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Curbside Consult with Dr. Jayne 5/23/16

May 23, 2016 Dr. Jayne 6 Comments

I’m working with a client who hired my partner and me to do a complete review of their practice operations and both financial and clinical workflows. Initially, they had requested us for a system selection engagement since they were ready to jettison their vendor and look for greener pastures.

Since I’ve worked with this particular vendor multiple times, I strongly suspected that the problem wasn’t with the system at all, but with how it had been implemented and was being used. The client has been on the system for a long time and I suspected they hadn’t been keeping up with newer releases, or if they had, that they hadn’t been adopting new features and incorporating them in their workflows.

They understood that paying us for a thorough review and potentially executing a remediation plan would definitely be more economical than completely throwing out the system. My partner started digging through their financial workflows a couple of weeks ago and we didn’t find anything too surprising there.

The practice is a group of procedure-driven subspecialists. In our experience, those groups tend to be fairly strong at maximizing their financial returns. We found some opportunities as far as them not using some of the automation available in their system. Although it may save them a couple of staffing FTEs, in a group their size, it wasn’t truly earth-shaking. If we had to give them a grade on how well they’re using the system and keeping up with the times, we’d give them a solid B+.

The clinical team’s use of the system was something else entirely. As we worked through their clinical workflows, it was apparent that they hadn’t taken advantage of many of the system upgrades that had occurred since their initial go-live more than five years ago. Once we review the user workflows, we typically meet with the physician champion or super users to determine whether they are aware of new workflows and made a conscious decision not to use them or whether they were not aware of the best practices. We try to avoid having these conversations with end users because they become frustrated when they learn that there were enhancements that could have helped them and their practice didn’t implement them for one reason or another.

The group has had a fair amount of turnover with regard to EHR super users, although the same EHR lead has been present since system selection. With every feature we discussed, her answer was, “Nobody told me about this” despite the vendor offering free Web-based training every time a system upgrade was available.

The physician champion just wanted to argue about how poor the system was and how they were going to replace it anyway rather than wanting to learn about the features that would eliminate their pain points. He clearly was not on board with the practice’s executive committee decision to bring us in to try to fix the current system rather than chuck it.

We also found that essentially they had been doing what needed to be done to get their Meaningful Use incentive payments, but hadn’t at all embraced the clinical realities of the metrics they met. For example, they made sure that every patient had an entry on his or her problem list, but the lists were not up to date; nor was there any policy or procedure in place to cover how often they should be updated or by whom. As far as they were concerned, since their vendor provided documentation that the problem list was “in use,” that’s all they needed.

One of the providers I interviewed told me that he didn’t put any problems on the patient’s list that he didn’t personally treat. This is the classic view of the problem list as “the physician’s problem list” rather than “the patient’s problem list.” I tried to have a conversation with him about the goals of Meaningful Use in providing more comprehensive records for patients, making it easier for practices to integrate data, the evolution of patient-driven medicine, etc. but he was having none of it.

He mentioned that his job was to take care of patients and made statements that sounded an awful lot like he felt he was above making sure he was aware of all the different problems impacting the patient. I tried to use logic with him, noting that although he doesn’t manage a patient’s hypertension or diabetes, they’re certainly important factors to consider prior to putting the patient on an operating table.

I also demonstrated his system’s functionality to filter the problem list by sorting the problems that are attributed to him to the top of the list, but he continued to push back. Although he seemed to agree in principle, he wouldn’t arrive at the point where he admitted that he (or his staff) should be keeping an updated problem list.

Having tried the “it’s good clinical care” angle and failed, I decided to press a little more on the MU aspect. I asked how he felt about the fact that he accepted federal incentive payments for doing something that he clearly wasn’t doing.

Mind you, I had no problems pressing this guy because he’s taking home more than half a million dollars a year. He’s also pontificating about being there to care for the patient, but refusing to do the basics. I tend to get a little aggravated with people like this, having come from the primary care trenches where many of my peers were working long hours updating charts to provide complete and accurate data for their patients (simply because it is the right thing to do) while making 70 percent less money than this guy.

He rationalized his actions (or lack thereof) by saying that the EHR vendor provided documentation that he met the performance threshold. I explained that the reports deal with the fact that the problem list contains data, not that anyone is actually working with it or keeping it current. Ultimately the physician is responsible when someone attests on his behalf that he has done something that he clearly hasn’t.

Although this guy may be a technically brilliant surgeon, I’m not impressed with his professional ethics. When I told this story to a friend, he assumed the surgeon in question was older and had been trained in a more paternalistic model. This physician finished his training within the last decade, so I’m not buying that excuse.

Medical schools are doing a lot of work trying to shift physician culture and educate in the benefits of patient-centric care. Regardless of whether you use an EHR to document your work or not, we need to be doing things differently and this guy clearly doesn’t get it.

Still, as one of the highest-compensated physicians in his region, he’s being rewarded because we still value procedures over cognitive skills. Ultimately the drive towards value-based care should help with some of this, but I don’t think I’m going to see the change in my career lifetime.

Is it just me, or are there still a lot of physicians like this out there? Do you have to deal with them? Email me.

Email Dr. Jayne.

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Currently there are "6 comments" on this Article:

  1. I wonder if this dude understands “falsification of records submitted to the federal government” – a criminal offense for attesting to work not done for which federal funds are paid.

  2. Wow. This article has way too many examples to comment on, but overall, I shudder to think someone like this is out there practicing medicine and wish there was a way to flag such individuals so the patients would know to steer clear of them. Sadly though, many patients would not understand anyway and think “he’s a brilliant surgeon” because his surgical technique may be great, but miss the point that he chooses on to collaborate with colleagues for the benefit of the patient. I hope he’s not in my hometown!

  3. Dr Jayne, you got played. You wanted someone to do this to you. To push your buttons.
    You even admit that no one really cares about all these data entry points and numbers, attesting, numerators and denominators, not even CMS. He embodied exactly what you wanted, someone that sees no benefit from the EHR experience, as long as the software says he is meeting those meaningless points, that is good enough for him. To rail on him because he doesn’t spend an inordinate amount of time entering data, makes you mad, Dr Jayne, not him. Sure he gets paid for his skills, and pretty well, but compared to traders and financial folks and other careers, its a mere pittance. I think Dr Jayne actually has a bigger issue with primary care MDs not getting paid enough, rather than this person getting a half a million per year. Could easily make the same argument for teachers. But don’t forget, if you got skills, you got skills, which means he knows what he needs to know to take care of his patients. And technical skills do matter, whether you like it or not. If you get smashed in an accident and need the best surgeon out there to fix your hip, you want him, and THAT is what bothers you. You cannot reconcile that he has skills, gets paid, but could care less about MU and EHR data entry. You actually need people like this. Most of my surgeon friends could care less about EHR and MU. In fact, we don’t even participate, which may be the better answer for him. We use the EHR for making our care better, without all the nonsense. We enter everything we need, and forget about attesting and that garbage. We are the top ortho group/hospital in all of Ohio in total knees and hips, in the published quality data from CMS, and we get penalized by CMS because we don’t do MU. Funny isn’t it? you would think CMS would be paying us even more? And with MACRA, looks like we will be paid even less. But this little “value based payment” thing will pass, just like HMOs, and all the other regulatory nonsense that doesn’t work. I would argue, check yourself first Dr Jayne, as famously said at the end of Ferris Buehler’s Day off, “you are the problem”, not him.

  4. Have to agree with meltoots above.
    If this person is generating this type of income (whether or not you agree with this method of payment) OR if you want to look at it as the doc is taking responsibility for the medical care of his patient at this high a risk–

    1) Hire a facilitator to help with documentation, train them well. You could even make him pay 10% of his salary to do it (oh, wait, that is the penalty for “noncompliance” with MACRA).

    2) Perhaps a “solution” to your quandry as the tecnical advisor is to recommend the above, OR design an interface to assist in this. What a novel idea!

    I also have to wonder if this is a “repetitive problem” and the “turnover” is high, that there may truly BE a problem with the system as it stands. Remember, the final measure, of “value based care” is VALUE TO THE PATIENT. Have we demonstrated that the administrative drag on the system is improving pt care? Have we even shown it to save money.

    Or is your specialist actually getting the job done, and providing the value….

    I am a solo in primary care. I did do Meaningful Use (with a facilitator) for 2 years, then could NOT comply for the 3rd year as I was required to integrate imaging into my database, and integrate the labs into my note. Could not do. Does this make me a “low value doctor?”

    I pay an answering service… maybe the answer is to pay facilitators at the point of care. Oh, wait, isn’t that what the ERs are doing?

    Soooooooo the answer is NOT to make those “bad docs” do more administrative trivia but to hire scribes.

    Oh, wait, then the system would cost more with no added value.

    QED.

    My geometry proof for the day.

    Dr M in Western PA; matlev@comcast.net
    Thoughts?

  5. Dr. Jayne – I have been in healthcare IT for several years now and I couldn’t agree with you more.

    There are times when I feel disillusioned, and disheartened enough to leave the industry altogether. Big Health is rotten to the core and there’s plenty of blame to go around for $3 trillion/year that we are spending with no great outcomes to speak of:

    – Lobbying by interest groups (AMA, AHA, PhRMA, Biotechnology Industry Organization, MDMA) continues to operate largely in the vested interest of the respective industries that bankroll them
    – Patients continue to look for quick-fixes to problems that require lifestyle changes and a commitment to health
    – CMS is a mess consisting of red-tape, haphazard mandates from political overlords in the Congress (who are servile to lobbyists money), and some well-intentioned bureaucrats who don’t fully understand healthcare that tries to do what it can to move Big Health in a different direction. Doesn’t help that they largely created the fee for service market

    Your last sentence rings true – don’t see this changing in my lifetime. Every time I visit a small town with crumbling schools, roads, bridges and libraries but gleaming hospital lobbies and construction for new hospital towers, I develop a new crack in my heart.

  6. The future of medicine is care teams. Solo artists, no matter how smart, are going to lose value, credibility and support. If you are a difficult solo artist then multiply that times 10.

    “House” makes for great drama but is a lousy care provider in the real world.







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