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Curbside Consult with Dr. Jayne 11/17/14

November 17, 2014 Dr. Jayne 2 Comments


Color me less than thrilled that the Institute of Medicine is now asking for EHRs to capture additional social and behavioral data as part of Meaningful Use Stage 3. That’s assuming that Meaningful Use is still viable now that the money is nearly gone and more than half of ONC’s senior leadership has left in recent months. Practice administrators have been dazed and confused trying to figure out if they are better off trying to apply for hardship exceptions, take advantage of the flexibility rule, or throw in the towel altogether.

I recently met a practice administrator who swore up and down her providers were attesting for Stage 2, even though they hadn’t yet installed a patient portal and didn’t have a Direct interface. Then again, she also thought that Patient-Centered Medical Home was some kind of design/construction initiative rather than a practice transformation activity, so I shouldn’t have been surprised.

I understand that the Institute of Medicine sees EHRs as a great place to mine data for research, but patients are already weary of having their privacy invaded. Anyone remember the Florida legislation to control whether providers could ask about firearms in the home? My vendor actually had to code in a setting where a practice could hide the firearms questions to avoid running afoul of the law.

Although we’re pushing patients to be more engaged and it’s nice to work with them when they are, at least in my world the majority of patients don’t care about engagement. They just want to be treated and get back to work, their kids, or whatever else was going on in their lives before they got sick. They’re not interested in proactively managing their health when they’re living paycheck to paycheck and think that even questions about alcohol and tobacco use (which are clearly linked to major health outcomes with most people understanding their significance) are over the line.

When we had to start asking about race and ethnicity, we spent on average two to three minutes per patient explaining why we needed that information and helping patients figure out how to answer the question. Many patients thought they were interchangeable, so we were at the front desk educating them on the vagaries of demographic data rather than collecting their co-pay and speeding them back to see the doctor. At least those particular pieces of demographic information don’t change over the life of the patient, so you only have to ask them once.

Now the academic crowd is going to push us to ask about factors that could change at every visit, including depression, education, intimate partner violence, financial resource strain, physical activity, social connections/isolation, and stress. I can tell you without gathering data or an exhaustive chart review that most of my patients would require discussion of the last four.

As a good primary care physician, I should be asking about these things anyway, but I want to ask about them at an appropriate time during an appropriate visit, after I have built a relationship with the patient. I don’t want them turned into screeners that my staff has to administer to every single patient so we can avoid being penalized.

Will providers be judged on the percentage of patients who follow advice to manage these issues, like we’re currently judged on the number of patients we can convince to go for colonoscopies or mammograms? That’s not what I signed up for as a physician. I should do my best to encourage my patients, but didn’t I spend a lot of time in medical ethics learning about patient autonomy and how the paternalistic model of healthcare delivery has to go? We’re just asking for more cherry-picking by providers as they dismiss non-compliant patients from their panels to improve their numbers.

Most patients don’t understand that their data is already being used for research by health plans and other payers without their specific understanding or consent. Sure, it’s probably in the fine print somewhere and it’s either aggregated or de-identified, but if you asked them whether they understand where their data goes or what it’s used for, they would say no. When people think their information might be used in a way they don’t want it to be used (or to be out of their control), they’re going to lie.

Mr. H’s recent poll showed that nearly half of HIStalk readers have withheld medical information from a provider due to privacy concerns. I’m one of them, I admit. Parents are lying on the California home language survey  because they don’t want their children labeled as “English learners” for fear they will miss out on other educational opportunities. The old medical school adage of “take the amount of alcohol the patient says he uses and double it” reminds us this is not a new phenomenon.

How about let’s actually get people to use the EHRs they already have and use them well rather than pushing more minutiae on overburdened end users? A friend of mine has an EHR with a great onboard reporting tool, yet hasn’t leveraged it at all for actual clinical care. They’re so busy trying to get their patient portal enrollment numbers up and micromanaging the rest of their “all or none” Meaningful Use metrics that they’ve lost their ability to do cancer prevention outreach, immunization campaigns, or other interventions that have been actually proven to save money as well as improve people’s lives. And that, dear readers, is a shame.

What do you think should be in Meaningful Use Stage 3? Email me.

Email Dr. Jayne.

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November 17, 2014 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 11/10/14

November 10, 2014 Dr. Jayne 1 Comment


Assuming that it doesn’t get delayed yet again, ICD-10 is a little less than 11 months away. For those of us who had been preparing for the most recent and now-postponed transition date, it’s time to dust off our implementation and training plans if we haven’t done so already.

My organization had already done a fair amount of informational outreach to physicians and other providers, so most people know what it is and that eventually they will have to use it. Their actually readiness to do so, however, is variable.

I have to admit that I’m not well versed on our plans for the transition in the hospitals. As our employed physician base has grown, I’ve had to focus more and more of my time on the ambulatory projects. Although I’m still privileged for inpatient medicine, I rarely see patients in that environment.

Even so, the communication from our hospital to rank-and-file admitters has been spotty at best. I think I’ve seen maybe a handful of emails since the last delay. Hopefully they will get on their game soon at least as far as communicating with community providers is concerned.

On the ambulatory front, however, we’re really gearing up. We’ve been on the ICD-10 ready version of our EHR and practice management software for a year. It was helpful that they bundled the ICD-10 functionality in with the 2014 Meaningful Use Stage 2 content so we didn’t have to take multiple upgrades.

Now that they’ve had a little bit of a hiatus with regulatory requirements, our vendor has again turned to coding actual functionality and usability updates, which puts me in the lane again for an upgrade prior to ICD-10.

Timing the need to educate everyone around an upgrade is tricky with ICD-10. We do plan to bring all the ambulatory end users in for some type of formal training for both processes and don’t want them too close together (training fatigue) or too far away from the go-live dates. We also have to remain sensitive to the realities of pulling people out of office.

Although I wrote a few weeks ago that we’re doing computer-based modules for new practice go-lives and for addition of incremental staff, we’re still planning to do classroom training for these two projects. We’ll likely supplement them with on-demand resources as well, but right now I’m planning for traditional training.

We did purchase some external vendor content for ICD-10 for certain high-dollar and complex subspecialties, but I’m responsible for organizing the plan for medicine-based subspecialties and primary care. We had external trainers in last year to train our core team (physician leaders, compliance officers, auditors, training staff, etc.) but I’m sure most of us have forgotten the nuances. We’re going to have them back after the first of the year to deliver a refresher.

In addition to the classroom training planned for closer to October 1, we’re scheduling monthly lunch and learn sessions to re-familiarize people with the concepts of ICD-10 and prepare them for more intense documentation. During the decade we’ve been on EHR, many of our providers have developed an affinity for voice recognition-based narrative documentation. Since they’re not using the discrete elements of the EHR as much as they used to, their ability to leverage discrete data to suggest appropriate ICD codes will be limited.

We anticipate that those who are afraid of learning a new coding system may want to rely more heavily on the EHR’s computer-assisted coding features, which will require retraining on the template-based workflows for those providers. Being able to identify those individuals early will be good, especially since we didn’t exactly budget for basic EHR retraining as part of our ICD-10 transition. I’m hoping we can leverage super users in the practices and our regional physician champions to assist, but I want to make sure all the bases are covered.

Although some of our providers complain about the restrictions of being employed, ICD-10 is a prime example of why physicians are willing to give up a degree of autonomy in exchange for corporate management structures. I’m working with two other people to put together our strategy and it will be rolled out to all of our practices. If those sites were independent, they’d be on their own to find a consultant, develop a program, or potentially try to just wing it.

Of course, those organizations that aren’t even on their ICD-10 ready software yet have additional work cut out for them. I don’t envy the upcoming months for them. With the estimated cost of the transition ranging from $50K for small practices to millions of dollars for the rest of us, there’s a lot at stake.

Are you ready for ICD-10? What’s your strategy? Email me.

Email Dr. Jayne.

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November 10, 2014 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 11/3/14

November 3, 2014 Dr. Jayne No Comments

I’ve taken a few clinical informaticists under my wing over the last couple of years. I shouldn’t be surprised, but I am still baffled that organizations expect someone to take a lead role with clinical software but don’t give them any training or support. I’m not talking about software training (although that may be a factor) but rather assistance with the skill set needed to manage the things that are about to come their way.

Clinical informaticists come in all shapes and sizes and with all kinds of titles and varying levels of experience. That’s the first thing I tell them – to forget about what their title might be and figure out what their duties actually are. The second thing to do is to figure out whether they have the skills to tackle their given areas of responsibility and to put together a plan to prepare for them.

Organizations tend to be penny-wise and pound foolish in this regard. They expect physicians to learn many of these things on the job, but sometimes forget to tell teams they’re responsible for helping to build that provider. That can create fiction among the teams and is often a challenge when providers are not comfortable with exposing a lack of knowledge and need for assistance.

In my first CMIO-type job, I was responsible for managing clinical content for a good-sized outpatient medical group. There was a team of young-ish (well, at least younger than me after umpteen years of training and medical practice) analysts that held the keys to the system as far as modifications were concerned. I was overwhelmed in my role (trying to do the job in four hours a week) and trusted that they were being straight with me.

They weren’t too keen on trying to help me learn the back side of the EHR. The IT team didn’t budget any time for me to go to training other than what I had as an end user. I decided to dig in with the system’s user manual and, believe it or not, read it cover to cover.

That experience was a serious eye-opener. First, I learned that the system had many more capabilities than I knew of. Second, I learned that my team had been snowing me as far as how challenging various configurations and customizations really would be if we wanted to perform them.

The trick was figuring out how to leverage my new knowledge without letting the team know I had discovered the mismatch between their work capacity and the product delivered. In hindsight, the portable putting green and disc golf equipment in their part of the office should have been a clue.

Although I tell them to try to forget about the title, it can be important especially if the title indicates the level of respect or support a clinical informaticist will have in the broader organization. My first stab at this was as a medical director. The CMIO title wasn’t even an option, as there had never been one and the CIO stated he didn’t feel it was necessary to have a CMIO. In itself, that gave me significant insight as to what I was signing up for. However, the only other titled physician leader was also a medical director and that was reassuring.

Regardless of the title, the ambulatory arm of the organization positioned me well and publicly explained my role and responsibilities as far as approving clinical content and working with providers to optimize the EHR implementation and ongoing use. This was important when physicians pushed back in areas that were clearly in my realm because I knew I could count on leadership to back me.

Unfortunately, some of my new colleagues are facing less than optimal situations. One is already chief of service in his procedural subspecialty at the hospital (with all the committee meetings and responsibilities that go with that) and yet is charged with leading a rollout for a largely ambulatory medical group. Although he’s very interested in clinical informatics and has done some coursework, the deck is already somewhat stacked against him.

The odds are also not in his favor regarding how the leadership positions him. Although they’re publicly telling physicians he is going to “run” the application team and “lead” implementations, the staff actually reports in a different vertical whose top leader is openly hostile to the idea of physician leadership. He’s gone on record as saying that CMIOs are “useless” and it does not appear anything has been done to modify the behavior or to ensure public support of the new physician leader.

I’ve seen that before firsthand, when IT and operational teams had difficulty working together. In one organization where I worked, the project’s executive sponsor forced the IT director and the operations director to have regular breakfast meetings with a report out of the issues they were working on to build their relationship and ability to collaborate. No one likes being “forced” to play nice, but sometimes that type of structured intervention is helpful (and often necessary).

In addition to title and responsibilities, the other thing newly minted clinical informaticists need to address up front is compensation. There are still organizations out there that think the job can be done under the “other duties as assigned” clause of the job description. Unless a clinician is only expected to manage a narrow window of content or functionality, it’s just not realistic.

I’m a full-time CMIO (my clinical practice is all on the side, outside of my primary employer’s control) and trying to manage user needs, application limitations, regulatory requirements, accountable and value-based care, and everything else requires coordination with multiple teams and resources. Compensation needs to be appropriate for the level of work being done as well as the responsibility involved and the overall impact to the organization.

Compensation should also include a budget for continuing education in informatics as well as the calendar protection needed to attend sessions and spend time gathering new skills. In my first medical director position, I actually lost my continuing education budget because our bylaws decreed that only full-time clinical physicians received CME funding. It took me 18 months to get training courses approved through our IT staff development budget, which specifically excluded CME courses. Talk about a Catch-22.

Being a CMIO, medical director, director of medical informatics, or clinical champion — or in my case, Jayne of All Trades — can be a rewarding experience. It’s even more so when organizations are committed to setting us up for success, although that’s not always the case.

Have a CMIO horror story? Email me.

Email Dr. Jayne.

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November 3, 2014 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 10/27/14

October 27, 2014 Dr. Jayne 2 Comments


In this week’s Monday Morning Update, Mr. H mentioned the UberHEALTH promotion where customers could use the Uber app to summon a nurse to administer a flu shot. The idea came from John Brownstein, a Harvard epidemiologist who saw the mismatch between importance and convenience of getting a flu shot. After the success of the program, he feels it might be a possible delivery model for basic preventive care as well.

Given the ebb and flow of my happiness as a CMIO of late, I decided to run the math and see what it would look like to take to the road.

Although as an Uber promotion the nurses had a driver, I could certainly drive myself. That would cut costs right there. I’d be seeing fewer patients each day, which would actually lower my professional liability insurance premiums. I wouldn’t be paying rent or utilities either.

I have a friend who has a retainer-based practice and does only house calls, so I know that I’d have to trick out a decent-sized vehicle that could handle vaccine and specimen storage, various equipment, and more, but it would still be cheaper than paying for office space.

EHR costs would be about the same, although if I ran it as a cash practice they would be significantly less due to the savings in billing services, audits, etc. I went back and forth thinking about a cash practice. Looking at the percentage of cash-pay patients I see at a local urgent care, it may be more realistic than one would think. There are increasing numbers of patients with high-deductible health plans, which may make a reasonably-priced cash practice very attractive.

Having limited equipment would actually help to keep costs down. There’s no temptation to order x-rays because it’s convenient if you don’t have a machine.

Several countries in Europe offer house calls as part of standard medical care. One of my medical school classmates who lives in Germany recently had a baby and was telling me about her benefits. Rather than cutting services as payers do here, plans offer generous coverage and even things we wouldn’t think about. She was able to get “homemaker” services to perform light housework while she recovered from her delivery and had home visits from a lactation specialist and a pediatrician with very little out-of-pocket cost.

Her family physician actually takes “first call” at night, alternating with other physicians, rather than screening the calls through an answering service. My friend asked her family doc how he liked that. He said the patients are respectful because they know they’re waking the doctor up and they only call if it’s an emergency. Because he’s the one on the phone with them, it’s easier to negotiate an office visit the next day or even a house call, rather than potentially just sending everyone to the emergency department.

It’s certainly not inexpensive to deliver care this way. Coverage is funded by a flat percentage of each worker’s income that is paid to a non-profit coverage fund. It’s mandatory, but due to the flat percentage, it varies by income, with higher wage earners paying more. Although most Americans would balk at paying 8-10 percent of our gross income individually for healthcare, when you do the math and look at what employers are paying, the cost of individual insurance, and the level of service, it seems like a contender.

Although she’s a physician, my friend isn’t licensed in Germany and works part-time as a medical editor. She did mention that highly compensated employees can opt out of the requirement and purchase “private” coverage from a for-profit plan, but she doesn’t personally know anyone who has.

My friend isn’t an expert on healthcare finance, but that model of care brings up some interesting concepts. She didn’t have a lot of feedback about EHR use among physicians other than to say that they’re significantly less stressed out about it than most of her friends in the States.

I’d love to hear from readers that have deeper knowledge on those topics or who have experienced that type of health system first hand. I’d also love to hear from providers in the US who have incorporated health IT into either mobile or direct/cash primary care practices.

In the mean time, I’m going to start shopping for a vehicle worthy of a diamond-plate accessorized vaccine refrigerator.

Got a sweet ride for patient care? Email me.

Email Dr. Jayne.

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October 27, 2014 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 10/20/14

October 20, 2014 Dr. Jayne 6 Comments


One of my friends from residency contacted me last week for advice on converting from one EHR to another. She’s a medical oncologist. Her organization is bucking the single-vendor system trend by allowing its oncology practice to move onto a specialty-specific EHR. They’re planning to use a private HIE to tie it all together for patient care and data integrity.

She wanted to know what kind of skills would be involved in supervising a data extract and migration since she had been asked to be the physician champion.

I started explaining that there are multiple dependencies involved – from how willing the “old” vendor is to participate in an extraction, to what kind of data is moved, to how ready the “new” vendor is to handle a conversion or data insert.

As we talked through demographic conversions, what to do with scanned documents, and various strategies to handle discrete data, it became apparent that no one had been discussing this process with the physicians at her organization.

She told me a little about the vendor they had selected — how great the demos were and how much better they think it’s going to be than their single-vendor platform. We talked about her current workflows and how they might change in the new system.

It sounded like they are heavily dependent on voice recognition technology at present, so I asked how the new vendor proposed to handle that. She wasn’t sure, so I asked if there were questions around that topic in the RFP. I was quite surprised to hear that they had just started working on it.

I asked if she even knew what RFP meant and she didn’t. I told her it was a Request for Proposal and explained that the RFP isn’t just something you send to the vendor for response. Ideally, creation of the RFP involves a thoughtful review of your current state and your desired future state. It’s your way of letting a vendor know what your organization looks like as well as learning what their organization looks like.

She interrupted me part-way through my informatics lecture. “But we’ve already had three demos with them and we really liked it. Why do we need to go through all that?”

I explained that the fact that she has been tagged as the physician champion for this system yet she has no idea whether the system can handle their current preferred method of documentation is a big problem. I brought up other key features that she should be knowledgeable about that would be largely covered in the response to the RFP: MU certification status and track record, eRx capabilities and intermediaries, Direct messaging capability and provider, support, etc. Then I dug into how they should be requesting information on how the vendor plans to support the transition, etc.

Since they’re coming off an existing EHR, those questions should have been included in the RFP rather than being posed to an old friend halfway across the country.

We talked about the requirements analysis that should have been done before they even looked at other systems. Did they actually document how they thought their other system was failing them, or what they wanted to have different? Who was involved in the discussions? Do they know who the decision-makers really are? What is the budget? What will they do if they can’t take their legacy data with them into the new system? Will they keep their current practice management system or transition completely to a new platform? Do they need a vendor who is willing to interface?

It never occurred to her that some EHR vendors will not interface with a third-party practice management system. I explained this is why the RFP process is important and not just to receive the vendor’s response, but to even know what business problems you’re trying to solve. We also talked about how proposals should be obtained from multiple vendors, not just the one you’ve pre-selected. In my organization (which has a strong and highly-regimented RFP process) we’ve had situations where one vendor’s answer to a question lead to additional questions for the other vendors as we hadn’t thought of a particular angle or process.

We also talked about the fact that her organization is a highly visible non-profit that receives a lot of state and federal funding, meaning if they don’t have multiple vendors competing for the contract, that might be a serious problem. Realizing that if they neglected to complete a proper RFP process they were probably cutting corners elsewhere, I had some additional questions for her. Did you check the vendor’s financials? Do you think they’re at risk to be acquired or to have financial difficulties? Do they have a chief medical officer and what are his/her credentials? Who has input into product development? Did you do any reference calls with current clients? Did you do any site visits?

As the call unfolded, she realized that being a physician champion (and thereby putting her stamp of the approval) was going to be a little more involved than she originally thought. I told her I’d send her some reading material and had my assistant drop my dog-eared copy of Jerome Carter’s EHR textbook in the mail. It’s not the current edition, but it will help her prepare for what’s ahead and figure out whether she even wants to be involved given the way her organization is operating.

It never ceases to amaze me that organizations are willing to put themselves at risk by failing to follow basic business processes. Even in her single-specialty situation, there are millions of dollars at stake. Not only the purchase, implementation, conversion, and support fees, but the potential loss of revenue if they don’t get this right.

Does your organization put the cart before the horse? Email me.

Email Dr. Jayne.

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October 20, 2014 Dr. Jayne 6 Comments

Curbside Consult with Dr. Jayne 10/13/14

October 13, 2014 Dr. Jayne 2 Comments


We are in the process of adding a variety of self-directed learning options to our EHR training. Up until now, we have had formal classroom training for clinical support staff and practice-based group training for providers.

Although we’ve had good outcomes from training, our paradigm is fairly resource-intensive. Additionally, providers complain about the time they spend in training sessions since it often cuts into their office hours even though we offer sessions before and after typical practice schedules.

One of the advantages of a resource-intensive training program is that it is the resources are intensely involved. When we train in small groups, we can provide individualized attention and can monitor who is catching on and who might be struggling. We can also ensure immediate follow up if attendees don’t pass our competency exam.

In turn, our learners can provide feedback on the effectiveness of our curriculum and presentation style so that we can modify it if needed. This is important when we bring new specialties live that our trainers might not be as familiar with as they are with other specialties.

We’ve had online refresher training for the last several years. It’s largely in the form of recorded web presentations, although we have a number of clips that were done with Adobe Captivate. They’re tied to our learning management system so we can see how many times each piece has been viewed and whether a particular employee is taking advantage of the resources. Managers can access a report of their employees’ activities, but the sessions are not required.

Our goal was to create some 5-10 minute segments that people could watch if they were having difficulty with a particular functionality or a new feature. Feedback has been good.

Given the budgetary pressures facing healthcare organizations, we’ve been asked to enhance our online offerings with a goal of reducing classroom training time. Staff will now be required to view a core set of e-learning offerings and managers will be responsible for tracking compliance.

I’m in favor of e-learning because it can be completed at the employee’s preferred time and location. However, I’m concerned that since reduced training time is the goal, that employees will be shortchanged. I can’t see some of our managers carving out protected training time for new employees. In particular, I know some of them will expect employees to jump right into patient care and learn the EHR on the fly.

Those same managers are likely to expect employees to complete the sessions on their own time even though that’s a violation of company policy. Staff working on uncompensated time might rush the training, or worse, multitask their way through it, diminishing mastery. We have a plan to gather data on whether the new strategy is effective, but based on the number and frequency of new hires, it will likely be six months or more before we know if it’s equivalent to our current platform.

I don’t like the idea of experimenting with our practices. We’ve worked hard to have a successful program and our practices get up to speed very quickly with only rare exceptions. Although we pull new hires out of the office for several days of training, when they return to the practice, they’re able to hit the ground running.

I guess my biggest concern is that there’s really no way to shortcut the material. A trainer — whether in person, recorded, or as part of an e-learning platform — can only impart information so fast. In turn, learners can only absorb so much in a given amount of time.

If this was an experimental drug, we’d first have to experiment on healthy subjects (or those who didn’t really need the training) to make sure it was safe. If it passed those tests, we’d have to experiment on more subjects to determine if it was more effective than placebo. Finally, we’d have to have a limited head-to-head trial against current training standards to determine if we should switch to it or not. Only if it passed certain statistical tests would we use it to replace our current training platform.

Since this is mostly about saving money, you can bet we didn’t have the opportunity to really study the new approach, let alone have an actual pilot or trial. We are being forced to switch everyone over without proof that it’s not going to lead to problems. As normally happens in healthcare IT, we were given a short deadline and limited budget to get it ready.

We’ve been in the business of delivering the impossible for a long time, however, so we’re up to the challenge. As for outcomes, only time will tell.

Have you been able to pare down training and maintain quality? Have great ideas? Email me.

Email Dr. Jayne.

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October 13, 2014 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 10/6/14

October 6, 2014 Dr. Jayne No Comments


Given the recent events at Texas Health Presbyterian Hospital Dallas, the Ebola virus is all our hospital can talk about. We’ve been combing through our infectious disease protocols and scheduling education sessions to ensure people have access to all the resources available.

It’s daunting to think of what might happen should the disease get a toehold in the US. Many of our hospitals are already taxed with the usual communicable diseases. During flu season last year, one of the local pediatric hospitals had to put a M*A*S*H style tent in the parking lot to handle all the cases coming in.

Although Ebola is statistically less infectious than other diseases (including HIV, SARS, mumps, and measles), the lack of available treatments and high mortality rate frighten the average person. NPR had a great graphic that we’re using to help educate staff and patients about the need to ensure we have appropriate precautions in place to treat all communicable diseases, not just the most worrisome ones.

We have measles outbreaks in our community every couple of years due to some concentrated populations who do not vaccinate. Measles has a fatality rate of around 25 percent in underdeveloped nations, compared with an average fatality rate of 50 percent with Ebola (although specific outbreaks have ranged from 25 percent to 90 percent). For readers who don’t have a clinical background, the World Health Organization fact sheet provides good information about what your clinical co-workers are contemplating.

According to WHO, single travelers have spread the disease to countries including Nigeria and Senegal, which adds to the worry around a traveler bringing it to the US. Unfortunately, the early phases look a lot like other viral illnesses – fever, fatigue, muscle aches, and headache.

I probably saw 10 patients with those symptoms in the emergency department during my last shift. If we had treated each one like a potential carrier, it would have brought our patient flow to a screeching halt. From an epidemiology standpoint, IT resources are going to be critical for surveillance and identification of potential cases in the US.

I’m glad Texas Health Resources released a clarification on their earlier statement that cited a “flaw” in the EHR as contributing to the release of the patient at his initial presentation. Ultimately, it’s up to the physician to take a detailed history and physical. We all know that even with the best nursing protocols, patients will occasionally add details when a second (or third) interviewer talks with them.

It used to drive me crazy as a student when a patient would tell the resident (or worse, the attending) a detail that they had omitted even when I asked specifically about it. It may be the time between evaluations that makes the patient think about other details, or maybe one feels more empowered and able to formulate thoughts after telling the story previously.

My initial response to their statement about a flawed EHR was to take offense on behalf of their physicians. It was almost like saying their physicians aren’t responsible for thinking about elements not prompted by the EHR, or that they’ve totally given themselves over to cookbook medicine. I reached out to a friend on staff there who shared my opinion. Whether there was pressure from Epic to update the press release or whether it was from the medical staff, it was the right thing to do.

Now I’d like to see their root cause analysis on why the history was not taken fully into account and whether the presence of scribes was contributory. I’d also like to know what kind of providers saw the patient and whether there were other circumstances at play, such as shift change, a full patient board, staff who called out sick, etc. Those factors have led to mistakes at my institution and they’re much harder to place solutions around than making sure the EHR fires alerts and that personal protective equipment and isolation rooms are readily available.

I’m curious as to what other institutions are doing to prepare themselves for a potential outbreak. Are you modifying your EHR workflows? Email me.

Email Dr. Jayne.

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October 6, 2014 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 9/29/14

September 29, 2014 Dr. Jayne No Comments


As a CMIO, I often feel my attention is all over the place. I’m dealing with clinical documentation needs for various constituencies while trying to ensure compliance with a host of federal, state, and other quasi-regulatory standards bodies. I’m also trying to implement tools to measure patient, physician, and employee satisfaction while maintaining my sanity in what seems like an upside-down healthcare world.

Given that background, you can’t imagine the serendipity I found when Dr. Andy’s recent CMIO Rant coincided with my weekend project to review E&M coding.

Due to some discrepancies in coding volumes after a recent ambulatory EHR upgrade, our compliance officers asked for a thorough review of the system’s E&M calculation tools. There are quite a few nuances to how the system codes and we’ve also had some recent coding education outside of the EHR, so I wasn’t convinced we weren’t dealing with another variable.

Our system is flexible and allows physicians to choose either 1995 or 1997 guidelines for each encounter. What if the recent coding class had physicians making different choices than they did previously? What if they were scared by the gloom-and-doom predictions of a RAC audit and undervalued their documentation?

I had been sitting for several hours with my trusty-rusty paper coding review forms, scoring visit documentation based on the guidance from our coding and compliance team. Once a visit was scored, I compared the results to the EHR’s calculations. Our EHR breaks down its coding suggestions parallel to E&M guidelines, so it is fairly easy to compare the bullets it counted vs. what I counted on paper.

Fortunately, our system does not advise on the level of Medical Decision Making, but rather requires providers to select that coding component. I can’t imagine how controversial the review would be if the EHR was prompting it.

There’s so much going on with HIStalk I tend to get behind from time to time. When I couldn’t handle any more bullet-counting, I took a break to catch up on HIStalk Connect and HIStalk Practice. Imagine my delight when I found Dr. Andy’s response to the AMA’s comments on EHR design. His first counter-request for the AMA is for them to help us fight “regulations that require overly detailed physician documentation, like the CMS E&M coding guidelines, which really set a floor of complexity below which we cannot sink.”

I laughed out loud, as I do every time I receive an email from CMS advocating their brand of “administrative simplification,” which has to be the biggest oxymoron ever. Just that morsel would have been enough to make my day, but then he covered their seemingly contradictory request for EHRs to lower cognitive workload while requiring them to enable dozens more tasks than we ever handled on paper. “Massive cognitive workflow” were the words he chose. Having had a 40+ patient clinic day this week, I can attest to the massive nature of the volume of information I had to process to care for them.

Note that I didn’t say data. Data implies the information is in the EHR or another accessible system that I could theoretically review. The reality is that physicians have to handle information on a much broader scale – the patient’s history, family members’ version of the same events, stories about what the patient read on Google, the physical exam itself, in-office testing, and more – on top of the actual electronic data available. Add to that mountain of information the fact that we’re now caring for patients in the office that would have been cared for in the hospital five years ago and it would be easy to become buried.

Reflecting on this massive cognitive workload inspired my new and improved “guidelines” for E&M coding. I didn’t have enough time (or martini fixings) to flesh out the entire scheme, so let’s confine our thoughts to established patient office visits.

Traditional E&M coding poses five levels of service – 99211, 99212, 99213, 99214, and 99215. The value of the visit (and thus the payments) increase as the level of service increases. Typically 99211 and 99212 are not used to bill actually physician services, so I threw them out. Talk about administrative simplification – I just slashed the number of things I have to think about by 40 percent.

Looking at the rest of the codes and what you have to have to justify documentation in the traditional coding construct, I identified some sample visits that were reflective of the codes even by conservative standards. They fell into nice groupings based on the amount of information the physician had to interact with during the visit. I’m not just talking about information that one would have to review, but also information one might have to deliver. Out of ten charts reviewed for each level of coding, I had a 90-100 percent concordance when using the “information burden” scheme to value my efforts.

Here’s how it works.

99213 – Now called “Mild Information Burden”

  • Patient has fewer than three issues he/she wants to be seen for today.
  • Patient has been seen at fewer than three healthcare facilities/providers in the last three months.
  • None of today’s issues will cause death or serious consequences if left untreated.
  • Determination of proper treatment requires review of fewer than three data sources (EHR, clinical data warehouse, HIE, antibiogram, CDC bulletin, guidelines website, Sanford guide, discussion with colleague, etc.)
  • Treatment requires fewer than three instructions, outside orders, or documents (patient education handouts, prescription, therapy order, referral, prior-auth, FMLA papers, etc.)
  • Visit requires less than 15 minutes for documentation.

99214 – Now called “Moderate Information Burden”

  • Patient has more than three issues he/she wants to be seen for today.
  • Patient has been seen at three or more healthcare facilities/providers in the last three months.
  • At least one of today’s issues will cause death or serious consequences if left untreated.
  • Determination of proper treatment requires review of three or more data sources.
  • Treatment requires three or more instructions, outside orders, or documents.
  • Visit requires more than 15 minutes for completion, including documentation.

At this point, based on my “rules of three” and the two levels of coding, you could quit. However, neither category covers what I had to manage for several patients seen in this week’s clinic. I decided to reserve the highest coding level for those special circumstances, but in keeping with the rules of three:

99215 – Now called “Severe Information Burden”

  • There are three or more non-office personnel in the exam room (patient, family members, children, interpreter, etc.)
  • Patient has been seen by facilities/providers that are members of three or more ACOs.
  • At least one of today’s issues will lead to hospitalization in the next three months.
  • There are three or more possible ways to treat one of today’s issues, depending on the patient’s insurance status and/or ability to pay for non-covered services.
  • More than three separate logins and passwords are required to access the data needed to care for the patient.
  • Visit takes long enough that it requires cutting three or more subsequent appointments short in order to catch up.

Maybe it’s just me, but those rules would be much easier to follow than what we currently have. I’d rather use my cognitive skills to deliver quality care and build relationships with patients than to remember whether I’m supposed to be documenting by organ systems or body areas. What does “expanded problem focused” mean anyway? Or “detailed”? I like to think that all my visits are detailed, if not comprehensive. Current E&M coding turns those perfectly good words into something incomprehensible.

Give it a shot – pull a couple of visits and see whether my proposed coding system holds up under the stress of your clinic day.

Do you dream of a world without E&M coding? Email me.

Email Dr. Jayne.

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September 29, 2014 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 9/22/14

September 22, 2014 Dr. Jayne No Comments


A couple of weeks ago, we performed a major upgrade on our ambulatory system. Officially we’re now ready for both Meaningful Use Stage 2 and ICD-10, with all the bells and whistles installed. As upgrades go, this wasn’t my first rodeo. It went smoothly with only one minor IT concern and no significant incidents for the end users.

Since no good deed should go unpunished, management is now looking to cut our personnel resources for the next one. They can’t seem to understand why several hundred hours of work went into the upgrade because clearly it was “no big deal.” Mind you, these are not old-school IT managers, but members of our ambulatory operations team who want to avoid having super users out of the office.

We rely on the participation of super users, not only from the ambulatory practices, but also from our central business office, central scheduling department, and central referrals department. No one knows end user workflows like the super users who work with them day in and day out. We have detailed test scripts for our internal testing, but we need real-world expertise to tease out the smallest bugs. Like any organization, our users have some creative workflows that we don’t train, and if we don’t have their participation, we won’t find those issues until go-live.

We’ve been using the same upgrade methodology for half a decade, which is usually goes off without a hitch. It’s a belt-and-suspenders approach, with some duct tape and baling wire thrown in for good measure. We do a dry-run upgrade just prior to the super user testing so that we can get our timing down pat for the main event. The upgrade weekend playbook has some elements timed to the minute and there is a single upgrade commander responsible for ensuring every step is completed and communicated.

Because of the need to involve a couple of third-party vendors to handle some data migrations that we wanted to perform while we had the system down, timing for this one was even more critical. There were numerous handoffs among DBAs, access management, application analysts, build analysts, internal testers, and end-user smoke testers in addition to the third parties. Although we don’t make everyone sit on a bridge line and talk through their work and the hand-offs, we do require people to notify the team when they complete a step or if they’re running behind so that we can adjust if necessary.

The lead analyst that usually quarterbacks our upgrades had an unexpected medical issue a handful of hours before we were due to take the system down, so I ended up co-managing it with one of our analysts. This meant being on call overnight for issues, which doesn’t bother me. Once you’ve been on trauma call or managed an ICU full of patients overnight, being on upgrade call doesn’t seem very scary. Still, you never want to hear that phone ring in the middle of the night. Shortly after midnight, I decided to grab some sleep since we weren’t expecting a handoff until early morning.

When the phone rang at 3 a.m., my heart was pounding. The tone in the tech’s voice wasn’t reassuring as she apologized for calling. Apparently the upgrade was running nearly three hours ahead and she wasn’t sure if she should wake someone up to tell them or not. I have to say, seeing an upgrade run ahead, especially by that much, isn’t something you see every day. I shuffled out of bed and we walked through the checklists to make sure nothing had been missed. I cruised the error logs as well. Nothing was amiss, so we had to chalk it up to the production server being faster than our test platform.

We must have our share of either insomniacs or nervous Nellies on our team because a couple of people were showing available on our instant messenger service. They were happy to launch the next few steps early. Despite the call being a non-issue, once your adrenaline is flowing, it’s hard to get back to sleep. I curled up on the sofa with some journal articles, which thankfully did the job. By our 8 a.m. status call, I was rested up and eager for the build and testing teams to get to work.

Even though everyone has remote capabilities, we require the regression testers and analysts to be on site. We’ve learned the hard way that people are sometimes less attentive when working remote on the weekends. Sometimes it’s just better to have two sets of eyes looking at the same screen together (without a WebEx lag or dogs barking in the background) for troubleshooting. It’s a sacrifice for the team to come in, but we try to make it as fun as possible. The kind of team-building you get from an event like this is often priceless. It’s also important for the end user and analyst teams to work closely together and build mutual respect.

In response to the questions about why we spend so many hours preparing and delivering an upgrade, I’m going back through the last couple of months and highlighting some key milestones that may have been riskier with a leaner team. We have multiple people trained to do each task, which was clearly helpful when our quarterback unexpectedly sat out the game. I’m also working to quantify the intangible benefits of having disparate teams work together.

We ended up being able to re-launch the system two and a half hours early, which meant less downtime procedural re-work for the patient care sites that are open on weekends. Due to the diligent prep, we also had fewer phone calls Monday morning than we’ve ever had. That’s got to be worth something as well. The question is whether the Administralians will agree with our analysis. If they don’t, maybe we can let them run the next one and see what happens. We’ve already documented our lessons learned and updated the project plan, so it’s ready to ride.

Ever jumped in when someone said “Cowboy up?” Email me.

Email Dr. Jayne.

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September 22, 2014 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 9/15/14

September 15, 2014 Dr. Jayne No Comments


I was having a pretty pleasant week until one of my group’s more challenging physicians walked into my office with a copy (printed, of course) of an article entitled, “Physicians report losing 48 minutes a day to EHR processing.” Once again, Medical Economics uses an eye-catching headline to remind us why EHRs are evil.

When looking at patient care, my colleagues will sit in Journal Club and rip scholarly articles to shreds, dissecting them and discussing why they do or do not apply to our patient population and care paradigm. They’ll argue about the composition of the study population as well as the methodology. Only when they’re fully convinced as to the integrity of the data and the statistical analyses performed will they agree to add the paper’s recommendations to their clinical protocols.

When there’s disparagement of EHRs to be had, however, they take the article as gospel without a single moment of review and pass it all around the physician lounge. This is the same physician who barged into a meeting last year with a survey of EHR satisfaction, demanding we replace our system. He didn’t both to notice that fewer than 20 respondents use the same EHR as us and are likely not in the same situation.

He took the same approach with this article and wouldn’t listen to anything I had to say, ultimately storming out when I wouldn’t feed into his negative energy. For anyone who does want to listen, however, here is my critical review of the article.

First, the article cites a survey by the American College of Physicians as the source of the data. Key points cited in the Medical Economics article included:

  • 89.9 percent reported at least one data management function was slower with EHR
  • 63.9 percent reported that note writing took longer
  • 33.9 percent said data review took longer
  • 32.2 percent said it took longer to read electronic notes

In digging deeper, the survey results were published in a letter in the Journal of the American Medical Association’s Internal Medicine. They weren’t published as part of a peer-reviewed study, which is an important distinction.

In looking at the letter itself, I’m not following the math. They said they sent the survey to 900 ACP members and 102 non-members. That’s 1,002 people by my math. In the next paragraph, they talk about “845 invitees.” Since 485 opened the email, that gives them a contact rate of 62.5 percent. But if you divide by the original 1,002 people to whom the survey was sent, I get 48 percent. Either way, only 411 of the responses were valid.

The survey also found differences in the time “lost” by residents vs. attending physicians differed – 48 minutes vs. 18 minutes, respectively. They suggest “better computing skills and shorter (half-day) clinic assignments” as possible contributing factors. I found the last sentence of the results section particularly interesting: “For the 59.4 percent of all respondents who did lose time, the mean loss was 78 minutes per clinic day.” Pulling out my handy math skills again, that would seem to indicate that 40 percent of respondents did not lose time.

The fact that this data was self-reported makes it less reliable than observer data. Their methodology relies on physicians remembering what their days were like a year ago (or two, or three, depending on when they went live on EHR) and comparing it to the present. I don’t know about you, but my clinical time is significantly harder for a lot of other reasons other than the fact that I’m on an EHR.

I’ve used EHRs for more than a decade and have to say that the Meaningful Use program (with its many required data elements) alone increased the time I spend charting. It wasn’t due to the EHR per se, but due to the required data. It’s kind of like when E&M coding was introduced – notes took longer because the volume of required data increased.

They authors seem to acknowledge this with their statement: “The loss of free time that our respondents reported was large and pervasive and could decrease access or increase costs of care. Policy makers should consider these costs in future EMR mandates.”

I also find it interesting that they didn’t mention results of any questions asking about how many data functions were faster with EHR. From my own experiences (across eight or nine different platforms) there are always areas that work faster and better in EHR and others that were faster on paper. But faster doesn’t equal safer, more reportable, or higher quality – it simply means faster. You can’t look at speed alone as a marker of EHR value, but I’ll take my EHR’s telephone message system over chart pulls and little pink pieces of paper any day.

When our medical group initially went live on ambulatory EHR, we actually did the time and motion studies pre-EHR and at multiple points post-EHR. We had data that showed that the EHR was neutral for time as well as for revenue. It didn’t matter that we had good data, however, because physicians naturally assumed that we “cooked the books” on it to show the EHR in a favorable light. That kind of bias is hard to overcome.

Looking at some of the raw data from our observations, we found the presence of a computer during documentation to be a confounder. Physicians were more likely to access other resources, such as UpToDate,  formulary information, or our system’s clinical repository, while reviewing data and documenting. Those resources were simply not available to them in the paper world. It’s hard to separate that kind of computer use from the actual use of the EHR product when you’re considering how long it takes to complete your notes.

I would much rather take a little longer because I spent a few minutes validating something in UpToDate than to simply finish faster. I also spend time in the EHR making sure patients get appropriate personalized education handouts, which I couldn’t do in the paper world. A survey cannot control for these other types of computer usage within the context of the EHR. Because of single sign-on and CCOW, half of my physicians would be unable to tell you where the EHR proper ends and the rest of our data universe begins.

What’s the bottom line? Although this survey has scholarly trappings, if other research was conducted this way, it would have holes like a block of Lorraine Swiss. The fact that review and documentation takes longer may not necessarily be a bad thing.

I’m interested to see what readers thing about the publication of this letter. Have thoughts about it? Or a favorite Swiss of your own? Email me.

Email Dr. Jayne.

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September 15, 2014 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 9/8/14

September 8, 2014 Dr. Jayne 2 Comments

Our EHR implementation team is in full swing again, thanks to a mad rush of acquisitions. Like many health systems, we’ve been frantically snapping up practices as we try to tighten our grip on market share.

Although it makes sense that we’d want to build the membership in our accountable care organization, it doesn’t mesh with the quality of some physicians we’ve decided to employ. At this stage in the game, if you’re not employed, you generally fall into a handful of groups: successful independent practice; member of an IPA or other group bargaining arrangement; renegade individualists (such as direct primary care providers); or disasters.

Although we’ve purchased a couple of the former, we’ve apparently acquired some of the latter. It’s easy to see why these disasters would want to be employed in the current economy. The medical group takes over credentialing, HR functions, operational management, billing, marketing, managed care negotiations, and the all-important provision of medical liability insurance. In return, the medical group stamps out competition and gets a captive patient population to add to its ancillary services pipeline.

Usually when practices are acquired, it’s a race to get the physicians migrated to employed status as well as to bring them up on our EHR. For the more savvy practices that have already been on an EHR, we’ve gotten pretty good at conversions. As long as there is data integrity in the source system, we’re able to do a fairly seamless transition. In this round of acquisitions, though, we’ve had a disproportionate share of practices coming off of paper or transcription.

As we race to get them started in our system, there is often little involvement by the operational teams to really look at the practice’s workflow and habits. The EHR implementation team is often sent in as the shock troops with the assumption that they’ll get the practice in line. I’ve fought for years to try to get operational management to understand that you can’t use the EHR as a weapon to beat physicians into submission. If there are serious issues with their office processes or habits, those need to be addressed first. At the current breakneck, pace those concerns are consistently being cast aside.

What do you do, then, when an EHR implementation uncovers serious problems in a practice? I joked to my CEO that if I could file as a Medicare whistleblower, I could retire on my share of the recovery for what I’ve seen this year. Although some of them are “typical,” such as phone messages on sticky notes and passwords taped to the monitor, others are much more serious:

  • A provider with over 1,000 un-dictated visit notes over a 90-day period (all of which were billed out already).
  • Lab tests and medication refills being ordered by unlicensed phone receptionists and front desk personnel without standing orders or a verbal order (otherwise known in many states as “practicing medicine without a license”).
  • Paper controlled substance prescriptions being signed by staff (otherwise known as forgery).
  • Loose pills in a desk drawer (gross as well as inappropriate).
  • Inappropriate web surfing (and it wasn’t online shopping).
  • Inappropriate office relationships (leading to one of my trainers, for the first time ever, abandoning a training session due to the behavior taking place).

I continue to be amazed that district practice managers and other leaders expect us to not only look the other way when we find these issues, but also to figure out how to successfully implement a practice where these happenings are commonplace and accepted.

Just dealing with the first example of un-dictated charts – if the provider was 1,000 charts behind using dictation, there is no way he is going to be able to document visits in the EHR in a timely fashion. I know if I don’t finish my charts as I go, I can barely remember some visits by the end of the shift. There would be no way I could try to dictate a day or two later, let alone three months down the road.

I am also amazed (although I guess I shouldn’t be) that our hospital organization is willing to stoop this low, acquiring practices that are known to have issues just because they want the market share. It’s not like these offices are hiding these behaviors. Even a casual observer could have uncovered them. I can’t imagine someone doing due diligence before purchasing a practice would have missed them.

We’ve also had to work recently in a practice that has what I would consider basic hygiene issues – trash not being emptied regularly in patient care rooms, exam tables not being sanitized, filthy physician white coats, food in the lab, things like that. If a practice is that cavalier about the basics of patient care, it would be difficult to assume that they’re going to be star performers when we start applying standardized workflows and patient care algorithms through the EHR.

I met with our senior leadership to discuss strategy for these situations. Although everyone was wringing their hands and making the right statements, no one agreed to take action. Essentially, the EHR team was told to figure out how to deal with it and to get them live and ready to attest prior to October 1.

In the past, we’d have jettisoned these practices after a year or so, but now that they’re part of our MU payment base, I wonder how it will play out. I can’t imagine them being successful attesters on such a short timeline, so maybe their lack of performance will help them out the door.

It’s no secret at my organization that I’m job hunting. It’s challenging enough to be a CMIO, living in the middle ground between the CIO, CMO, and CEO, all of whom have opinions about how you do your job. It’s another thing entirely to be asked to overlook (if not enable) fraud, illegal activities, and poor patient care.

I know from chatting with colleagues that I’m not the only one seeing these issues, although I may be in the minority in that my organization refuses to take a stand.

Are you a CMIO on the brink? Email me.

Email Dr. Jayne.

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September 8, 2014 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 8/25/14

August 25, 2014 Dr. Jayne 6 Comments


I usually start my day with a bagel and the local news, courtesy of a newspaper website. Once I catch up on homefront happenings (the comments are usually more entertaining than the articles they accompany) I hit a couple of national websites.

In the course of my usual surfing, I came across a link to “The End of Absence: Reclaiming What We’ve Lost in a World of Constant Connection.” I was able to find a couple of reviews and it looks like it will probably be one of my next reads.

Author Michael Harris looks at people born before 1985, namely because they “know what life is like both with the Internet and without.” For non-IT professionals and the general consumer base, I’d broaden that to include those that experienced life BC and AC: before computers and after.

I enjoy history, but never thought of myself as having lived through a major transformation. Don’t get me wrong — there have been many sociopolitical changes in the last few decades, but I missed out on the moon landing and other key “tech” touchstones.

I remember thinking some years ago about my great grandfather (who was born in the late 1800s and died in his 90s) and all he had seen in his life: from the Wright Brothers to the Concorde, and from Sputnik to space stations. He also saw the progression from the crank-powered phone to the cell phone and many other advances. At the time I thought of how cool that would be – to see that kind of change – and I also remember thinking that technology had come so far that I couldn’t fathom something that revolutionary.

Back then, broadband Internet was available, but it wasn’t a fixture in peoples’ daily lives like it is now. There was no Facebook, no Twitter, no cell phones in every person’s pocket. The iPod had barely been invented and it was for music only. We didn’t know we were on the cusp of an information revolution.

I was talking about this idea with a friend of mine over lunch yesterday. She has kids in middle and high school and was joking about the classic “back in my day, we rode dinosaurs to school uphill both ways” sayings she finds herself throwing at them. We talked about when we were exposed to our first computers (Commodore 64, anyone? TI-99? Apple II?) and what kids of today would think if they saw them in action compared to the smartphone firepower in everyone’s pockets. It used to be a major undertaking to put a computer lab in a school and now it’s expected.

Still, there are completely different sets of issues that today’s kids are dealing with involving technology and its appropriate use or lack thereof. At my friend’s local school, some teachers demand that students use technology in the classrooms and others ban it. I can only assume that the pre/post Internet generation gap might have something to do with it.

In thinking about my physicians who complain about the EHR, I don’t see a clear line age-wise. At least in our group, some of the older physicians tend to be more forgiving of the software’s shortcomings, perhaps because they expect less than the more tech-savvy physicians who tend to be younger. It would be interesting to do some actual research on their attitudes and opinions regarding technology in general as well as the EHR, but I’m not likely to find the time (or funding) to do something like that anytime soon.

One of the other concepts the book addresses is how people now use technology to quantify their self worth. I know the HIStalk team enjoys seeing how many Facebook friends, LinkedIn connections, and Twitter followers we have, but we don’t let it drive who we are.

I’ve seen multiple discussions on physician forums looking at teenagers who have significant psychological issues that stem from interactions with social media. One might infer that those of us in the “before” column had established our own sense of self independently of that kind of input, where those in the “after” column “lose the ability to decide for ourselves what we think about who we are,” according to the review’s interview with Harris.

I mentioned my own run-in with the “quantified self” after my running GPS was waterlogged. Being able to translate subjective experiences such as daily activities into actionable numbers is a powerful thing. It’s made a tremendous difference in my health and well-being, but I can see how data points might be overwhelming or discouraging to some. I can’t run a half marathon as fast as I could three years ago, but I can chalk that up to a bad knee and an uncooperative training schedule rather than letting it get me down.

Harris ends up taking a month off from the Internet while writing the book. Most of us could never do that for occupational reasons, but I like the idea of the challenge. As a physician, I frequently ask patients to limit “screen time” for their children. For many adults, it might be time to do the same. A quick search of ICD-10 codes fails to reveal much Internet-specific pathology, but we’ll have to see what ICD-11 brings.

Who’s with me for some time off the ‘net? Email me.

Email Dr. Jayne.

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August 25, 2014 Dr. Jayne 6 Comments

Curbside Consult with Dr. Jayne 8/18/14

August 18, 2014 Dr. Jayne 1 Comment


Thanks to Bianca Biller, who shared information about the new Practice Management System Accreditation Program (PMSAP).  The accreditation was developed through a partnership between EHNAC and WEDI. Three vendors (GE Healthcare, Medinformatix, and NextGen Healthcare) will be participating in a pilot program.

The program’s web page says the program “reviews the key functions of portability, interoperability, clinical integration, compliance monitoring, billing, reporting, and industry certification/accreditation” and that it will serve “as a baseline standard for providers in the process of PMS vendor selection and KLAS reviews.”

Although I like the idea of a program to ensure practice management systems meet the baseline needs of practices, I worry about yet another certification program whose hoops vendors will have to jump through. They can barely keep up with Meaningful Use, ICD-10, and CMS rules. Now we’re going to throw another set of requirements at them.

I also wonder whether practices will really find the separate certification of practice management systems to be meaningful. Many sites use systems that have combined practice management and EHR features. I doubt the lure of PM certification would be enough to convince physicians to consider changing systems when they are still struggling to attest for Meaningful Use. For those who may use separate EHR and PM systems, interfacing is a challenge that most wouldn’t want to repeat with a new vendor.

There are also the vendors that don’t allow interfacing with other systems. Others require you to purchase their PM system with the EHR and most physicians don’t have enough spare cash lying around to purchase a separate PM and interface it. On the other hand, if there is anyone who wants to make a change in their systems, transitioning from one PM system to another is often easier than trying to do an EHR conversion.

I downloaded the criteria document. Some of its elements include:

  • A diagram of “all sites that create, receive, maintain, or transmit PHI for the delivery of the services provided, whether company sites or outsourced organizations.”
  • Determination of the candidate’s status as a Covered Entity, Business Associate, etc. under HIPAA.
  • PHI disclosure and protection policies.
  • Controls against malware.
  • Documented customer service and escalation policies.
  • Minimum availability and redundancy to assure 98 percent system access.
  • Capacity monitoring and plans for handling peak load.
  • Compliance with applicable federal and state requirements and regulations.
  • Offsite six-month backup archive, storage, and retrieval capacity for all batch transactions with progress toward a seven-year back-up archive.
  • Ability to regenerate transactions going back 90 days within two business days.
  • Intrusion/attack monitoring capabilities.

One of my favorites is the requirement that “candidate must have sufficient qualified personnel to perform all tasks associated with accomplishment of the stated mission.” In speaking with most of my ambulatory-based colleagues, many feel their vendors are understaffed and overwhelmed most of the time. It’s a good thing that particular element isn’t mandatory for certification.

I find it interesting that the certification program only targets practice management systems. In my experience (both clinical and administrative), the inpatient financial systems are much more in need of supervision than their outpatient counterparts.

What do you think about the new PMSAP certification program? Email me.

Email Dr. Jayne.

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August 18, 2014 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 8/11/14

August 12, 2014 Dr. Jayne 2 Comments


Several readers were in contact this week to share their stories of what is going right in healthcare IT as well as to sympathize with my experiences in the trenches. Others tried to guess the location of the lighthouse – no one has nailed it yet and I’m reluctant to give up my favorite beach just yet.

From Northern Lights: “I wanted to share what we are doing based on big data. Evidence has shown the outcomes are better if the mother carries the baby for at least 39 weeks. We’re working to reduce the number of elective births before 39 weeks to zero statewide! My little ‘ole community hospital captures the expected due date from the mother at the first maternity encounter. Then we programmed the scheduling system to not allow scheduling of elective inductions or C-sections before the 39-week threshold. Rocket science, I know, but our hospital hasn’t had elective early deliveries in over a year.” She went on to say that a couple of the providers were afraid this would cause problems with vacation schedules, but accepted it once they saw the evidence. These are the kinds of interventions we should be doing with big data. I appreciate your sharing it with me.

From The Other Jane: “I saw Mr. H’s post about OBs having to take down the photos of the babies they’ve delivered, even when the photos in questions have been provided by the babies’ mothers. It’s sad that HIPAA is so restrictive.” I agree – I hadn’t seen that article before I read the Monday Morning Update. Most of our OB offices still have a baby board, so I forwarded the article to a couple of my colleagues. I thought our compliance offers were uber-conservative, but they haven’t caught onto this one yet. I doubt they read HIStalk and I’m going to pretend that I didn’t see the article.

I forwarded it to a couple of friends out of state as well. One sent back a copy of the consent form they keep on the checkout desk for parents who want to drop off a picture. Another said they’re skirting under the premise of implied consent and the parents have to physically place the picture on the bulletin board. The article mentioned fertility clinics not wanting to “out” parents who used an egg donor. I’m guessing that parents in that situation might not be so apt to give their infertility specialist a picture to post in the first place if they have that concern.

As a family doc who had a solo practice in a small town, I had to get used to patients who didn’t care about showing off their problems in the supermarket checkout lane. Patient privacy took a back seat to impromptu consultations or the chance to avoid a co-payment.

My favorite privacy violation took place one year during the Founders’ Day parade, when I was riding on the hospital’s float. A patient’s wife called over the crowd to tell me how much better her husband’s hemorrhoids were doing. No one batted an eye or looked shocked, which tells you a little about life in a small town.

Over on HIStalk Connect, Dr. Travis has written a fair amount about mobile fitness trackers and applications to promote health and wellness. I have used Garmin devices to track my runs for nearly five years. Unfortunately, my current one’s specifications for being waterproof didn’t stand up to my recent beach activities. I tried to resuscitate the patient using a Tupperware container full of rice, a Ziplock bag with silica gel, and even prayer, but it could not be saved.

I only use a fraction of its capabilities and use the same routes all the time, so I thought I’d test drive using a regular sports watch and manually logging my activities on the GarminConnect website. Even though I had the same data points, there was something less satisfying than having all the details for each unique run. I hadn’t realized how much I had subconsciously bought into the concept of the quantified self until I could no longer track my activities.

I could have done an out-of-warranty replacement for my GPS, but I decided to instead go for something newer and smaller. The process of trying to find the “right” device was daunting to say the least. One of my vendor friends turned me on to the DC Rainmaker blog, which had some great device comparisons that ultimately helped me make up my mind. I’ve never used a Fitbit or any of the other activity trackers, but ended up selecting a running watch that also has those capabilities. It was actually the battery life that made me choose that device over a similar one, but I thought I might have fun with some of the other features.

I braved the back-to-school tax-free shopping madness and it’s on the charger for tomorrow morning. I can’t wait to wear it to work. The inactivity indicator tells you to MOVE when you’ve been sitting more than an hour. I think that feature might become an integral feature for Meeting Monday.

What do you use to track your activities or quantify yourself? Email me.

Email Dr. Jayne.

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August 12, 2014 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 8/4/14

August 4, 2014 Dr. Jayne 5 Comments


I took some much-needed time off this week to try to gain perspective on where my career is going. What was once a pretty fun job has become a bit of a grind.

Ten years ago, we felt like we were doing cutting-edge work to transform patient care and help physicians deliver better outcomes. We were in the EHR business for the all the right reasons and were able to implement systems and functionality we needed when we needed them.

A good chunk of my responsibilities have been taken over by Meaningful Use. In our world, this has caused us to take workflows that were already improving patient care and then micromanage them to death. Maybe it’s the actual Meaningful Use certification requirements or maybe it’s the way our vendor has implemented them, but we may never know which is to blame. It’s probably a combination of both.

Either way, physicians and end users are unhappy with the volume of documentation they now have to do. They complain that it’s not really helping them in daily patient care.

As the CMIO, I take those concerns seriously and often personally. Although I have workflow experts and an advisory board backing me up, I’m the one who ultimately approves all clinical workflows before they’re implemented and all clinical system changes before they’re coded. If our vendor’s workflow is clunky and we don’t identify the potential problem before it goes out the door, that’s on me.

Our administration understands that sometimes we’re going to miss problematic content. They also understand that some of the MU requirements are so specific there’s just not a way to make them less annoying.

Our physicians are less understanding, however. I’m the one who has to deal with their concerns, complaints, and threats to quit. That’s not something they really train us to deal with anywhere along the CMIO training path, assuming we’ve actually been trained other than in on-the-job fashion.

I’m still relatively early in my career, but I’m wondering if I can take another 10 or 15 years of this. Considering my particular hospital situation, the bloom is definitely off the rose. I’m thinking about throwing my hat into the ring at another health system. The thing that makes me somewhat hesitant, though, is the thought that it could be just the same, if not worse, anywhere else.

How do you truly screen a potential employer or supervisor to know if they’re really visionary or just saying what they need to in order to get a position filled? I’ve had a couple of bosses that I would walk through fire for. It’s difficult to top that. At this point, however, I’d settle for someone who knew what he was doing and had the conviction to do the right thing rather than the easy thing or the politically expedient thing.

We’re in the middle of evaluating vendors for a massive system overhaul. I’m not sure our current leaders will survive, depending on which vendor is selected. That could be an opportunity for me to help move the remaining players around in a way that will rejuvenate some of our key players. Or it could be a reason for team members to jump for fear that they won’t make the cut. I’ll know more about what this is going to look like in six or eight months. Right now, we’re in a special kind of limbo.

It was good to get away, but increasingly difficult to completely unplug. There’s so much going on that it’s tempting to just peek at email, but I know better. One minute will quickly become one hour if you let yourself look.

When I got back in town last night, I had multiple voice mails from one ambulatory director with increasing anxiety in her voice because I wasn’t calling her back or returning her emails. Apparently she didn’t listen to my outbound message or pay attention to my out-of-office message that I wasn’t going to be on the grid.

I picked out two books before I left and they were an interesting contrast. I like southern fiction and the first one, The Hurricane Sisters, was available from my library’s e-book site. I checked it out for my iPad. It started with a lot of key southern elements, but I was shocked when I reached the point where Google Glass played a role as a significant plot device. Times are certainly a-changing! It was a quick read, not the best book ever, but good in the moment. I was pleased with my choice and it took my mind off things as I headed out of town.

The second one, On Call in Hell: A Doctor’s Iraq War Story was not exactly your typical beach read. It’s pretty graphic as only a book about Marines in combat can be, but I was amazed at the ability of the author and his colleagues to maintain their humanity and occasionally a sense of humor in the ultimate adverse conditions. Regardless of your feelings about war in general, reading about the experience puts everything in a different perspective.

One of the ideas that author Richard Jadick emphasizes is to be constantly improving one’s situation, whether it’s basic survival (sandbagging the forward aid station so you don’t get shot while caring for casualties) or figuring out better techniques to treat the wounded. It’s a powerful concept. It’s not about finding solutions to the chaos all around, but about figuring out your own sphere of influence and improving what you can within that space.

I’m taking that thought back to the office with me this week to see what I can do with it. I’ve already got a list in my head of what’s in my sphere of influence and what’s not, and some ideas on what we might be able to change for the better. I’m feeling pretty rejuvenated, but all that will change Monday morning when I finish tackling my inbox.

Have a transformative vacation story? Email me.

Email Dr. Jayne.

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August 4, 2014 Dr. Jayne 5 Comments

Curbside Consult with Dr. Jayne 7/28/14

July 28, 2014 Dr. Jayne 5 Comments

I had a chance to catch up with an old friend this weekend. He’s an OB/GYN, and as an employed physician, he’s had EHR in both the hospital and ambulatory settings for years.

Their efforts have resulted in massive amounts of data that can be mined to improve patient care. Surgeons can easily access their own outcomes data and compare morbidity and mortality data when incorporating new techniques (such as robotic surgery) into their practices.

There’s a dark side to that big data, however, and it’s starting to rear its head.

Although most laypeople are aware that babies are going to arrive when they’re going to arrive, administrators at his hospital may have missed that part of health class. They’re creating reports looking at delivery times and labor lengths under the guise of optimizing patient care. The seedy undercurrent of their research, however, is a desire to reduce staffing costs. Although they haven’t overtly said it, he suspects they’re on the verge of asking physicians to start acting in the hospital’s best interest rather than the patient’s.

I delivered babies at the beginning of my career. When you’re caring for a mother in labor, it can be hours of waiting punctuated by moments of terror. Although delivering a child is a natural human process, in the US, we’ve medicalized it for a variety of reasons. As a result, over the past quarter century, we’ve seen an increase in the percentage of babies delivered surgically (it sounds a little scarier when you say it that way, rather than “by C-section”) and there have been concerted efforts to try to reduce this trend.

It’s not just a problem in the United States. The World Health Organization has set a goal of 15 percent C-sections as realistic number for the procedure. In the US, it’s at about 28 percent, in Britain it’s 25 percent, and in Brazil, nearly 80 percent of women delivering in private hospitals have C-sections. Some blame cultural factors for the rise in the procedure. The ability to deliver “on schedule” is certainly a plus for some women as well as for their physicians. Others blame our medical payment system, because reimbursement is higher for a surgical delivery.

It’s not just C-sections, though. We’ve seen a rise in labor inductions, where drugs are used to start labor, often before the due date. Although there are definitely medical reasons when this might be indicated, it had become so prevalent (one in every five women) that ACOG, the OB/GYN professional organization, issued revised guidelines to try to ensure appropriate use of medical interventions.

Why would someone want to electively deliver a baby (through induction or C-section) anyway? Some blame the risk of litigation in the case of a poor outcome. Others blame physicians who want to deliver babies at their convenience. In my practice, I had a fair number of women request induction because they live far from their families and wanted to schedule the delivery to ensure relatives could travel to assist with the baby or help with young children at home.

In countries that spend a lot of money on post-partum home visits or in-home assistants, this may be less of an issue, because women may feel more supported at home after a delivery. Data is shared between community-based caregivers and coordinating physicians so that care can be delivered outside of the hospital. That kind of care has a cost, though, and isn’t an option for many US women, hence the request for inductions.

When thinking about cost controls, however, the idea of asking physicians to intervene in the labor and delivery process to try to better match facility staffing capacity is just too much to accept. Using data in this way sets us on a very slippery slope. What’s a little extra Pitocin? We can convince ourselves that it would be better for the baby to be delivered sooner than later, and if it happens so we can deliver before shift change, so much the better. Looks like the extra drugs may be creating some fetal distress, better prep the OR.

I haven’t delivered a baby in years, but I can’t imagine the stress of having my labor and delivery management decisions questioned by someone who has motives other than reducing maternal and neonatal morbidity and mortality.

Pregnant women are some of the most empowered patients I see in practice. They have more time to research various options and choose the best for themselves and their families, unlike patients facing cancer, injuries, and other unexpected issues. They share the knowledge of how to fight back against the medical establishment (as proven by anyone who has had a patient arrive with a 20-page Birth Plan) and are increasingly demanding of alternatives to the hospital birth experience. Many women in my area are using Doulas and Labor Coaches to have a dedicated patient advocate with them if they do deliver in hospitals. Some can cite the labor and delivery data and the risks of interventions better than a med student prepping for boards.

If the hospital is serious about this, I hope the physicians and nursing staff stand their ground. Better yet, I hope the patient community gets wind of it and reacts strongly.

As for my friend, he’s trying to work from the inside to convince hospital leaders that this is the wrong way to use big data. I hope he’s successful, but I also know he’s fearful for his job as an employed physician.

Have any other examples of misuse of Big Data? Email me.

Email Dr. Jayne.

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July 28, 2014 Dr. Jayne 5 Comments

Curbside Consult with Dr. Jayne 7/21/14

July 21, 2014 Dr. Jayne 4 Comments

A lot of people are talking about the recent JAMIA article that looked at whether Stage 2 Certified EHRs are ready for prime-time interoperability. It concluded that four key areas need to be addressed to improve CCDA quality. One area is “terminology vetting” for the multiple vocabularies used including SNOMED, LOINC, and RxNorm. Another area is reducing the amount of data that can be “optional” with a product still receiving certification.

I agree with both of those, as well as the paper’s assertion that document quality needs to be assessed in “real-world clinical environments.” However, it’s highly focused on the technical aspects of document exchange rather than the actual intellectual quality of the document being exchanged. I wrote about the quality (or lack thereof) of some physician notes a couple of weeks ago. Unfortunately, there are more elements besides the provider’s narrative and abbreviations that are problematic.

My health system is the ultimate best-of-breed nightmare, so I can attest to the fact that some vendors’ incorporation of the clinical problem list into the CCDA reads like one of those “choose your own adventure” novels. Is it an active problem, chronic problem, recurrent problem, or something that just happened once in the past? With some of our documents, I just cannot tell what it is trying to depict. I often feel like I have chosen a path to nowhere, just like the books.

There are fundamental differences between how physicians and other clinicians are trained to sort information. When I trained at a fairly “classical” medical school, we were taught that all of the patient’s problems were part of the Past Medical History, even those that were not truly past such as chronic hypertension, diabetes, obesity, etc. When I helped bring our organization into the EHR universe more than a decade ago, it took while for providers to get used to the idea of a chronic problem list being different from the PMH because many providers still wanted to include everything in the PMH.

Now we’re at the point where we have to educate them on the SNOMED-codified Problem List and how it differs from the ICD-10 Assessment List, even though there may be two codes that represent a single disease. I have finally gotten over it, but many of our physicians are still struggling with the concept despite having been trained two or three times.

Some of the CCDAs seem to comingle the two. It’s maddening. I’m tired of opening vendor support tickets to try to figure out if they’re functioning as designed or just messy. They must meet the letter of the law to receive certification, but that doesn’t necessarily mean they’re good for patient care or educating the patient on the conditions noted in his or her record.

Whether or not Eligible Providers are meeting the letter of the law or the spirit of the law with Meaningful Use is another hot topic. Lately, my running habit has been taking a toll on my feet, which prompted a trip to my favorite foot specialist. He’s a good friend of mine and part of a husband and wife team practice. They’re fiercely independent and have successfully deployed a Certified EHR over the past couple of years. We always chat about EHRs and where they stand.

I knew they were getting ready for attestation when the rooming technician came in with a wrist blood pressure cuff. In practice, I’ve found those kinds of cuffs to be notoriously unreliable, so I asked him if he wanted me to just self-report some numbers that would be accurate. He declined my offer and proceeded to document the 141/87 that the cuff read out. My blood pressure hasn’t ever been that high, but now it’s in my chart. When my colleague came in, I asked him what he thought about it. He wasn’t thrilled and said it sounded like some coaching was in order.

We talked a little bit about integrated vital signs monitors that would make things easier. He then he admitted that they’re thinking about throwing in the towel on MU. Their vendor has been doing a good job helping them dot the Is and cross the Ts, but the thought of an audit scares them. With all the points that must be perfect for an honest attestation, they are wondering if it’s worth the risk. Right now their patients are happy, their staff is happy, and their practice is running well enough from a business standpoint, so why upset the apple cart?

I don’t disagree with them. At times it doesn’t seem like it’s worth it. A lot of practices are just operating out of fear of future penalties or fear that commercial payers will adopt the CMS standards. Fear isn’t really a healthy way to run a business, however.

Since we’ve been friends for a long time, I offered to do a peer audit for them using my knowledge of MU to see how close to compliance they are. There are plenty of professional consulting firms that will do practice audits and they may want to ultimately do that, but are interested in seeing where they sit from a friendly point of view.

In the olden days (or in a truly free market economy) we could have traded some consulting for a free cortisone shot or something like that, but the insurers would take a dim view of that, I’m sure. Given my CMIO role, I also have to be careful about doing anything that could be interpreted as a donation from the health system so I don’t run afoul of any anti-kickback rules. When all is said and done, it will be interesting to see how many providers end up opting out of MU and what percentage of them are independent physicians.

Are any of your providers opting out of MU? Email me.

Email Dr. Jayne.

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July 21, 2014 Dr. Jayne 4 Comments

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