The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists. The purpose of this publication is to keep our members updated on the NACNS headquarters news; connect our members with fast-breaking clinical news; and update clinical nurse specialists on state and federal legislative actions.

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Featured Articles

  1. NACNS President’s Award Presented to First Awardee

Headquarters News

  1. NACNS Election Results
  2. 2013 Annual Conference A Success
  3. NACNS to Exhibit at National Meetings
  4. NACNS 2013 Summit Planning

Clinical Headlines

  1. NIH Evidence Based Methodology on Polycystic Ovary Syndrome
  2. Agency for Healthcare Policy and Research (AHRQ) Report Projected Hip Replacements
  3. New Children's Electronic Health Record Format Announced
  4. FDA approval of generic version of cancer drug Doxil is expected to help resolve shortage
  5. Study shows unassisted method works best to restore independent breathing in patients on ventilators
  6. Value of Emergency Checklists
  7. NIEHS Researchers Find Prenatal Inflammation Linked to Autism Risk

Association News

  1. American College of Nurse-Midwives (ACNM) Announces Evidence on Safety and Quality of Midwife Care
  2. IOM – Delivery Cost Effective Cancer Care
  3. ONS – New Clinical Guide

Federal and State Policy News

  1. The Family Medical Leave Act is Now 20 Years Old
  2. CMS Proposes Rule to Eliminate Onsite Physician Supervision in CAH
  3. Medicare and Medicaid EHR Incentive Program for Eligible Professionals
  4. NACNS Supports Dr. Tavenner for Appointment as CMS Administrator
  5. Sequestration


Featured Articles

11. President’s Award Presented to First Awardee

Dr. Kelly Goudreau, DNS, RN, ACNS-BC, FAAN received NACNS' new award – the President’s Award. This award recognizes an individual for extraordinary service to NACNS. This award was established in 2012 to honor individuals or groups who contribute significantly toward the accomplishment of the NACNS' mission. This award is given by the NACNS President and is not considered an annual award. It may be given at the discretion of the President. This candidate was selected by the 2012 NACNS President, Rachel Moody and endorsed by the NACNS Board of Directors.

Dr. Goudreau is an amazing NACNS member and had been invested in the growth and workings of NACNS over her professional career. Dr. Goudreau is currently Associate Director for Patient Care Services/Nurse Executive of the Veteran's Affairs Southern Oregon Rehabilitation Center and Clinics (VA SORCC) White City, Oregon.

Dr. Goudreau is the Associate Editor for Clinical Nurse Specialist: The Journal of Advanced Nursing Practice since 2008. She served as the NACNS president-elect from 2005-2006 and became NACNS President in 2006-2007. Dr. Goudreau represented NACNS as a participant on the Joint Dialogue Workgroup that created the APRN Regulatory Model (published July 2008).

"Dr. Goudreau's self-less work for the nursing profession as well as NACNS make her the perfect inaugural recipient of this award. Dr. Goudreau's ongoing efforts and unique achievements have helped NACNS to achieve many organizational goals and make significant steps toward defining the invaluable contribution of the clinical nurse specialist role." said NACNS 2012 President, Rachel Moody, MS, CNS, RN.

Headquarters News

2. NACNS Election Results

NACNS is proud to announce the 2013 Election results. Carol Manchester, MSN, ACNS, BC-ADM, CDE, is currently employed as the Diabetes Clinical Nurse Specialist at University of Minnesota Medical Center, Fairview, assumed the NACNS Presidency during the Annual Conference.

Les Rodriquez MSN, MPH, RN, ANCNS-BC, APRN, has been elected to the role of president-elect. Les Rodriquez will assume the NACNS presidential role in 2014 at the NACNS Annual Conference. He has been a member of the Board of Directors since 2010. Mr. Rodriquez is employed as a CNS in the Division of Surgical & Oncology Services at Baylor University Medical Center. Mr. Rodriquez provides pain management support to the inpatient patients.

Peggy Barksdale, MSN, RN, OCNS-C, CNS-BC, has been elected as the 2013-2015 vice president. Peggy has been on the NACNS Board of Directors since 2010. She serves as a CNS at the Community Health Network, Indianapolis, Indiana. She is the team leader for clinical standards, education and research and is actively involved in the analysis and implementation of evidence-based practice to improve patient outcomes. Ms. Barksdale clinical expertise is musculoskeletal/orthopaedic conditions.

Anne Muller, MSN, ACNS-BC, RN, was elected to serve the 2013 term as treasurer. Last year she was appointed to complete Ms. Manchester’s term as Treasurer. Ms. Muller is currently employed as the Director of Critical-Care, Acute Care Division for Universal Health Services, Inc.

Ginger S. Pierson, MSN, RN, CCRN, CNS has been elected to a second term on the NACNS Board of Directors. Ms. Pierson has been employed at Hoag Memorial Hospital Presbyterian, Newport Beach, California since 1990 and is currently the CNS for the very active, 56 bed Emergency Department.

Fiona Winterbottom, MSN, CCRN, ACNS-BC, has been elected to her first term to the NACNS Board of Directors. She is currently employed as a Critical Care CNS for Ochsner Medical Center, New Orleans since September, 2007. She is also a member of the American Association of Critical-Care Nurses and the Society of Critical Care Medicine.

The NACNS membership also elected members for the NACNS Nominating Committee. The following new individuals will be serving on the 2013 – 2014 Nominating Committee:

Ann M Mayo, PhD, RN, Hahn School of Nursing & Health Science, University of San Diego, Professor MSN/PhD Programs

Sherri L. Atherton, MS, RN, CNS- BC, CIC, Infection Prevention CNS, Portland Veterans Affairs Medical Center.

Kathleen M. Rea, MSN, RN, ACNS-BC, PCCN, CNL, Advance Practice Nurse 1- Clinical Nurse Specialist, University of Virginia Health.

3. NACNS Conference

Almost 550 attendees convened in San Antonio, TX for the NACNS 2013 Conference, The CNS: Leading Innovations for Health Care Change- March 7-9. Thank you to all who contributed to the content and networking opportunities! The sessions featured robust presentations spanning education, research and practice. We were thrilled to have general session speakers that spoke to the future of nursing, CNS leadership in innovation and the value of CNS work:

  • Alexia Green, PhD, RN, FAAN
    The Future of Nursing: Opportunities for the CNS in a Reformed Healthcre System
  • Anna Gawlinski, RN, DNSc, CNS-BC,FAAN
    CNS Leadership in Implementing Innovations in the Acute Care Hospital Setting
  • Nancy Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCC
    The Value of CNS Work: Making & Saving Dollars for Your Institution

We look forward to maintaining our momentum and progress as we look toward the 2014 Conference- The Best Kept Secret – The CNS's Contribution to Quality Care – March 6-8 in Orlando, Florida. Save the Date!

4. NACNS Exhibits at AONE and NSNA

In an effort to spread the word about CNS's contributions to health care as well as the importance of NACNS membership, the association is exhibiting at the American Organization of Nurse Executives (AONE) meeting in Denver in March and the National Student Nurses Association (NSNA) meeting in Charlotte in April. In addition, NACNS will be exhibiting at the American Association of Critical Care Nurses (AACN) National Training Institute (NTI) Meeting in Boston in May. If you are attending any of these meetings, please stop by the NACNS booth. If you'd like to volunteer to help staff the booth, please contact NACNS.

5. 2013 NACNS Summit

Planning is under way for the 2013 NACNS Summit. The Summit is scheduled for July 23 in Washington, DC. Traditionally, the NACNS Summit has been held as an invitational conference, but once again we will be opening the conference to interested CNSs as well as our association colleagues. If you are interested in receiving an invitation to this meeting or for more information about this program, please email your request to

Clinical Headlines

6. National Institutes of Health (NIH) Convenes Panel on Polycystic Ovary Syndrome

The Office of Disease Prevention at NIH convened a independent panel to assess the available evidence on Polycystic Ovary Syndrome on December 3- 5, 2012. Polycystic ovary syndrome (PCOS) is a common hormone disorder that affects approximately 5 million reproductive-aged women in the U.S. Some of the symptoms include difficulty becoming pregnant due to hormone imbalances that cause or result from altered development of ovarian follicles. In addition other common symptoms of PCOS include:

  • Irregular or no menstrual periods (for women of reproductive age)
  • Acne
  • Weight gain
  • Excess hair growth on the face and body
  • Thinning scalp hair
  • Ovarian cysts.

Women with PCOS are often resistant to the biological effects of insulin and, as a consequence, may have high insulin levels. As such, women with PCOS are at risk for type 2 diabetes, high cholesterol, and high blood pressure. Obesity also appears to worsen the condition. Costs to the U.S. healthcare system to identify and manage PCOS are approximately $4 billion annually; however, this estimate does not include treatment of the serious conditions associated with PCOS.

In 1990, the National Institutes of Health (NIH) held a conference on PCOS to create both a working definition of the disorder and diagnostic criteria. The outcome of this conference, the NIH Criteria, served as a standard for researchers and clinicians for more than a decade. In 2003, a consensus workshop in Rotterdam developed new diagnostic criteria, the Rotterdam Criteria.

The 2012 NIH Evidence-based Methodology Workshop on PCOS sought to clarify:

  • Benefits and drawbacks of using the Rotterdam Criteria
  • The condition’s causes, predictors, and long-term consequences
  • Optimal prevention and treatment strategies.

The final report from this meeting is now available.  In addition to the summary, additional resources from this workshop are posted for review.   

37. Agency for Healthcare Policy and Research (AHRQ) Report Projected Hip Replacements

For the end of 2012, it was estimated that the total national hip replacements was to reach 440,000. Two-thirds of these hip replacements are due to osteoarthritis. The cost of each surgery is estimated to be $19,000. Musculoskeletal conditions affect muscles, joints, tendons, ligaments, and nerves and are the leading cause of chronic disability in adults worldwide. According to the 2008 National Health Interview Survey (NHIS), 110 million U.S. adults (approximately one out of every two people) report having a musculoskeletal condition. They are among the most disabling and costly conditions experienced in the United States, contributing to an estimated $849 billion in direct and indirect costs per year.
Orthopedic medical procedures can mitigate many common musculoskeletal conditions and improve patients’ mobility and quality of life.  The most common procedures for musculoskeletal conditions are knee arthroplasty (surgical reconstruction or replacement of the knee), spinal fusion (correction of an unstable part of the spine by joining two or more vertebrae), and hip replacement (total and partial). To read more about hip replacements see: HCUP Projections: Mobility/Orthopedic Procedures 2011 to 2012.

8. New Children's Electronic Health Record Format Announced

On February 3, 2013, AHRQ announced the availability of an electronic health records (EHR) for children that may become more widely available through an EHR format for children's health. Many existing EHR systems are not tailored to capture or process health information about children. The EHR format for children's health care includes recommendations for child-specific data elements such as vaccines and functionality that will enable EHR developers to broaden their products to include modules tailored to children's health.

The children's EHR format was authorized by the 2009 Children's Health Insurance Program Reauthorization Act (CHIPRA) and developed by AHRQ and CMS. The format is intended to improve care for children, including those enrolled in Medicaid and the Children's Health Insurance Program (CHIP), by guiding EHR developers to understand the types of information that should be included in EHRs for children. The format is designed for EHR developers and providers who wish to augment existing systems with additional features or to build new EHR systems for the care of children.

The format includes a minimum set of data elements and applicable data standards that can be used as a blueprint for EHR developers seeking to create a product that can capture the types of health care components most relevant for children. Child-specific data elements and functionality recommendations are sorted into topic areas that include prenatal and newborn screening tests, immunizations, growth data, information for children with special health care needs and child abuse reporting. The EHR format provides guidance on structures that permit interoperable exchange of data, including data collected in school-based, primary and inpatient care settings. The format is compatible with other EHR standards and facilitates quality measurement and improvement through the collection of clinical quality data.

Next steps include testing by two CHIPRA quality demonstration grantees, the Commonwealth of Pennsylvania and the State of North Carolina. As part of the longer term vision, CMS will work toward integration of the format into future editions of the Office of the National Coordinator for Health Information Technology's EHR Standards and Certification Criteria. This would be required for achieving "meaningful use" of certified EHR technology in future stages of the Medicare and Medicaid EHR incentive programs.

9. FDA approval of generic version of cancer drug Doxil is expected to help resolve shortage

On February 4, 2013 the U.S. Food and Drug Administration today approved the first generic version of the cancer drug Doxil (doxorubicin hydrochloride liposome injection). Doxorubicin hydrochloride liposome injection is currently on the FDA’s drug shortage list. For products on the shortage list, the FDA’s Office of Generic Drugs is using a priority review system to expedite the review of generic applications to help alleviate shortages.

 Generic drugs approved by the FDA have the same high quality and strength as brand-name drugs. The generic manufacturing and packaging sites must pass the same quality standards as those of brand-name drugs. The generic is made by Sun Pharma Global FZE (Sun). Doxorubicin hydrochloride liposome injection is administered intravenously by a health care professional. Sun’s generic will be available in 20 milligram and 50 milligram vials.

10. Study shows unassisted method works best to restore independent breathing in patients on ventilators

Use of a device that supplies humidified oxygen is more effective than a technique that reduces positive airway pressure delivered to the lungs in helping patients who have been on a ventilator more than 21 days regain the ability to breathe on their own, according to a study supported by the NINR, National Institutes of Health. The mission of the NINR is to support basic and clinical research that develops the knowledge to build the scientific foundation for clinical practice, prevent disease and disability, manage and eliminate symptoms caused by illness, and enhance end-of-life and palliative care.

The research compared two common methods for removing such patients from a ventilator, a practice known as weaning. One is to use a tracheostomy collar, which is placed over a breathing tube in a tracheotomy incision in the throat, and through which humidified oxygen is given. The other is to reduce the pressure support supplied via the ventilator.

The study found tracheostomy collars significantly outperformed pressure support in helping patients breathe on their own again. Researchers examined data on patients in long-term acute care hospitals (LTACH), which specialize in weaning patients from ventilators. Such patients are increasingly sent to LTACHs from intensive care units, or ICUs. The study found the median weaning time among the 194 study participants in an LTACH was six days shorter with tracheostomy collar use.

"By contributing to the evidence base for weaning from machine-assisted breathing, this study will help improve the quality of life for patients on ventilators by helping them regain their ability to breathe on their own more quickly," said NINR Director Patricia A. Grady, Ph.D. "Clinicians also benefit from patient-centered data — which nursing science studies such as this are providing — to develop the most effective guidelines for common procedures such as weaning."

Use of LTACHs for weaning increased 267 percent between 1997 and 2006. Yet the relative efficacy of these two weaning methods (tracheostomy collars and pressure support) within the LTACH setting has received little or no scrutiny.

The study was led by Amal Jubran, M.D., from Edward Hines Jr. Veterans Affairs Hospital, Hines, Ill., RML Specialty Hospital, Hinsdale, Ill., and Loyola University of Chicago Stritch School of Medicine in Maywood, Ill. Jubran and colleagues used a five-day unassisted breathing screening procedure to select participants from among 500 patients enrolled for the study. Three hundred twelve patients were selected and randomized, and 194 completed the study (118 died or withdrew, but were included in the analysis).

Participants were divided into two groups based on the time it took them to fail the screening procedure: an early-failure group (0-12 hours) or a late-failure group (12-120 hours). They were then randomly assigned to pressure support or a tracheostomy collar for weaning. Successful weaning for both groups was defined as the ability to sustain five days of unassisted breathing.

In addition, the researchers discovered several clinical variables associated with the time required for successful weaning in addition to weaning technique: age, ventilator duration before randomizing, the ratio of how fast and deep a patient could breathe, and the strength of a patient’s ability to inhale. The data also indicated that some patients could have been weaned at the ICU, avoiding the need for transfer to the LTACH, since more than 32 percent of the 500 enrolled passed the five-day unassisted breathing challenge.

11. Government-funded Study Shows Value of Emergency Checklists

A new AHRQ study (published January 16, 2012) demonstrated that health care providers are 75 percent less likely to miss a critical step in a surgical emergency if they follow a written safety checklist. While the use of checklists is rapidly becoming a standard of surgical care, the impact of using them during a surgical crisis has been largely untested. This study was also published in the New England Journal of Medicine.

Surgical crises are high-risk events that can be life threatening if clinical teams do not respond appropriately. Failure to rescue surgical patients who experience life-threatening complications has been recognized as the biggest source of variability in surgical death rates among hospitals, the study authors noted.

For this randomized controlled trial, investigators simulated multiple operating room crises and assessed the ability of 17 operating room teams from three Boston area hospitals-one teaching hospital and two community hospitals—to adhere to life-saving steps for each simulated crisis.

In half of the crisis scenarios, operating room teams were provided with evidence-based, written checklists. In the other half of crisis scenarios, the teams worked from memory alone. When a checklist was used during a surgical crisis, teams were able to reduce the chances of missing a life-saving step, such as calling for help within 1 minute of a patient experiencing abnormal heart rhythm, by nearly 75 percent, the researchers said.

Examples of simulated surgical emergencies used in the study were air embolism (gas bubbles in the bloodstream), severe allergic reaction, irregular heart rhythms associated with bleeding, or an unexplained drop in blood pressure.
Each surgical team consisted of anesthesia staff, operating room nurses, surgical technologists and a mock surgeon or practicing surgeon. Hospital staff who participated in the study said the checklists were easy to use, helped them feel more prepared, and that they would use the checklists during actual surgical emergencies. In addition, 97 percent of participants said they would want checklists to be used for them if a crisis occurred during their own surgery.

The practice of using checklists is borrowed from high-risk industries such as aviation and nuclear power, where checklists have been tested in simulated settings and shown to improve performance during unpredictable crisis events.

12. NIEHS Researchers Find Prenatal Inflammation Linked to Autism Risk

Maternal inflammation during early pregnancy may be related to an increased risk of autism in children, according to new findings supported by the National Institute of Environmental Health Sciences (NIEHS), part of the National Institutes of Health. Researchers found this in children of mothers with elevated C-reactive protein (CRP), a well-established marker of systemic inflammation.

The risk of autism among children in the study was increased by 43 percent among mothers with CRP levels in the top 20th percentile, and by 80 percent for maternal CRP in the top 10th percentile. The findings appear in the journal Molecular Psychiatry and add to mounting evidence that an overactive immune response can alter the development of the central nervous system in the fetus.

"Elevated CRP is a signal that the body is undergoing a response to inflammation from, for example, a viral or bacterial infection," said lead scientist on the study, Alan Brown, M.D., professor of clinical psychiatry and epidemiology at Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, and Mailman School of Public Health. "The higher the level of CRP in the mother, the greater the risk of autism in the child."

Brown cautioned that the results should be viewed in perspective since the prevalence of inflammation during pregnancy is substantially higher than the prevalence of autism.

"The vast majority of mothers with increased CRP levels will not give birth to children with autism," Brown said. "We don't know enough yet to suggest routine testing of pregnant mothers for CRP for this reason alone; however, exercising precautionary measures to prevent infections during pregnancy may be of considerable value."

"The brain develops rapidly throughout pregnancy," said Linda Birnbaum, Ph.D., director of NIEHS, which funds a broad portfolio of autism and neurodevelopmental-related research. "This has important implications for understanding how the environment and our genes interact to cause autism and other neurodevelopmental disorders."

The study capitalized on a unique national birth cohort known as the Finnish Maternity Cohort (FMC), which contains an archive of samples collected from pregnant women in Finland, where a component of whole blood, referred to as serum, is systematically collected during the early part of pregnancy. The FMC consists of 1.6 million specimens from about 810,000 women, archived in a single, centralized biorepository. Finland also maintains diagnoses of virtually all childhood autism cases from national registries of both hospital admissions and outpatient treatment. 

From this large national sample, the researchers analyzed CRP in archived maternal serum corresponding to 677 childhood autism cases and an equal number of matched controls. The findings were not explained by maternal age, paternal age, gender, previous births, socioeconomic status, preterm birth, or birth weight. The work was conducted in collaboration with investigators in Finland, including the University of Turku and the National Institute for Health and Welfare in Oulu and Helsinki.

"Studying autism can be challenging, because symptoms may not be apparent in children until certain brain functions, such as language, come on line," said Cindy Lawler, Ph.D., head of the NIEHS Cellular, Organ, and Systems Pathobiology Branch and program lead for the Institute’s extramural portfolio of autism research. "This study is remarkable, because it uses biomarker data to give us a glimpse back to a critical time in early pregnancy.”

This work is expected to stimulate further research on autism, which is complex and challenging to identify causes. Future studies may help define how infections, other inflammatory insults, and the body’s immune response interact with genes to elevate the risk for autism and other neurodevelopmental disorders. Preventative approaches addressing environmental causes of autism may also benefit from additional research.

The study was funded primarily by an American Recovery and Reinvestment Act grant from NIEHS, with additional support from the National Institute of Mental Health.

Association News

13. American College of Nurse-Midwives (ACNM) Announces Evidence on Safety and Quality of Midwife Care

American College of Nurse-Midwives (ACNM) has announced the publication of The National Birth Center Study II (NBSCII), a new piece of evidence regarding the safety and quality of midwifery care. NBCSII is a landmark study of more than 15,000 birth center clients that indicates midwife-led birth center care is a viable solution to the rising need for higher quality, cost-efficient maternity care in the US. The study appears in the January/February issue of ACNM's peer-reviewed journal, the Journal of Midwifery and Women's Health, and reports impressive outcomes, including a cesarean rate of just 6% - well below the current national average of nearly 33%. It also suggests that midwife-led birth center care could significantly drive down costs for US health care consumers.

14. New IOM Report – Delivering Cost Effective Cancer Care in the 21st Century

Spending on health care currently accounts for 18 percent of the United States' GDP. By 2037, that percentage is expected to increase to 25 percent of the GDP. Spending on cancer care is expected to increase because of the rapid influx of new cancer diagnoses as the population ages. Also, as more expensive therapies and technologies become the standard of care, there are concerns that the costs of cancer treatment could begin to outpace health care inflation as a whole. The IOM held a workshop to examine the drivers of current and projected cancer care costs as well as potential ways to curb these costs while maintaining or improving the quality of care. This report was published on February 13, 2013. 

An IOM workshop report is a summary of the presentations and discussions at the workshop. This document will contain only the opinions of those who attended and presented at the workshop. There are no consensus findings or recommendations in these types of reports.

15. ONS Publishes New Guide

The Oncology Nurses Society (ONS) has announced the publication of a new guide Cardiac Complications of Cancer Therapy. This clinical reference book is designed to help nurses and APRNs to assess and manage complex cardiac problems in patients with a cancer diagnosis. Describing the assessment and management of common cardiac problems, chapters in this quick-reference guide examine issues such as cardiovascular anatomy, the development of cardiotoxicity and the management of cardiomyopathy in patients. Other topics include:  cardiomyopathy, acute coronary syndromes, cardiac inflammatory conditions, cardiac tamponade, hypertension and heart failure in patients with cancer.

Federal and State Policy

16. The Family Medical Leave Act is Now 20 Years Old

According to an article published in the Detroit Free Press on February 7, 2012, the Family Medical Leave Act (FMLA), now in its 20th year, continues to provide support for American workers. This past year, approximately 16% of eligible workers took time off under the FMLA. About 57% went on leave for an illness. An additional 22% took leave for pregnancy or child care and 19% cared for a sick relative.

The law allows eligible workers up to 12 weeks of unpaid leave and requires that employers hold a job for these workers. About 57% went on leave for an illness. Other reasons to take leave are reported to be for pregnancy or child care (22%); and care of a sick relative (19%). It is interesting to see that most of the leave times requested under the FMLA is 10 days or less. Still, some workers do indicate that they would have used FMLA if they could afford time off without pay. Employees covered by the FMLA are those that work in companies with 50 or more employees and work at least 24 hours a week. It is important to see that employers do not note a significant lack of productivity when their employees utilize the FMLA. Of course, this law only covers about half of the workforce. Worker advocacy groups, such as the National Partnership for Women & Families, continue to advocate for expansion of this law to cover more employees and smaller size employers. In addition, advocates are interested in Congress passing a national paid family and medical leave insurance program. The Department of Labor implemented a slight expansion of the FMLA through regulations. They published new rules to allow military families to take leave to care for service members who are injured or called to active duty on short notice. The rules also extend the law to airline personnel and flight crews.

17. CMS Proposes Rule to Eliminate Onsite Physician Supervision in CAH 

On February 7th the CMS proposed a rule that would eliminate the onsite physician supervision of Clinical Nurse Specialists (CNS), Physician Assistants (PAs) and Nurse Practitioners (NPs) in Critical Access Hospitals (CAHs). The current rule requires a physician to make an onsite visit every two weeks. Instead they are proposing that a doctor of medicine or osteopathy should be present for sufficient periods of time to provide medical direction, consultation and supervision of services and are available through direct radio and telephone for consultation. CMS believe that proposing language to remove these barriers will enhance patient access to care in rural and remote areas.

Comments in support of this rule change can be made to CMS no later than April 8, 2013. Comments can be submitted electronically. You may submit electronic comments on this regulation at to and follow the "Submit a comment" instructions or by mail by sending to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-3267

18. Medicare and Medicaid EHR Incentive Program for Eligible Professionals

The National Quality Forum’s (NQF) Measure Application Partnership (MAP) is a public-private partnership convened by the National Quality Forum that reviews performance measures for potential use in federal public reporting and performance-based payment programs, while working to align public programs with measures being used in the private sector. MAP is the first group of its kind to provide upstream, pre-rulemaking input to the federal government on the selection of measures. MAP’s goals are to achieve improvement, transparency, and value in health care, in furtherance of the three-part aim of the National Quality Strategy (NQS): better care, affordable care, and healthy people in healthy communities. MAP reviewed more than 500 measures on HHS’ list of measures under consideration for twenty federal programs covering clinician, hospital, and post-acute care/long-term care. MAP supports the immediate application of 141 measures for federal programs and supports the direction of another 166 measures, contingent on further development, testing, or endorsement. MAP recommends phased removal of 64 measures, while also recommending six measures that are not on HHS’ list of measures under consideration be added to programs.  The Affordable Care Act (ACA) requires HHS to publish annually a list of measures under consideration for future federal rulemaking and to consider MAP’s recommendations about the measures during the rulemaking process. For a list of the measure proposed by the MAP and the proposed measure to be discontinued go to:

19. NACNS Joins Nursing Groups in Support of Marilyn Tavenner as Centers for Medicare & Medicaid Services (CMS) Leader

Marilyn Tavenner is currently the Acting Administrator for CMS. Previously, Ms. Tavenner was Principal Deputy Administrator for CMS. As the Principal Deputy Administrator, Ms. Tavenner served as the agency’s second-ranking official overseeing policy development and implementation as well as management and operations. Ms. Tavenner a nurse and hospital administrator has compiled a distinguished record of service in the public and private sectors. Prior to her entry into federal service, Ms. Tavenner serve in a key leadership posts with the major hospital system HCA.  She also chaired the Virginia hospital association. Congress will be acting on this appointment in the near future. 

20. Sequestration and Other Federal Spending Efforts

Sequestration went into effect on March 1, 2013.  The sequester is a group of cuts to federal spending. The sequester concept came into being as part of the Budget Control Act of 2011 (BCA), better known as the debt ceiling compromise. It was intended to serve as incentive for the Joint Select Committee on Deficit Reduction (aka the “Supercommittee”) to come to a deal to cut $1.5 trillion over 10 years. This Committee met, but opted to not come forward with a plan. As a result, the sequestration provision remained active.

The legislation called for the sequester to originally go into effect on January 1, 2013.  This would have been paired with the expiration of the Bush tax cuts and the payroll tax cuts. This was coined the "fiscal cliff." Knowing that these “hits” to the economy would be excessive at one time, a deal was reached by Congress to avoid the "fiscal cliff" and move the effective date of the sequester to March 1, 2013.

In the sequester, the budget funding cuts are evenly split between domestic and defense programs, with half affecting defense discretionary spending (weapons purchases, base operations, construction work, etc.) and the rest affecting both mandatory (which generally means regular payouts like Social Security or Medicaid) and discretionary domestic spending. Only a few mandatory programs, like the unemployment trust fund and, most notably, Medicare (more specifically its provider payments) are affected. The bulk of cuts are borne by discretionary spending for either defense or domestic functions. Most mandatory programs, like Medicaid and Social Security were exempt from the sequester.

The 2013 sequester includes and estimated total of $85.4 billion in cuts:

  • $42.7 billion in defense cuts (a 7.9 percent cut).
  • $28.7 billion in domestic discretionary cuts (a 5.3 percent cut).
  • $9.9 billion in Medicare cuts (a 2 percent cut).
  • $4 billion in other mandatory cuts (a 5.8 percent cut to nondefense programs, and a 7.8 percent cut to mandatory defense programs).

It is important to know that in the sequester deal, it was stipulated that more will be cut in 2014 and later; from 2014 to 2021, the sequester will cut $87 to $92 billion from the discretionary budget every year, and $109 billion total. 

On March 6, 2013, the House passed a continuing resolution (CR, H.R. 933) by a vote of 267 to 151. The CR includes language for some spending bills, but funds the Labor, Health and Human Services (LHHS) appropriations as part of a CR. This legislation would essentially keep the existing funding levels for most accounts and sets the total discretionary spending at $984 billion after the sequestration cuts that began on March 1, 2013. On March 11, 2013, Senate Committee on Appropriations Chair Barbara Mikulski (D-MD) and Ranking Member Richard Shelby (R-AL) proposed a bipartisan amendment as a substitute to the House continuing resolution.

A second appropriations CR plan is being proposed by the LHHS-ED Appropriations Subcommittee Chairman Senator Tom Harkin (D-IA). He hopes to offer an LHHS amendment to the Mikulski-Shelby substitute amendment. Chairman Harkin’s amendment will include the same total spending level as the CR, but is different than the Mikulski-Shelby substitute as to how it allocates funds. Of note is that Chairman Harkin’s amendment appears to provide funding for the Public Health Service Act's Title VIII Nursing Workforce Development programs. Some of the Title VII Health Professions programs appear to receive an increase, while all others are funded at their FY 2012 level.


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