview (see this CMS Fact Sheet for levitra discount prices more information) What is a “Surprise Bill”?.

Generally speaking, a Surprise Bill is a bill a patient receives from an out-of-network (OON) provider when the patient believed the service received was provided by an in-network (INN) provider and therefore covered at a greater rate by their health insurance. NY FIN SERV § 603(h). What does it mean to be “balance billed”? levitra discount prices. A patient is balance billed when they are billed by their medical provider for the balance remaining on a bill after the patient paid their expected cost-sharing (co-pay, coinsurance, and/or deductibles), and the patient’s insurance paid the most the plan agreed to pay for services the patient received.

If you get health coverage through your employer, a Health Insurance Marketplace, or an individual health insurance plan you purchase directly from an insurance company, these new rules will. Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior levitra discount prices authorization). Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.

Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or levitra discount prices radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility. Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider). If you don’t have insurance or you self-pay for care, in most cases, these new rules make sure you can get a good faith estimate of how much your care will cost before you receive it. For services provided in 2022, you can levitra discount prices dispute a medical bill if your final charges are at least $400 higher than your good faith estimate and you file your dispute claim within 120 days of the date on your bill.

What if my state has a surprise billing law?. The No Surprises Act supplements state surprise billing laws. It does not supplant levitra discount prices them. The No Surprises Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibility for patients.

So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law generally will apply. For example, if your state operates its own patient-provider dispute resolution process that determines appropriate payment rates for self-pay consumers and Health and Human Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements under the levitra discount prices federal patient-provider dispute resolution process, then HHS will defer to the state process and would not accept such disputes into the federal process. As another example, if your state has an All-payer Model Agreement or another state law that determines payment amounts to out-of-network providers and facilities for a service, the All-payer Model Agreement or other state law will generally determine your cost-sharing amount and the out-of-network payment rate. Other Protections -- consumers already benefit from the following protections.

The No Surprises Act and The New York Surprise Bill Law The New York Surprise Bill Law and the NSA provide further protections for NY consumers, including levitra discount prices those with private health insurance. The NSA sets a floor for consumer protections and will work in coordination with New York State’s existing health care consumer billing protections that became effective March 31, 2015 via the New York Surprise Bill Law, NY PUB HEALTH § 24;passed along with NY FIN SERV § 606. The Department of Health (DOH) and the Department of Financial Services (DFS) will both be charged with ensuring consumers in NYS benefit from elements of the NSA that NYS’s laws do not already address. Prior to the NSA, the New York Surprise Bill law applied to consumers with “fully insured” plans that levitra discount prices were therefore subject to NYS insurance law.

Consumers with “self-insured” plans did not fully benefit from NYS insurance protections because self-insured plans are regulated by and subject to federal law, such as ERISA. Now consumers with both types of coverage are protected from most surprise bills. If a consumer receives a surprise bill in the following situations the consumer will only be responsible for their in-network cost-sharing obligations. Treatment for Emergency Services and post-stabilization care Treatment by an out-of-network provider at levitra discount prices an in-network hospital or ambulatory surgical center.

A consumer was treated by an out-of-network provider at an in-network hospital or ambulatory surgical center if an in-network provider was not available. Or an out-of-network provider provided services without the consumer’s knowledge. Or there were unforeseen medical services provided and done so by levitra discount prices an out-of-network provider. The NSA expanded the types of out-of-network provider services this protection applies to beyond only physicians.

It now also applies to services provided by emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalists, or intensivist services. Referral to an out-of-network provider by one’s in-network provider levitra discount prices. A consumer did not sign a consent acknowledging that the services were out-of-network AND. An out-of-network provider treats the consumer during their visit with an in-network provider.

OR a consumer’s in-network provider sends a specimen to levitra discount prices an out-of-network lab or pathologist. OR any other referrals by an in-network provider to an out-of-network provider when referrals are required by the insurer. Out-of-network air ambulance services NSA additional protections Continuity of Care. If an in-network provider leaves the consumer’s insurance network, consumers are entitled to 90 days of continued care from the provider levitra discount prices at the in-network cost.

Health insurance identification card requirements. DFS implemented regulations in April 2021 that require NYS health insurance plans to print specific information on their consumer’s health insurance ID cards, such as plan name, consumer name and ID, coverage type, plan contact information, and specific cost-sharing amounts for primary care, specialists, urgent care, emergency care, and prescription drugs for 30-day supply. NSA requirements also include listing on the card the levitra discount prices consumer’s annual deductible and annual maximum out of pocket expense. Up-to-date In-Network Provider Directories.

Providers are required under the NSA to keep health plans informed as to their network status and current provider directory information. Consumers who relied upon network misinformation from the provider directory or through phone queries, including when not receiving a response from the plan within 1 business day of reaching out for network information, must be reimbursed by the provider for any amount the consumer paid above their in-network levitra discount prices cost-sharing. NYS law requires health plans to maintain provider directories with specific enumerated provider information, with the written directory to be updated annually, and the online directory to be updated within 15 days of a provider changing a network or changing a hospital affiliation. The NSA provisions requiring directory updates are more stringent, but DFS is still evaluating whether changes might need to be made to current regulation https://www.dfs.ny.gov/industry_guidance/circular_letters/cl2021_12 Providers are required to ask consumers scheduling an appointment whether they have insurance, what kind, and if they do, whether they will be using their insurance for the appointment.

When is a bill not a levitra discount prices surprise bill?. Consumers have the right to choose out-of-network providers. If a consumer agrees to see an out-of-network provider, then the consumer’s bill will not be a Surprise Bill. The NSA allows for consumers to agree, usually 3 days in advance and in writing, to balance billing in certain circumstances although consumers can never agree to out-of-pocket costs for certain specialists (i.e., emergency medicine, anesthesiology, laboratory, etc.).

The provider must provide a list of alternative in-network providers, and a “good faith estimate” of the service. An “advanced explanation of benefits”, as in advance of the service, will follow. If the fee ends up being $400 or more in excess of the good faith estimate, the consumer may dispute the bill. Complaints may also be filed with CMS within 120 days of the date of your first bill.

Https://www.cms.gov/nosurprises/consumers/complaints-about-medical-billing or by calling 1-800-985-3059. Providers are prohibited from assessing late fees or pursuing collections until the complaint is resolved.

Levitra side effects long term

Bacteria and clinicians levitra side effects long term have one thing in common. Resistance. As widespread antibiotic use has increased, antimicrobial resistance has risen.1 Despite this, many clinicians remain resistant to changing their antibiotic-prescribing habits.1 Antimicrobial stewardship—which focuses on interventions to help optimise antibiotic selection, dose and duration—has gained substantial public health interest while continuing to face frequent frontline clinician opposition.2 3 In this issue of BMJ Quality and Safety, Saini and colleagues’ findings support a seemingly simple antimicrobial stewardship tool. Documentation of antibiotic indications so that explicit reasons for the prescription are recorded.4 In a scoping review of 123 publications, Saini and colleagues found beneficial effects of antibiotic indication documentation on the quality of patient care, including preventing errors, improving antibiotic prescribing and supporting communication at care transitions.4 Yet, critical barriers—often in the form of clinician resistance—diminish the ability of many antibiotic stewards to implement the documentation of antibiotic indication.

Critical questions remain unanswered related to best practices for implementation of antibiotic indications to maximise the benefits and minimise these challenges. Here, we seek to address these questions and offer key insights for implementation.The competing purposes of antibiotic documentationTo understand how best to implement antibiotic indication documentation and engage stakeholders, it is important to understand the myriad and often competing purposes of documentation. Generally, documentation—both related and unrelated to antibiotics—serves many purposes. These vary from the immediately patient relevant (eg, improving interclinician or patient/clinician communication, enabling prospective audit and feedback by pharmacists) to those with delayed clinical relevance (eg, enhancing retrospective research), and those largely for administrative purposes (eg, billing, resource distribution).

In some countries, such as the USA where 35 of the studies included in the scoping review occurred, documentation also serves for legal protection (ie, defensive medicine).5 For antimicrobial stewardship in particular, there is another useful purpose of documentation to consider. Improved mindfulness. Specifically, the act of documentation itself may trigger a mindful moment that forces clinicians to pause and move from system 1 (fast) to system 2 (slow) thinking.6 Slower, deliberative thinking has been shown to serve as an antibiotic self-timeout which reminds clinicians to reconsider antibiotic necessity and appropriateness.7 Similarly, accountable justification, which requires clinicians to explicitly justify an antibiotic treatment plan, has been shown to reduce inappropriate antibiotic prescribing.8Because documentation purposes and thus priorities vary, changes in antibiotic indication documentation can be difficult to implement. For example, Saini and colleagues found that notable barriers to documenting antibiotic indications included competing priorities and time burden.9–11 In our practice, we find that documentation that is not directly and immediately clinically useful is often perceived by clinicians as an irrelevant administrative burden.

Likewise, documentation interventions that hinder billing or quality compliance (eg, public reporting) may encounter leadership resistance. Thus, to engage clinicians and improve rates of antibiotic indication documentation, antimicrobial stewardship programmes must reframe the need for documentation in terms of clinical relevance, while not running counter to administrative needs.9One way to improve clinician buy-in is by focusing on the salient, patient-relevant reasons for improving antibiotic documentation. Take, as one example, care transitions. Nowhere is the need for documentation more acute than during transitions of care, where adverse events are common, often harmful, and where accurate documentation can serve as a critical tool for improving communication.12 Because other forms of communication (eg, notes, verbal) are less common and reliable during care transitions (eg, to retail pharmacies), accurate documentation of antibiotic indications can prevent medication errors.13 When antibiotic prescriptions sent to pharmacies do not include the indication within the patient instructions, the pharmacist is left inferring the indication, reducing their ability to confirm prescription accuracy and prevent errors.13 Antibiotic stewards who wish to improve antibiotic indication documentation at discharge for one purpose (ie, optimising discharge antibiotic prescribing) could therefore have more successful clinical buy-in if they instead framed documentation in terms of improving communication and reducing harmful errors (eg, ‘bug-drug’ mismatch).What do we mean by good documentation?.

As we pause to consider best practices for implementation, it is important to first define what we mean by antibiotic indication documentation. Critically, this includes where documentation should occur. As clinicians ourselves, we recognise that clinicians often document antibiotic indications not once—but many times—including in clinician notes, interclinician handoff tools, inpatient antibiotic orders, outpatient antibiotic prescriptions and patient instructions. This complexity is not accounted for in most studies of antibiotic indications.

In Saini and colleagues’ paper only 19 of the studies refer to documentation of the antibiotic indication as part of the prescription itself. For better or worse, many documentation interventions are operationalised in orders, including adjustments to the electronic health record (EHR) through order sets, drop-down menus and prompted indications.4 This type of EHR-driven documentation can serve as a nudge to improve prescribing, but come with unintended costs.14Notably, all documentation interventions require additional clinician work. While demonstrably important, EHR-focused documentation interventions fail to account for documentation that may—or may not—already be occurring elsewhere. For example, the rise of EHR note templates can both hinder and benefit documentation.

While note templates may remind clinicians to include antibiotic indications, they can lead to ‘note bloat’ and additions that are clinically irrelevant. The disjointed approach to documentation can lead to alert fatigue and annoy end-users who fail to see the value in including an indication in the order when it is already documented elsewhere.10 Similarly, too many documentation requirements can lead clinicians to over-ride or bypass mandatory fields.10 11 Finding the ‘sweet spot’ of antibiotic documentation to improve compliance and help stewardship without impeding clinician workflow is critical.Best practices for implementation of antibiotic indicationsWe have summarised some high-level best practices for increasing antibiotic indication documentation in table 1. Critically, improving antibiotic indications requires an easy, user-centred, well-designed process. When not designed and implemented with end-user engagement, clinicians may manipulate or game clinical decision support tools to bypass restrictions and take short cuts.

For example, in a study by Baysari and colleagues, the investigators created a drop-down system for restricted antibiotics that was meant to improve antibiotic-prescribing habits.10 The drop-down included only appropriate indications and clinicians were required to obtain stewardship approval if the planned use was for an indication other than in the drop-down. Rather than waste time by calling for approval, clinicians instead bypassed the approval process and gamed the system by selecting ‘appropriate’ indications, even when that indication was untrue.10 Because of this gaming, the intervention had no effect on antibiotic prescribing or documentation habits.10 When interviewed about these workarounds, clinicians reported they wanted to save time and minimise disruptions to their workflow.10View this table:Table 1 Documentation best practices, barriers and additional questionsIn their scoping review, Saini and colleagues mapped barriers and facilitators using the Capability, Opportunity, Motivation (COM-B) model for behaviour change. They acknowledge opportunity in the form of incentives, rewards and EHR improvements may overcome barriers to documentation such as lack of time and logistical challenges.4 Long term, we need better systems to allow open interactions between all members of the patient’s care team and improve interclinician communication around antibiotic indications. For example, in Taiwan, cloud-based technology allows clinicians, nurses and pharmacists to access patients’ prescription history and has resulted in enhanced medication safety.15 A similar system exists in the USA for opioids and controlled substances.

However, this is a state-dependent rather than a nationwide database. As technology improves, having interoperable systems to allow communication of medication information—including antibiotic indication, dose and duration—may become more feasible.Additionally, Saini and colleagues noted strategies to reduce alert fatigue and increase ease of documentation could help with clinicians’ capability and motivation to provide an indication on the antibiotic prescription.4 For example, automating or prepopulating indications based on documentation elsewhere (eg, in notes) could reduce the burden on clinicians and prevent gaming. Or the reverse—prepopulating notes based on antibiotic orders or prescriptions may better fit into workflow where orders are often written before notes. This latter solution would also provide an opportunity to incorporate ‘nudges’ to prod clinicians towards better prescribing.In summary, we operate in an imperfect system where antibiotic indication documentation serves many purposes and occurs in many forms which can impede implementation.

Myriad strategies to improve documentation have been attempted with mixed results. Until we have a system that can facilitate communication across all pertinent individuals, we must work to optimise what we have. This includes leveraging technology and behaviour change strategies to help documentation serve multiple purposes simultaneously. Doing all that, without increasing burden on clinicians, is the key to any successful antimicrobial stewardship—or documentation—intervention.Ethics statementsPatient consent for publicationNot applicable..

Bacteria and levitra discount prices news clinicians have one thing in common. Resistance. As widespread antibiotic use has increased, antimicrobial resistance has risen.1 Despite this, many clinicians remain resistant to changing their antibiotic-prescribing habits.1 Antimicrobial stewardship—which focuses on interventions to help optimise antibiotic selection, dose and duration—has gained substantial public health interest while continuing to face frequent frontline clinician opposition.2 3 In this issue of BMJ Quality and Safety, Saini and colleagues’ findings support a seemingly simple antimicrobial stewardship tool. Documentation of antibiotic indications so that explicit reasons for the prescription are recorded.4 In a scoping review of 123 publications, Saini and colleagues found beneficial effects of antibiotic indication documentation on the quality of patient care, including preventing errors, improving antibiotic prescribing and supporting communication at care transitions.4 Yet, critical barriers—often in the form of clinician resistance—diminish the ability of many antibiotic stewards to implement the documentation of antibiotic indication. Critical questions remain unanswered related to best practices for implementation of antibiotic indications to maximise the benefits and minimise these challenges.

Here, we seek to address these questions and offer key insights for implementation.The competing purposes of antibiotic documentationTo understand how best to implement antibiotic indication documentation and engage stakeholders, it is important to understand the myriad and often competing purposes of documentation. Generally, documentation—both related and unrelated to antibiotics—serves many purposes. These vary from the immediately patient relevant (eg, improving interclinician or patient/clinician communication, enabling prospective audit and feedback by pharmacists) to those with delayed clinical relevance (eg, enhancing retrospective research), and those largely for administrative purposes (eg, billing, resource distribution). In some countries, such as the USA where 35 of the studies included in the scoping review occurred, documentation also serves for legal protection (ie, defensive medicine).5 For antimicrobial stewardship in particular, there is another useful purpose of documentation to consider. Improved mindfulness.

Specifically, the act of documentation itself may trigger a mindful moment that forces clinicians to pause and move from system 1 (fast) to system 2 (slow) thinking.6 Slower, deliberative thinking has been shown to serve as an antibiotic self-timeout which reminds clinicians to reconsider antibiotic necessity and appropriateness.7 Similarly, accountable justification, which requires clinicians to explicitly justify an antibiotic treatment plan, has been shown to reduce inappropriate antibiotic prescribing.8Because documentation purposes and thus priorities vary, changes in antibiotic indication documentation can be difficult to implement. For example, Saini and colleagues found that notable barriers to documenting antibiotic indications included competing priorities and time burden.9–11 In our practice, we find that documentation that is not directly and immediately clinically useful is often perceived by clinicians as an irrelevant administrative burden. Likewise, documentation interventions that hinder billing or quality compliance (eg, public reporting) may encounter leadership resistance. Thus, to engage clinicians and improve rates of antibiotic indication documentation, antimicrobial stewardship programmes must reframe the need for documentation in terms of clinical relevance, while not running counter to administrative needs.9One way to improve clinician buy-in is by focusing on the salient, patient-relevant reasons for improving antibiotic documentation. Take, as one example, care transitions.

Nowhere is the need for documentation more acute than during transitions of care, where adverse events are common, often harmful, and where accurate documentation can serve as a critical tool for improving communication.12 Because other forms of communication (eg, notes, verbal) are less common and reliable during care transitions (eg, to retail pharmacies), accurate documentation of antibiotic indications can prevent medication errors.13 When antibiotic prescriptions sent to pharmacies do not include the indication within the patient instructions, the pharmacist is left inferring the indication, reducing their ability to confirm prescription accuracy and prevent errors.13 Antibiotic stewards who wish to improve antibiotic indication documentation at discharge for one purpose (ie, optimising discharge antibiotic prescribing) could therefore have more successful clinical buy-in if they instead framed documentation in terms of improving communication and reducing harmful errors (eg, ‘bug-drug’ mismatch).What do we mean by good documentation?. As we pause to consider best practices for implementation, it is important to first define what we mean by antibiotic indication documentation. Critically, this includes where documentation should occur. As clinicians ourselves, we recognise that clinicians often document antibiotic indications not once—but many times—including in clinician notes, interclinician handoff tools, inpatient antibiotic orders, outpatient antibiotic prescriptions and patient instructions. This complexity is not accounted for in most studies of antibiotic indications.

In Saini and colleagues’ paper only have a peek at this web-site 19 of the studies refer to documentation of the antibiotic indication as part of the prescription itself. For better or worse, many documentation interventions are operationalised in orders, including adjustments to the electronic health record (EHR) through order sets, drop-down menus and prompted indications.4 This type of EHR-driven documentation can serve as a nudge to improve prescribing, but come with unintended costs.14Notably, all documentation interventions require additional clinician work. While demonstrably important, EHR-focused documentation interventions fail to account for documentation that may—or may not—already be occurring elsewhere. For example, the rise of EHR note templates can both hinder and benefit documentation. While note templates may remind clinicians to include antibiotic indications, they can lead to ‘note bloat’ and additions that are clinically irrelevant.

The disjointed approach to documentation can lead to alert fatigue and annoy end-users who fail to see the value in including an indication in the order when it is already documented elsewhere.10 Similarly, too many documentation requirements can lead clinicians to over-ride or bypass mandatory fields.10 11 Finding the ‘sweet spot’ of antibiotic documentation to improve compliance and help stewardship without impeding clinician workflow is critical.Best practices for implementation of antibiotic indicationsWe have summarised some high-level best practices for increasing antibiotic indication documentation in table 1. Critically, improving antibiotic indications requires an easy, user-centred, well-designed process. When not designed and implemented with end-user engagement, clinicians may manipulate or game clinical decision support tools to bypass restrictions and take short cuts. For example, in a study by Baysari and colleagues, the investigators created a drop-down system for restricted antibiotics that was meant to improve antibiotic-prescribing habits.10 The drop-down included only appropriate indications and clinicians were required to obtain stewardship approval if the planned use was for an indication other than in the drop-down. Rather than waste time by calling for approval, clinicians instead bypassed the approval process and gamed the system by selecting ‘appropriate’ indications, even when that indication was untrue.10 Because of this gaming, the intervention had no effect on antibiotic prescribing or documentation habits.10 When interviewed about these workarounds, clinicians reported they wanted to save time and minimise disruptions to their workflow.10View this table:Table 1 Documentation best practices, barriers and additional questionsIn their scoping review, Saini and colleagues mapped barriers and facilitators using the Capability, Opportunity, Motivation (COM-B) model for behaviour change.

They acknowledge opportunity in the form of incentives, rewards and EHR improvements may overcome barriers to documentation such as lack of time and logistical challenges.4 Long term, we need better systems to allow open interactions between all members of the patient’s care team and improve interclinician communication around antibiotic indications. For example, in Taiwan, cloud-based technology allows clinicians, nurses and pharmacists to access patients’ prescription history and has resulted in enhanced medication safety.15 A similar system exists in the USA for opioids and controlled substances. However, this is a state-dependent rather than a nationwide database. As technology improves, having interoperable systems to allow communication of medication information—including antibiotic indication, dose and duration—may become more feasible.Additionally, Saini and colleagues noted strategies to reduce alert fatigue and increase ease of documentation could help with clinicians’ capability and motivation to provide an indication on the antibiotic prescription.4 For example, automating or prepopulating indications based on documentation elsewhere (eg, in notes) could reduce the burden on clinicians and prevent gaming. Or the reverse—prepopulating notes based on antibiotic orders or prescriptions may better fit into workflow where orders are often written before notes.

This latter solution would also provide an opportunity to incorporate ‘nudges’ to prod clinicians towards better prescribing.In summary, we operate in an imperfect system where antibiotic indication documentation serves many purposes and occurs in many forms which can impede implementation. Myriad strategies to improve documentation have been attempted with mixed results. Until we have a system that can facilitate communication across all pertinent individuals, we must work to optimise what we have. This includes leveraging technology and behaviour change strategies to help documentation serve multiple purposes simultaneously. Doing all that, without increasing burden on clinicians, is the key to any successful antimicrobial stewardship—or documentation—intervention.Ethics statementsPatient consent for publicationNot applicable..

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