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Curbside Consult with Dr. Jayne 12/30/13

December 30, 2013 Dr. Jayne 10 Comments

One of my favorite readers shared last week’s EP Talk with one of her struggling physicians. He made a lot of good points and they’re similar to those expressed by many physicians out there, so I thought I’d take a stab at responding to some of them. If you work directly with physicians and end users, they should resonate.

Dr. Jayne makes using the EHR seem like a piece of cake. I would like to see how it is working in her organization.

Actually, lots of people have seen how it works for us. We’re a reference site for several vendors (ambulatory, hospital, hardware) so we have sales prospects come on site to see how our physicians work with the system. We’ve also served as a reference site for existing clients who want a “do over” after failed implementations.

Our model has worked well for us and has been cloned by other clients and even by some who didn’t end up buying from our vendor. Keep in mind, though, that we’re seven years into our EHR journey, but I’d say most of the major kinks were worked out in the first 18 months while we were implementing. Key things that have made us successful compared to our peers:

  • Heavy use of piloting for everything we do, whether it was the initial rollout, adding a module, adopting PCMH workflow, etc. You name it, we pilot it first. Would-be pilots have to apply – it’s not a political giveaway and they have to understand what piloting means. It’s not a cakewalk. We use them to break the product and re-engineer the workflows to make it better before mass rollout. Sometimes it’s not pretty. Sometimes they never ask to pilot again, and that’s OK. It’s supposed to be shared learning.
  • We heavily incent our physicians to do the desired workflows and gather specific discrete data. We initially hoped for compliance through altruism or desire for quality, but what made the difference was cash. It’s remarkable what tying an annual bonus to EHR use can do to a physician’s attitude. We phased the requirements in over three years for legacy physicians, but new hires are expected to be immediately compliant.
  • Strong governance. We’re not afraid to terminate disruptive physicians or to encourage those who can’t meet our standards to leave the organization. Our non-compete is written so that providers can purchase their practices and keep their panels and stay in the same location as long as they don’t go to work for a corporate competitor. This lets those who are not a good fit depart without losing their livelihood. This is rare, but it’s one element of our success.

The quality of EHR progress notes is much worse than it was on paper. You get consults back with 5-6 pages of fluff but lacking the important information. This is only because the truly useful medical data is limited by the data entry speed.

I agree. Some of the notes that I receive are unmitigated garbage. Documentation quality is part of our peer review process as well as our coding review process. We’ve heavily modified the “stock” vendor notes for formatting, font, layout, and overall readability. Chart notes are in the APSO format with Assessment and Plan first rather than traditional SOAP format where the important information is at the bottom. We permit providers to dictate assessment and plan so that it’s readable and data entry speed is not a concern.

We assume wrongly that the doctors can be taught fast typing. The young doctors who learned at a young age will be proficient. And voice recognition sucks at this time, even for physicians without accent.

From experience, I disagree. Many of our more seasoned physicians are proficient with touch typing and with the EHR in general. One of them often reminds me how well he does with his favorite statement: “Young lady, I have been waiting for an electronic medical record since before you were born. I’d go up against any of you young pups with it.” He’s not kidding, either. For those who can’t type, they’re allowed to dictate through voice recognition.

Incidentally our voice recognition also does navigation and complex macros within the EHR templates. It’s truly amazing. I wasn’t specific about this in the EPtalk piece last week. A couple of readers reached out to me about similar systems in their organization and I agree they’re extremely valuable and very helpful for physicians who are challenged by EHR.

The training phase for voice recognition can’t be short cut. Our vendor has worked one-on-one with physicians who are having difficulty. We didn’t struggle so much with accents as we did with what I’ll call “surgical mumblers” who are used to hospital-based transcriptionists who slow down the dictation to listen at molasses speed so they can make out the words. When they complained about the system, I went and shadowed them. Frankly, I couldn’t tell what they were saying, so I wasn’t surprised that the system had problems with it.

Patients aren’t happy that we don’t give them undivided attention during the visit. Some physicians can multitask but others can’t, but the impression on patients is the same.

Again from experience (and also from data), I disagree. We actually surveyed the patients (during pilot phase of rollout) about EHR use by the staff and used it to reshape workflow during the rollout. Before they’re ready to go live, physicians have one-to-one coaching sessions and mock patient visits where they are critiqued on how they use the EHR. I’ve personally taken a Sawzall to office cabinetry when maintenance was taking too long and the exam room layout was a barrier.

If physicians still struggle, we’ll bring them to our residency program practice (which has cameras in the exam rooms) and work with them both in person and with mock patients. It’s not cheap and I don’t know any other organization that does this to the degree that we do, but it has saved a couple of physicians from leaving when they truly wanted to be successful.

Those physicians who did multitask before (such as performing physical exam while talking to the patient) do well on EHR. Those who didn’t multitask before don’t do so well with it. No surprises there.

What we do, though, is help those who don’t multitask by identifying what tasks must absolutely be done in the room (meds, allergies, orders, and patient plan is our policy) and the rest they can do immediately after the patient visit. We don’t force everyone into a cookie cutter workflow. We also include questions about EHR and the visit on our patient satisfaction surveys. Those results factor into physician bonus payments as well.

Looking at patient satisfaction scores before and after EHR, we noted no substantial differences on a per-provider basis. Those who struggled with patient satisfaction continued to do so after EHR, and some worsened. Those who were doing OK continued to do well. A fair number even improved, although most patients indicated patient portal and decreased wait times due to better scheduling as causative reasons rather than bedside manner.

Our product doesn’t work properly in Windows 7, only Windows XP, which is an issue. A good EHR should be multi-platform, should work on Apple computers, Linux, and other operating systems as well.

I absolutely agree with you here. Many vendors have struggled with this issue. I ran across one the other day whose product only runs on Google Chrome. I actually like Chrome, but it’s not exactly the most widely used, and is especially problematic considering that the limitation also applies to their patient portal. Chrome isn’t as popular among the Social Security set who seem wedded to Internet Explorer. I think they’re going to regret that narrow niche and I do wonder what exactly is going on with the programming that it won’t even run correctly on Firefox.

For client-server apps, the popularity of Citrix has helped systems feel more agnostic to end users, although Citrix itself can be a complicating factor in support and maintenance.

There were quite a few more comments, but I’m going to save them for the next EPtalk. What do you think about these issues? Leave a comment or email me.

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10 Responses to “Curbside Consult with Dr. Jayne 12/30/13”

  1. 1
    Keith McItkin, PhD. Says:

    “We’re not afraid to terminate disruptive physicians or to encourage those who can’t meet our standards to leave the organization.”

    What is a disruptive physician, exactly?

    And how many patients died unexpectedly during your 18 month get the links out period, exactly.

  2. 2
    Fourth Hanson Brother Says:

    Dr. Jayne cutting up a exam room with a Sawzall- I think I’m in love…

  3. 3
    MIMD Says:

    ” We heavily incent our physicians to do the desired workflows and gather specific discrete data. We initially hoped for compliance through altruism or desire for quality, but what made the difference was cash. It’s remarkable what tying an annual bonus to EHR use can do to a physician’s attitude. We phased the requirements in over three years for legacy physicians, but new hires are expected to be immediately compliant.”

    What a novel concept – paying professionals for work. Imagine that! Dr. Jayne, can you be a little more patronizing? You’re just too nice.

    “Strong governance. We’re not afraid to terminate disruptive physicians or to encourage those who can’t meet our standards to leave the organization. Our non-compete is written so that providers can purchase their practices and keep their panels and stay in the same location as long as they don’t go to work for a corporate competitor. This lets those who are not a good fit depart without losing their livelihood. This is rare, but it’s one element of our success.”

    How generous of your organization’s Commissars – oops, I mean executives.

  4. 4
    kevin Says:

    No matter how much saccharine added to the mix, there is still a heck of a lot of Kool Aid to drink with EHRs before you get the desired effect. Pity.

  5. 5
    In the field Says:

    As someone who is in the field like Dr. Jayne, I’d take her as a CMIO any day. We have no shortage of snarky whiners who choose to criticize from the sidelines or blogs. Taking a leadership stance and doing something about it is rare. Creating a clear, unambiguous picture of what is expected is key in any successful organization. Those that don’t agree are free to go elsewhere and it sounds like Dr. Jayne’s org has created a professional and compassionate process to allow for that. Its the cancerous minority that complains in the shadows yet doesn’t have the courage to do much more that needs more explicit action.

  6. 6
    Ann Farrell Says:

    Keith,

    Dr. Alan Rosenstein, MD MBA is a well respected Disruptive Behavior Specialist, consultant and long practicing MD. He began career in Medical Management with later focus on impact of MD disruptive behavior on RN satisfaction and quality of care. If not familiar, see his research in 50+ publications. (www.physiciandisruptivebehavior.com/about.php) Given growing cost implications, there is greater attention to the problem in many organizations.

    MIMD,
    Your accusations of Dr, Jane seems like projection given patronizing response. MANY decades-long proven approaches are blatantly ignored in HIT. Rather than a learning industry, we meet definition of insanity. Thus reinforcing critical success factors seems sadly warranted.

    Term Commissars reflects hostility toward execs conveyed by many MDs who sold practices to health systems, earlier with managed care (1990s), more rampant with ACA and global payments. In focus groups, MDs relay that much EMR pushback masks deeper concerns re loss of autonomy, “bean counter” corporate mentality and Big Brother surveillance enforced via computers. EMRs (particularly if poorly designed and implemented) can catalyze and direct anger and resistance to massive change being imposed. Long time happy users of well designed EMRs voices are drowned out.

    http://www.beckershospitalreview.com/uncategorized/umwe09424lk.html – link to a Becker’s-sponsored panel with HC diverse leaders (2 hrs. – MD employment discussion in first part).

  7. 7
    MIMD Says:

    Re: “Those that don’t agree are free to go elsewhere”

    “In the field”, what corporate spin control department do you work for?

    Free to go elsewhere?

    You obviously don’t know what can happen to a physlcian’s career when a loss of hospital privileges gets into the NPDB, or perhaps you do knopw but just don’t care.

    Also see my HC Renewal post “Some Year-End Observations on Healthcare IT: The Data Granularity Theater of the Absurd, Be Careful What You Ask For, And a Little Totalitarianism from HIStalk Blog.”

  8. 8
    Keith McItkin, PhD. Says:

    @ann_farrell The blogger was referring to disruptive physicians and EHRs, not RNs.
    The EHRs are disruptive and obstructive to doctors who try to take good care of their patients. RNs find them disruptive too but get fired if they complain, thus, they suck it up and ignore thier patients while tending to the EHR grids and forms unless their union complains. Besides, there is not any data showing that EHRs improve outcomes. They surely do not reduce costs.

  9. 9
    Gopal Singh Says:

    #disruptive physicians @Farrell

    In my hospitals, the nurses are disruptive to the doctors. They hog all of the computers with EHRs to enter stuff on their grids. They call incessantly for stuff because of their clinical decision support and need to document for the EHR, but they do not call for important stuff about the diseased patient.

    More over, the administration at my hospital is disruptive because they do not fix the EHRs when they get reports of trouble and they do not report the adverse events that occur from EHR problems.

    When the doctors complain, they are brought before the peer reviewers and are labeled disruptive, just as a Dr. Jayne’s place.

  10. 10
    (Almost) Retired doc Says:

    I agree with Dr. Jayne. The change is around us and for some of us, the change is hard. Rather than complaining about how medical practice is changing, we should should understand and embrace the change. It happens in every industry and as Darwin said “The weakest go to the wall”.

    @Gopal Singh

    It looks like that you don’t like the staff in your hospital nor the administrators. Why are you with the same hospital then? Posting complaints here is not going to solve these issues. Figure out a solution.

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