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Curbside Consult with Dr. Jayne 6/27/16

June 27, 2016 Dr. Jayne No Comments

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I’m having a little bit of professional déjà vu this week. I originally started working in healthcare informatics somewhat by coincidence. I was working for a group that wanted someone to test-drive an electronic health record for the practice, and since I was relatively new and didn’t have a large patient backlog, I volunteered. Little did I know that it would eventually grow into a full-time career in informatics.

After my time piloting the EHR (which turned out to be a total mess of a system), I was asked to participate in the search process for a replacement. When they selected a system and were looking for a medical director to oversee the EHR project from a clinical perspective, I threw my hat into the ring.

It started as a half-day a week, which was compatible with managing a full-time practice. As the project ramped up, it became a full day a week, which was still doable, but once they wanted me on the EHR project half time, I knew I would have to do something different about my office practice. I contracted with a nurse practitioner to help me co-manage my patient panel.

That worked for a while until the informatics work began to take even more of my time. Eventually I was only in the office one day a week, which created an unsatisfying situation for everyone. Patients weren’t happy that they couldn’t get in to see me. Since I had previously run an open access practice, they were used to same-day attention.

Some of the patients resented the involvement of the nurse practitioner since, in my part of the country, this was well before the concept of “team-based care” started taking root. Those patients felt that if they didn’t get to see the physician, they were somehow being shortchanged. It didn’t seem to matter whether it was an acute visit or whether it was a chronic condition that we were managing through a comprehensive plan of care. The bottom line was that they weren’t getting to see me, and eventually it reached a point where I felt like I was unable to give good care.

At that point, I went to informatics full time, cobbling together enough clinical work to keep the licensing folks convinced that I was in “continuous practice” as required in my state. It’s not entirely clear what happens when you have a lapse in practice, but I wasn’t willing to find out.

Sometimes I covered my former clinical partners in the office when someone was out, seeing acute visits or functioning in a locum tenens capacity. It was a little unpredictable, so I started doing more locum type work and working with some other groups, eventually working my way towards emergency and urgent care practice.

I’ve been in that space (with the occasional stint in a “traditional” primary care setting) for nearly a decade now. While staying on with the health system, I worked in their emergency departments both as an employee and as a contractor. After some changes in their clinical staffing, I bounced around a little until I wound up in my current clinical situation.

I’ve been working with this group for over a year and it’s been an interesting journey. The group is growing by leaps and bounds. The managing partners know that clinical informatics is my full-time gig, so they’re flexible with my work assignments, which is good.

I only had one near-miss with my consulting travel when I had a serious flight delay and wasn’t sure I’d be home to work my shift, but my colleagues were very understanding and were ready to back me up if I didn’t make it. It was a nice feeling since being a part-timer sometimes doesn’t lead to those kinds of relationships. Maybe it’s because they’re just nice people, or maybe it’s because I work a fair number of “undesirable” shifts (weekends and holidays) and they’re grateful. The rest of the physicians and staff know that I have a full-time job elsewhere and are always interested to hear my tales from the consulting trenches.

It’s been a little odd, though, because I have no real leadership or management role and I’m used to working in that capacity. They’ve tried to get me to move into a more permanent role a couple of times, but I haven’t been ready to just yet. Part of the reason is that I’ve been trying to build my consulting practice, but part of it is that I simply am not a fan of 12-hour clinical shifts and that was part of the role.

Recently, though, as the practice has grown, they’ve shown more interest in having someone with a solid informatics background take over that part of the administrative tasks. When they came to me recently with an ask to devote “just a half-day a week” to the EHR and its related operational and clinical impacts, I found myself unable to say no.

Although the pay is less than I’d typically make consulting, it’s nice to have 10 percent of your work hours accounted for without having to try too hard. Not having to write project proposals, do accounting and hours tracking, and deal with the payroll and task aspects balances out the relative loss of income. There’s also the intangible feeling of knowing that my work is making a difference in the grand scheme of things rather than just being an informaticist for hire. They’re willing to be flexible on the hours I spend with them given my travel schedule. Knowing the personalities of my employers, though, I can’t help but think that four hours a week is going to turn into something more.

One of my favorite books to read to my nephew involves a mouse who wants a cookie. When he gets it, he asks for a glass of milk. When he gets the milk, he’ll probably want a straw, and then a napkin, and so on. If you give a clinical informaticist four hours a week…. You never know what might happen. I do hope it involves cookies, though.

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June 27, 2016 Dr. Jayne No Comments

EPtalk by Dr. Jayne 6/23/16

June 23, 2016 Dr. Jayne 1 Comment

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Lots of readers have written with their favorite travel stories in response to my recent post. Long lines at security checkpoints continue to lead the tales, with at least two readers noting trips where the TSA PreCheck lines were longer than the regular ones. Lots of people are frustrated with the summer surge in travelers, many of whom aren’t used to packing their liquids appropriately or getting rid of their drinks before trying to go through the scanners.

I have one friend with a pilot’s license who flies himself to jobs. I went with him once and have to say there’s something to be said about boarding at the local general aviation terminal and heading on your way. His company pays for the trips as long as they’re equivalent to the cost of a commercial ticket, but they did have to get a special waiver for insurance reasons.

I’m still waiting for my red-light ticket, which I imagine will come in four to six weeks once it makes its way through the rental car company data trail. I have a little bit of a bet with my partner, who thinks it will come much faster. Considering the wager, I’m optimistic that he’ll be reconciling the travel expenses this quarter instead of me. There’s always a chance I’ll get stuck with it again as well as having to pay the ticket, but where’s the fun in not taking advantage of a friendly wager?

It’s been a fairly low-key week and I’ve been glad to be working from my home office. It’s nice to have a 20-foot commute and be able to work in shorts and flip flops for a change. It’s also probably been good from a career preservation perspective since I’ve been on a lot of calls where had I been there in person, my facial leakage would probably have gotten me fired. Sometimes it’s the little things that just make you smirk uncontrollably. One of my consulting offerings is around conducting effective meetings and I’ve not only identified some candidates for additional services, but added some examples to my teaching arsenal.

I’ve mentioned before that I typically schedule 25- or 55-minute meetings rather than 30- or 60-minute meetings. This allows people to reset and recharge before the next meeting as well as clear the room and get organized. Of course, not everyone subscribes to that strategy which often leads to overlapping conference calls. It’s always awkward to come on the line in the middle of a call in progress, especially when all you were trying to do was arrive early so you would be prepared.

On one call this week, I arrived to find the moderator saying that, “It sounds like a couple of people here have a hard stop, so we’ll have to go ahead and end the meeting.” Yes, when your meeting time is up, it’s a good idea to end it regardless of whether everyone has a hard stop or not. Just because some people are willing to stay over doesn’t make it acceptable.

I also had so many calls that didn’t start on time that I started keeping a tally. The worst was a call that actually started 22 minutes into its allotted time. Although I hate wasting people’s time and money, as a consultant sometimes it’s my job to stay on the call until the client dismisses me. This one was particularly painful because it was scheduled to allow a prospective vendor to present its solution to my client. I had been engaged to help the client evaluate the solution since they’re a small practice and don’t have a lot of experience in this particular area. I’m certainly not impressed by a vendor that shows up late and isn’t prepared. I understand that sometimes inevitable things happen, but those are situations where one wants to call or text or do something to let people know you’re not just standing them up.

My other favorite is when people feel the need to make sure they say that the group is pausing for a “bio break” or a “coffee dump” or some other description of bodily functions. When did it stop being OK to simply say, “Let’s take a 10-minute break?” Do we have to discuss exactly what people are going to do during the intermission?

One of my calls this week was an all-day strategy meeting, which had several examples of restroom-related euphemisms. I was grateful, though, that it had a formal lunch break rather than a working lunch. Although my headset has enough range to get to the kitchen and make a sandwich or reheat some leftovers, I always worry that I will forget to put myself on mute. I was jealous though of the outstanding Texas barbecue that I knew was being eaten on the other end of the conference call. I had to be content with my chicken salad sandwich, but that’s how it goes.

I spent all day Tuesday creating recorded training materials for a client. They’re getting ready to migrate to a different EHR and ran out of steam in getting ready to train their end users. I long ago made my peace with Adobe Captivate and don’t mind doing the recordings, especially when it means not having to travel. They can be tedious at times, but fortunately the client realized that it’s still more efficient to hire someone to do it who has done hundreds of them rather than struggling trying to create them on their own. Fortunately, they had created most of the scripts and I just had to do some minimal polishing before digging in.

I also had the chance to attend a couple of educational webinars, which is a rare treat. They’re nice because I don’t have to present and can actually absorb information. Sometimes if I’m lucky and can plan enough in advance, I’ll hit the treadmill while I tune in, but that’s a rarity. This week I was able to catch up on some laundry folding and pack my suitcase while reinforcing my knowledge of MACRA and MIPS.

I’m back on the road in the morning for a quick proposal presentation to a prospective client, and as long as the travel gods are smiling, I’ll be home by dinner time. I hope they end up accepting it because they seem to be a really cool medical group that is already moving in the right direction but just needs a little boost. Those are my favorite kinds of clients, and the fact that they’re in a cool city doesn’t hurt.

What are your thoughts about the summer travel season? Where is your next great trip? Email me.

Email Dr. Jayne.

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June 23, 2016 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 6/20/16

June 20, 2016 Dr. Jayne 2 Comments

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CMS sent an email notifying people that it will be making updates to the portion of the CMS website covering HIPAA administrative simplification. Although users might be looking forward to “streamlined content and easier navigation,” nothing says “administrative simplification” quite like creating a new URL and making tens of thousands of users across the country update their bookmarks.

Unfortunately, this is just the tip of the iceberg with CMS and all the other federal bodies that have a say in regulating how we practice medicine and how our EHR vendors should support us.

A physician friend of mine works for a vendor. We had the opportunity to get together over the weekend and commiserate about what medicine has become and what MIPS/MACRA is going to do to our respective customers. He’s completely frustrated by some of the clinical quality measures that he is expected to bake into his application. Some of them aren’t really ambulatory measures and would require a lot of manual abstracting of hospital data into the ambulatory chart. There are another group of measures that impact few patients unless you’re in a narrow subspecialty, which makes it difficult for EHR vendors that are trying to support all possible specialties.

Others require use of screening tools that his company doesn’t already have rights to use. This process can take months (plus a fair amount of cash) to get legal agreements in place allowing software vendors to use proprietary screening tools. In the spirit of interoperability, shouldn’t our federal and regulatory “partners” be selecting the open-source equivalent for the content they are specifying? I know there may not always be a non-proprietary option, but if there isn’t, maybe they can use their development dollars to create initiatives and competitions to create that content so everyone can use it.

Every time we get into a regulatory update cycle, vendors’ attention is diverted from providing the content that their users want and need to providing what they are required to provide, regardless of whether their users plan to use it or not. My consulting firm is involved in a fairly deep way with three vendors, all of which are in the same pinch whether they’re privately owned or publicly traded. Of course some vendors are more nimble than others and they have it a bit easier as far as creating content and distributing it to their respective client bases. Like physicians, though, they’re all having to focus on checking the box. This means that they’re not necessarily as focused on innovation as they otherwise could be.

Vendors are not entirely without blame in this game, though. One that I work with frequently recently made a decision that defied logic: they changed the provider home page to remove the instant messaging portion that had previously been embedded at the top of the screen. Now, physicians have to go to a separate screen to address their messages, which not only adds clicks, but increases the possibility that something will be missed.

Since they didn’t use the real estate for anything else, it boggles the mind why they would have thought this was a good idea. I can’t imagine they did usability testing on this before releasing it to the client base, and if they did, I’d be interested to talk to the people who thought it was a good idea so they can explain it to me because I’m missing it.

As with so many things in healthcare today, it feels like we’re focusing on the wrong things. Case in point: precision medicine. Don’t get me wrong, I think technology is sexy. The idea of being able to look at someone’s genetic makeup and use that information to diagnose disease before it happens is extremely sexy. But it’s expensive. Given the need for research, development, etc. it has a long lead time, so that makes it feel a bit like we’re pouring money into something that’s not going to provide benefit to everyone, and not for a long time. That’s my perception from the trenches and I’m sure the perception from academia or industry is likely to be different.

It might feel different it we were also pouring money into proven but un-sexy solutions like public health. Obesity prevention, anyone? Getting the number of obese people in our country down under 20 percent again is going to save more lives and provide more quality of life in the intermediate to short term than precision medicine will. But it’s not sexy.

I was on a webinar the other day for family physicians where the speaker was telling us we’re supposed to be referring our patients to community gardens and organic food pantries as ways to combat obesity and food insecurity. Yet another thing for primary care physicians to do while they’re trying to keep all the plates spinning and coordinate care in an increasingly fragmented environment.

Where’s the funding to promote these solutions? Can I get an embedded care coordinator to reach out to those patients and have the conversation about community gardens? Can I get someone to pay for the custom reporting I’ll need to identify eligible patients by diagnosis and ZIP code? Guess what, there’s no funding for that. And even if you have an EHR that can do it and a population health system that can do the outreach, there’s no recognition of the fact that it’s additional work on the practice.

Of course if the dreams of advanced payment models and whatnot come true and we start to see additional reimbursement for this additional work, it might all balance out. But that’s not the reality that most of my primary care clients are living in today. I’m watching my colleagues retire or move to non-continuity practices like urgent care or cosmetic medicine in droves.

Although I find issues like this to be exasperating, it’s a good reminder of why I’m in consulting. Many of my clients are small practices that can’t navigate this world on their own and rely on my partner and me to get it done. We’re their first line of education and sometimes the last line of defense at keeping their practices afloat. They trust us to help them, and by extension, their patients. When it all works out, it can be very satisfying. But most days it just feels like a grind.

What do you think about the tension between high-tech and public health fieldwork? Email me.

Email Dr. Jayne.

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June 20, 2016 Dr. Jayne 2 Comments

EPtalk by Dr. Jayne 6/16/16

June 16, 2016 Dr. Jayne 1 Comment

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It’s weeks like this that make me want to hang up my consulting shoes for sure. Storms have intermittently snarled air traffic in the Midwest, making it hard for my partner and me to get to clients. Fortunately, since we work for ourselves, we have the ultimate authority as far as rebooking and rerouting and can decide whether we want to absorb the cost of a new ticket or stick it out.

On Monday, I was surrounded by business travelers who weren’t as lucky as I overheard several frantically calling travel agencies or seeking management approval to reroute their flights. As the week progressed, I did my fair share of sitting on the tarmac and also had one round of going back to the gate. Early summer travel is always dicey (especially if you have to go through Chicago) and my plans to avoid it never seem to actually happen.

I was optimistic yesterday morning, as I found a seat on an evening flight that would allow me to avoid leaving my hotel at 4 a.m. to catch a 6 a.m. flight to the next client. The only wrinkle was that I had to arrive at a different airport than originally planned, but that seemed OK since the client is halfway between two major airports and the drive time from each is about the same. I could arrive at my destination airport at 10 p.m., hop in my rental, drive for an hour and a half, and still get a good night’s sleep. My friends at my favorite hotel chain were happy to waive any early check-out penalty because I was booking the night at another hotel in the chain.

Little did I know that the travel gods were going to make up for my seemingly good decision in a multitude of ways. I arrived at the rental car vendor to find that there were no cars. Seriously, none. The staff was kind and offered bottled water while we waited for vehicles to be brought around. There were six of us who had come off the shuttle bus from my flight, all of us had reservations, and our flight was on time, so I’m not sure why it was a problem. Since I wanted to get to my hotel to crash, I took the first car available and headed for the exit.

All was smooth until exited the airport proper and immediately got nabbed running a red light. It was a large intersection and the light turned yellow right as I entered it, but it went red while I was in the middle of it. I’d chalk it up to bad luck, but there were three other cars that also got caught so I think it’s a timing issue on the lights. Regardless, I’ll be looking forward to a ticket in the mail in a couple of weeks and really didn’t need to add that to my to-do list.

I finally made it to the highway and settled in. I knew that I was going to have to be on toll roads, so I came prepared with cash. What I didn’t know is that the toll roads were coin-only, unattended. At the first one, I didn’t have the right change but made note of the website where I can supposedly go online and pay later. At the second booth, there was an attendant, but I was so flustered by the previous incidents that I forgot to get a receipt. Depending on who you work for, there’s no reimbursement without a receipt. I’m not going to quibble about a couple of dollars, but was just annoyed at forgetting it. At the third booth, I remembered to get a receipt, so thought victory was just around the corner. Sure enough, a fourth booth (again, unattended and coin-only) loomed.

I had planned ahead at the previous attended toll booths by making sure I got my change in quarters, so I was ready. There was a car in front of me whose driver was clearly digging through the console for change. He’d come up with a coin, throw it in the basket, and start digging again. I had my window down ready to throw my quarters in when it was my turn and could hear when he started cursing and yelling. Apparently he had thrown in enough change and it still wasn’t changing his status from “Stop!” to “Thank You” and he was getting agitated. He was reaching out and punching the toll basket. The yelling was getting louder and at one point half his body was out the window. His car was shaking from side to side because he was a big guy and he was getting really, really agitated. Needless to say I put my window up – there’s nothing quite like being trapped in a line of cars with someone acting strangely near you and you know you can’t get away. Given our current times, I wasn’t sure if he was going to end up shooting the toll station or what. He finally drove through.

I confidently tossed my coins in the basket and waited for my “Thank You” and never got it either. By now it was well past midnight, I was tired and agitated, and I just drove through, thinking I’ll sort it out on the website later. Clearly the booth wasn’t functioning correctly, but what can you do at that point? I thought back to my exit from the rental car lot –  they didn’t even offer the magic toll pass option, but I promise if I ever have to rent a car in this city again, I’m definitely asking for one.

I arrived at my hotel well after midnight, but luckily check-in was uneventful. The travel gods did finally reward me, though, with the best hotel water pressure I’ve had in a long time. People without long hair don’t always appreciate the value of ridiculously high shower water pressure, and people who aren’t on the road day in and day out may not understand the value of the little things when you’re away from home. When I got to my room, I found dozens of emails waiting for me and am now addressing them intermittently while I eat breakfast and get dressed.

For those organizations who work with consultants, it’s good to understand what your hired help might have been through to get there. If they look less than rested, there’s a reasonable likelihood that they had a hard day of travel rather than staying up watching Netflix and surfing the net. (Of course I’ve had the latter kind of days too, but they’re extremely rare.) So offer them a cup of coffee and a comfortable chair (my current one at the hotel doesn’t adjust up enough to reach the desk correctly, so I’m getting tingly nerves as I type this) and let them get to work. Don’t assume their travel has been glamorous and ask them to tell you about it. You might just get more than you bargained for.

What’s your worst travel day story? Email me.

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June 16, 2016 Dr. Jayne 1 Comment

EPtalk by Dr. Jayne 5/26/16

May 26, 2016 Dr. Jayne 2 Comments

My hospital’s “chasing the quality numbers” work is in full swing. This morning I received a five-page packet on how to appropriately document our new tobacco cessation Core Measure.

I’m not sure why it takes that many pages to explain that a) everyone needs to quit using tobacco; and b) we are required to help them do it. What’s worse, the packet didn’t even include instructions on how to do the documentation in the EHR – it was strictly around the philosophy of the core measure.

I pinged the physician who replaced me when I left my leadership position and asked whether they had built the workflow into the EHR. Unfortunately, they haven’t. They didn’t add tobacco cessation medications to the admission orders, nor did they include an easy way to document when you’re not ordering them due to a medical issue. This would seem to be an area that is ripe for order sets and clinical decision support. It wasn’t clear whether timeline or capabilities were the barrier, but either way, it’s a sad commentary on missed opportunities.

Other than that, my visit to the hospital was uneventful. I stopped by the physician lounge to grab a bagel to go. There was some conversation about the pending “star ratings” for hospitals and a recent Washington Post article was being cited. One of the health systems interviewed noted that smaller hospitals that treat less complex patients earned higher ratings than tertiary care centers. According to the article, the preliminary calculations for the stars would result in awarding five stars to only 100 hospitals nationwide. There’s no firm date on when the ratings will be released (it’s been postponed from its July date).

I understand the desire to have some kind of composite rating system for patients to use, but the lack of granularity makes it difficult to truly assess how well a hospital is performing. If I were advising my relatives, I’d recommend they look at specific data for the procedure they were having or the condition for which they were being treated, not an overall “feel good” rating. I’d rather go to a hospital with fewer stars but the top rating for my disease, if I have that choice. When this rating scheme is rolled out at the provider level, as is planned, it will get even more interesting. More to come.

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The last couple of weeks, I’ve had an increase in unwanted email volume. It’s not truly spam, but a combination of things that have to be dealt with, even if it’s just by deleting it. The folks who do the email blasts for the Annals of Internal Medicine apparently sent out a test blast of what looked like an online journal notification. It was followed up by an email saying it was a technical error on a test, and that it included “online journal content that was not valid.” Sure, they may take seconds to read, but it adds up throughout the day. I’m also seeing a deluge of LinkedIn requests. Pro tip: If you don’t have a last name, I’m deleting the email without opening it.

Furthering the email overload, this week AMIA migrated to a new online community platform and asked the Clinical Informatics Community of Practice to confirm receipt of the migration by replying to an individual. This resulted in dozens of “reply all” emails and even a request to be removed from the group. Those were pretty easy to sift out, but the last category of unwanted emails is more insidious. I receive quite a few emails each week from different vendors and organizations wanting to partner with me, often on the recommendation of someone I know. They start along the lines of, “I was talking to X the other day and they said we should consider working together” and then range from a general assessment of interest to a, “We’d like to talk to you on Thursday at 2.”

When I think I have colleagues or vendors who might be a good fit, I say something along the lines of, “I work with someone who does X. Would you be interested in seeing if there could be some collaboration?” If they’re interested, I then talk to the other party to see if THEY are interested and if both are amenable, I do an introduction. I don’t ever give out people’s direct contact information and would be horrified if I connected someone who reached out to my contacts and demanded a meeting at a certain time.

I had one of these situations this week and the vendor (which is actually a competitor) emailed me daily asking for meetings at specific times. Apparently they didn’t get the message that when someone ignores a cold-call email, they’re not interested. I’m usually pretty good at taming the email beast, but lately it’s just gotten out of control.

My HIStalk email has also been fairly full of people asking for advice, career coaching, and more. I try to incorporate as much of the advice and coaching into my posts as possible because the topics in question are usually of interest to a broad segment of readers. I’ve had several recent requests, however, where readers want me to review books or papers they’re writing or give advice about specific situations they’re encountering. I’ve had a couple of people get pretty demanding when I said I wasn’t able to accommodate their requests.

I think people forget that HIStalk isn’t my full-time job. I run a consulting company and also see patients I usually write Curbside Consult and EPtalk while I’m on a plane or sitting in an airport. If I’m at home, I’m usually writing it well after midnight. I still enjoy writing it, but some weeks its harder than others to find the time.

How do you keep your email under control? Email me.

Email Dr. Jayne.

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May 26, 2016 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 5/23/16

May 23, 2016 Dr. Jayne 6 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

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May 23, 2016 Dr. Jayne 6 Comments

EPtalk by Dr. Jayne 5/19/16

May 19, 2016 Dr. Jayne 1 Comment

The week has been chock full of stories that unfortunately I can’t even remotely write about. Although some of my experiences are universal and could happen almost anywhere, sometimes I run into situations that I can’t imagine happen more than once. I’m pretty good about writing them down, though, in the hopes that I can change them up a little bit and use them in the future.

If nothing else, this week I have gotten a lot of practice in trying to maintain my composure when I literally wanted to laugh out loud. I’ve also made good use of my skills in talking executives off the proverbial ledge when they’re ready to jettison staffers, building hope that with hard work and thorough follow-up, we can turn things around and prevent further casualties.

One thing I can talk about is my work with customers who want to work on population health projects. The first thing I do is a run a working session called “What is Population Health” that forces the organization’s leaders to come to terms with the fact that it’s often ill-defined, and even more so given the fact that everyone around their table has a different idea of what they think they need.

Plenty of people still think they’re going to be able to buy a single technology solution that’s going to deploy itself with minimal input. These are the folks that also think that these are IT projects rather than clinical and operational ones, and who are generally surprised when I explain that it’s going to take a village to get them done and that no one is going to be allowed to abdicate their responsibilities.

My clients often complain about their software vendors, demanding more bells and whistles than what exists in current general release versions. In my experience, many customers are using only a fraction of the tools they’ve already got, and sometimes the continued banter about future content is just an excuse to avoid dealing with current-state problems.

One of my clients had been fighting with a vendor about their ability to create complex reports to identify certain sub-populations of patients. In reality, the client wasn’t ready to handle even the simplest of population health work flows and refused to admit it. They need to spend a lot more time looking at their staffing and deciding who they want to be as a practice before they start outreach and disease management programs. For starters, they have to deal with their six-month appointment backlog and their insane phone volumes. Until they address those issues, they can’t handle more patient visit volume or consider offering non-face-to-face visits.

I love a good challenge, and the groups I’m working with right now are unlikely to disappoint. Although they require the kind of long-term consulting that’s going to need not only my partner and me but some contractors to execute, some of the help they need is of a more routine nature. I’m never surprised by how many organizations lack the basics, such as communication plans, service level expectation agreements, and other types of policy and procedure documentation.

There are different ways to approach dysfunctional organizations. Sometimes it needs to be done from the top down, sometimes from the bottom up, and sometimes you just want to implode the whole thing and start from scratch. Figuring out the best way to approach it given an organization’s culture and leadership is sometimes more of an art than a science and sometimes it’s frankly voodoo.

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The week has also been full of non-work laughs, with the best occurring at my home airport, recently made infamous by a viral video about their TSA lines. Fortunately, I had TSA PreCheck, so I was in a shorter (yet still long) line when my companion and I observed a woman with a hula hoop trying to cut the line. She started all the way at the back of the regular line and just kept working her way past passengers until she got to the first airport employee who was sorting the PreCheck passengers from those with regular clearance. She was slurring her speech, explaining that she was going to miss her flight and that she needed to get to the front of the line with her friends. Although the agent stalled her for a bit, eventually she was let through.

By now plenty of people were watching the spectacle from all four or five lines that were snaking their way towards the actual TSA agents. She was just shoving past people by this point, with no one stopping her. Whether they were worried about getting into a confrontation with someone who was possibly impaired or disturbed or something else, most of them stepped aside as she pushed past, thumping passenger after passenger with her hula hoop slung over her shoulder. Most of us in the PreCheck line were waiting for TSA to send her packing, but were surprised that they let her through.

This circus was a stark contrast to my experience at another airport recently, where my friend was forced to check her bag because it was slightly non-rectangular, having been crushed on an earlier flight to the point where it exceeded the bag-sizer’s dimensions by half an inch due to its skewed shape. At that airport, they were examining bags before people were allowed in the security line, vs. my recent experience where the hula hoop was allowed through. I’m pretty sure a hula hoop fits neither in the overhead compartment nor under the seat in front of you, so I wonder what they did with it on the flight.

Regardless, it was good to have some diversion before I boarded a flight where I knew I’d be immersed in the exciting world of QRUR reports, which require a 20-page document to explain their contents. I envy the travelers that board with a stack of magazines or their headphones and eye mask. Those magical minutes during takeoff, taxi, and landing before I can fire up my laptop and get to work are always good times to reflect on the week ahead or behind, depending on which way I’m heading.

I chuckled to myself as I thought of one client leader who still can’t figure out how to pronounce my name despite multiple onsite visits. One of his colleagues told me they play a behind-the-scenes game to see how he’ll mangle it next. Someday I’m going to write a book, and it’s going to center around the fact that you can’t make this stuff up.

What are the craziest things you encounter during your work day? Email me.

Email Dr. Jayne.

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May 19, 2016 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 5/16/16

May 16, 2016 Dr. Jayne 4 Comments

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I’ve been doing a fair amount of travel lately, which usually ends up in administrative tasks being pushed to the side. Although I try to handle things real-time on the road, there are always things that accumulate at home.

I spent most of the weekend playing clean-up, doing such exciting things as organizing documentation for my accountant and making appointments for automotive maintenance and piano tuning. Being in a world where everyone wants to do everything online, I dread having to do business with people or organizations that insist on doing business by phone, yet have limited working hours. I also spent several hours getting information together for a financial planning session, but putting the documentation together just made me wonder if I’m ever going to be able to retire.

With all the turmoil of MACRA, MIPS, and the never-ending parade of acronyms that I’m sure will continue, I don’t have to worry about having enough business as a consultant. I probably work a little more than I want to, partly because I’m still playing catch-up with retirement planning, owing to the decade that I spent with student loan payments that prevented more than minimum savings.

I do some career counseling for pre-med students and always make sure to bring up the debt aspect for those considering careers in medicine. I’m hopeful for the future when I meet with young, idealistic go-getters who are ready to save the world. However, I find that most of them haven’t thought about all the ramifications of becoming a physician.

It’s graduation time, and thousands of recent grads are going to be packing up and heading off to medical school. Although there are more so-called “non-traditional” students in the ranks, the majority of medical school students come straight out of college. Once school starts, they’re immersed in a world that demands all their time and can wreak havoc on families, relationships, and personal well-being. Although there are safeguards now with regards to work hours and student and trainee supervision, it’s still a very difficult path for anyone to choose.

A non-medical friend came across this piece on bullying in the operating room and asked whether I had ever experienced that kind of treatment. Although it was never directed at me, I definitely witnessed it, especially in high-stakes specialties such as surgery and critical care. I did personally experience bullying that was less dramatic but no less distressing. Although those kinds of behaviors are less tolerated now than they were when I was in training, they haven’t gone away.

Organizations spend a great deal of time and money working on cultural problems. For people to do their best, they need to feel like they are part of the team and that their participation matters. They need to feel like their work is meaningful and that the people around them value and appreciate their efforts. Sometimes changing culture isn’t enough. In the case of bullying, there need to be clear policies and procedures around what is and is not acceptable behavior in the workplace. Those who break the rules need to be subject to corrective action that is applied evenly regardless of job title or political status.

When an organization aims to change its culture, it needs to do more than just pay lip service to the idea. I see a lot of groups just going through the motions, saying the right words while they take the wrong actions.

One hospital I worked with hired a vendor to deploy an electronic employee engagement platform while completely missing the point about what their employees wanted and needed to feel valued. They didn’t want to receive boilerplate e-cards – what they really wanted was meaningful feedback from their supervisors during the course of their day-to-day work. They didn’t want to hear about their “total rewards” when the organization eliminated personal days and the ability to roll over sick days from year to year. They wanted to believe that the leadership understood them and their needs.

I worry that the increasing stresses to the healthcare system will further strain employee morale as organizations are going to be asked to deliver more with resources that are already strained. For those of us straddling the tech and healthcare worlds, it’s increasingly difficult to watch tech vendors offer their employees perks such as unlimited vacation and gourmet employee catering when hospitals are cutting benefits and front-line clinical staff barely get lunch breaks. I think some of these vendors have forgotten where the money comes from – ultimately it’s all funded by you and me, whether we’re funding it as patients, payers of insurance premiums, or as taxpayers.

It’s not just IT vendors that are guilty – plenty of organizations are feeding at the healthcare trough. Even though we hear about the most egregious examples of drug markups and Medicare fraud, there are countless examples of profiteering. I recently overheard a conversation in a hospital cafeteria where a medical device sales rep was talking about his new Porsche. Although I believe everyone should have a chance to be successful and should enjoy the benefits of their hard work, bragging about it at a table within earshot of patients who might be choosing between paying for medicine and purchasing groceries is just tacky.

This is the environment that our idealistic future physicians will be faced with as they start their training. I can’t even fathom what healthcare will look like in four years when they complete medical school, let alone in seven to 10 years when they finish residencies and fellowships. Will we see mass exodus of seasoned physicians? Will we see mid-level providers and ancillary professionals delivering an increasing percentage of care? Or will physicians opt out of the new world order and go back to delivering care the old fashioned way, with direct payments from their patients?

What does your crystal ball show for the future of healthcare? Email me.

Email Dr. Jayne.

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May 16, 2016 Dr. Jayne 4 Comments

EPtalk by Dr. Jayne 5/12/16

May 12, 2016 Dr. Jayne, News 1 Comment

I spend a lot of time hearing physician complaints about EHR usability. It’s certainly sensitized me to the issue of usability in general.

Let’s face it – there is some pretty poor software out there, in all spaces. There are some websites I visit that just want to make me scream, especially ones that use technology reminiscent of Geocities circa 1990-something. No matter what industry one works in, if you have to use something day-in and day-out that makes your life harder, you’re not going to be happy.

I was grateful today that I only have to renew my state controlled substance number once every couple of years. It’s bad enough that I have to register with both the federal Drug Enforcement Agency and also with my state, but their website put me over the edge.

I knew it was going to be a pain when the login screen told you to make sure you had enough time to finish the renewal because the system might time out on you. Then, it told me to turn off my pop-up blocker, but not until I had been through multiple screens that had to be resubmitted when I arrived at the pop-up step. They also introduced new fields that had to be completed for each practice location — fields detailing the number of hours per week spent in various activities such as patient care, ambulatory administration, inpatient administration, research, etc. Since I work a varied schedule at more than a dozen sites, this meant pulling numbers out of the air to populate more than 72 fields.

Additionally, when you save each location, it fires a popup that tells you that you need to complete the fax number for the location if it has one, despite it not being a required field. That was another 12 clicks and 12 screen refreshes that I didn’t need to do.

The final usability flaw was when I arrived at the credit card payment screen. Although it leaves the card number and CVV fields blank, it pre-populates the expiration date. If you’re like me and either multitasking or simply get distracted, you look back and the expiration field has numbers in it, so you move on. Unfortunately it then pops up that your card is expired, and sends you back three screens for you to re-key the information.

It felt like an exercise in futility, but what’s a girl to do? Complaining to the board that regulates your ability to prescribe certain drugs feels like you’re just asking for an audit. There’s no competition and no choice, so you just have to pay your fee (which feels like a cash grab, since we’re already regulated by the DEA) and be happy about it. Or if not happy, at least resigned.

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On the opposite side of the usability chasm, there are plenty of vendors who are actually getting it done. One of the things I enjoy most about HIMSS is checking out emerging solutions and looking at vendors that are trying to break into the market with something novel. It doesn’t always have to be a “gee whiz” product. but it might be just someone who is doing things better or slightly different than the people who are already in the market.

I recently had a chance to look at iScribeHealth and learn about their journey to market. Their mobile app solution is an adjunct for EHR documentation. It allows providers to enter key data elements such as medications, problem list updates, histories, and more without using the EHR. It also supports dictation and charge entry.

They recently took their first batch of clients live. It’s quite different moving from the development phase to the real world and I’ll be interested to see how things go over the coming months. They’ve got some good hooks in their marketing material – encouraging users to “free yourself from late nights spent updating patient charts and wishing you had chosen a different career path.”

They’re also pushing the patient engagement aspect, allowing physicians to focus on the patient at the point of care and not on the technology. They also have automated reminders and surveys to connect with patients outside of the visit. Personally, they had me with their martini glass icon. Who doesn’t like a cosmopolitan in their daily workflow?

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Just when you thought you had recovered from HIMSS16, it’s time to start planning your submissions for HIMSS17. The call for proposals opened last week and runs through June 13. They’re also looking for reviewers to take a look at all the content submissions during the summer months. I’ll let you do the math on how many months it is from the time the submissions are due until the actual presentation and determine for yourself whether it’s easy to keep things fresh with that kind of lead time.

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I’ve previously been somewhat down on the American Academy of Family Physicians and other organizations for enabling some of the negative forces impacting physicians today. They have posted some introductory modules covering MACRA and the shift to value-based care. I appreciate their taking it down to the basic level that many physicians need to try to understand what’s about to happen to them.

In people news, today the National Institutes of Health announced the appointment of Patricia Flatley Brennan, RN, PhD as the new director of the National Library of Medicine. She has a long history in the informatics community. I find it most interesting that her doctorate is in industrial engineering and she has worked to leverage that knowledge in health care. The best implementation director I ever worked with was a ceramics engineer by training, so I appreciate what that background and mindset can bring to the table.

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May 12, 2016 Dr. Jayne, News 1 Comment

Curbside Consult with Dr. Jayne 5/9/16

May 9, 2016 Dr. Jayne 3 Comments

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John Halamka’s discussion of the MACRA NPRM was the topic of conversation at the client I was visiting last week. I’m working with them on a strategic planning engagement and am primarily in contact with senior clinical and operational leaders. People kept referencing it throughout our meetings on Friday and I saw the email link go around at least three times. You can always tell who works their email from oldest to newest and who works the other way by how they forward things that many others have already commented on.

In non-written discussion, it was interesting to see how the content of the blog morphed as it was passed from person to person. By the end of the day, Halamka was alleged to have made a call for physicians to boycott Medicare or quit practicing altogether. He didn’t exactly say this, although he did say, “There are probably only two rational choices for clinicians going forward – become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.”

Having been a salaried employee trying to run a primary care practice within the health system’s model, I’m not sure the former choice is entirely rational. Being employed isn’t always the answer. I have worked with physicians at health systems whose conservative and risk-averse nature caused them to significantly over-interpret the requirements of Meaningful Use to the point where practices were collecting completely unneeded information that no one ever looked at. Physicians in employed models often have little control over things like staffing ratios and productivity expectations, which frequently leads to physicians doing busy work because they are either inadequately staffed or have the perception of inadequate staffing.

As someone with experience in the DIY realm, I appreciated his analogy that, “Sometimes when you remodel a house, there is a point when additional improvements are impossible and you need to start again with a new structure.” That analogy should extend past MACRA and MIPS, however, to our entire healthcare delivery system. I do think we’re reaching the point where we’re spending such a high proportion of our resources on a system that isn’t delivering for our patients. Taking a 20-pound sledgehammer to it might not be such a bad idea.

Although Halamka wasn’t making a wholesale call for people to quit practicing medicine, he did say that, “As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.” I agree with him that it will be nearly impossible for organizations, whether small or large, to implement the rule as written on the timeline that is proposed. Having a final rule come out in November for implementation the following January with a full-year reporting period is absurd. How long did we give merchants to make the switch to chip-enabled credit cards? How long did we give states to implement the provisions of Real ID?

I’m eager to see the comments that are submitted regarding the proposed rule. Many physicians are finally feeling like it’s time to start fighting back, but others are selling their practices or just leaving. I spent most of my family’s Mother’s Day gathering hearing from relatives that aren’t happy that their physicians have retired, with one commenting that a successor physician “doesn’t have the knowledge in his whole hand that Dr. X had in his thumb.” Another lamented that her physician had joined a practice doing some “double billing,” which turned out to be provider-based billing because the physician’s office is considered an outpatient department of the hospital.

I also heard yet again about poor quality care being delivered because a physician is treating statistics rather than treating the patient. I’d love to call my grandmother’s physician and ask him exactly why he thinks tight glucose control with multiple meds is the right thing to do for a nearly 90-year-old patient who recently developed diabetes. Rather than sending her to the specialist to work up a possible inner ear cause of her dizziness, maybe he should have listened to her history of low blood sugars as a potential cause.

I’ve offered multiple times to go with her to her appointments, but she refuses, partly because she doesn’t want to inconvenience me, but partly because she’s of a generation that doesn’t dare question the doctor. Knowing the group he’s a member of, I can bet that the fact that his bonus rides on patient lab values might be playing a role in his decisions with her. Of course, he could exclude her from the calculations, but again knowing the group and their EHR, that would probably take too many clicks if he even knows how to do it.

It’s a fairly depressing time to be in medicine. I enjoy seeing patients and am lucky to work for a great group, but overall, morale is at an all-time low. More than half of the physicians that were in my residency class have left primary care. Most of those that have remained have changed employers at least a couple of times. Everyone seems to be looking for something better, but they don’t seem to be finding it.

There is one little ray of sunshine in the proposed rule, but I didn’t really process it until I read Dr. Halamka’s summary. That’s the change in wording from Eligible Professional to Eligible Clinician. At least someone, somewhere, remembered that those of us that are actually caring for patients are clinicians rather than just nebulous “professionals.” I like it. It also identifies the broadened scope of professionals covered by MIPS, although it’s not catchy enough for me to change my Friday post from EPtalk to ECtalk. Whenever I hear “EC” together, I think of the E-C clamp technique that you use when you’re using a bag-mask to ventilate a patient. That’s just another sign of how doctor brains work – only one of us would think of something like that.

What caught your eye in the proposed rule? Email me.

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May 9, 2016 Dr. Jayne 3 Comments

EPtalk by Dr. Jayne 5/5/16

May 5, 2016 Dr. Jayne No Comments

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Most of my colleagues are lamenting the proposed rule for MIPS and APM, citing the control that CMS is going to have over their day-to-day practice of medicine. I didn’t know until Wednesday, though, that the reach of CMS went even farther into the realm of fire safety. A newly-released final rule applies to hospitals, long-term care facilities, critical access hospitals, inpatient hospices, ambulatory surgery centers, religious non-medical healthcare institutions, programs for all-inclusive care for the elderly, and intermediate care facilities for individuals with intellectual disabilities.

The rule adopts provisions from 2012 fire codes. Unlike the MIPS rules, which require all kinds of work prior to January 2017, this rule gives facilities 12 years to come into compliance with sprinkler requirements. It also regulates the kinds of home décor items allowable in long term care facilities.

NCQA has weighed in on the proposed rules to implement MACRA, coming out in support, which is not surprising. They specifically cite independent third-party validation of Patient-Centered Medical Homes and Specialty Practices as a plus. If there is one thing that does make sense about the proposed rule, it is that patient-centered care is a winner. Practices that aren’t sure what they should be doing might want to consider a serious look at the models if they haven’t already.

I’m doing quite of bit of work lately with a customer who is switching EHRs. It always amazes me how easy people think this is, before they actually dig into it. The receiving vendors tend to over-promise on their ability to lift the data from the old system and place it into the new system in a usable fashion. Of course, they don’t mention that this often depends on the willingness of the legacy vendor to participate. Sometimes the legacy team will perform the data extract and sometimes a third party is used, but there is at least some baseline cooperation needed, especially if the legacy system is hosted.

Depending on the quality of the source data, there may be some degree of massaging of values to map to new data formats. Sometimes this requires clinical input, which can be extensive. When organizations look at the cost of physician time needed, it may impact decisions on how much data an organization decides to bring forward.

In this particular situation, the client is using a third party to perform the extract and manipulate the data so that the receiving vendor can perform the database insert. My client was concerned about some of the proposed mappings, so they asked me to take a look. I immediately identified some issues, and when I asked about them, the extract vendor became evasive. That’s never a good sign.

Working on behalf of the client, I asked to be put in touch with their clinical resources who were processing the data. It turns out they are using people who aren’t necessarily clinical. The extract vendor is actually operating from his home in a resort town in Thailand. On one call, I’m pretty sure I heard waves lapping in the background.

I asked the client to also reconsider their scope for the extract. They had been planning to move all the clinical data, but given that they have more than 15 years of data in their legacy system, it might not be the best clinical decision. If there are issues with data, it’s a lot easier to correct the most recent three to five years of data than trying to manipulate decade-old data that might involve drugs that no longer exist or diagnoses that are no longer valid.

We had already had a very difficult conversation about using the new system as their archive. They had originally planned to migrate all their patients, even if they were expired. It remains to be seen how this is going to work out, but the extract vendor is supposed to be working on another data pull for the client to review with me. I hope they’re successful, but in the immortal words of Han Solo, I’ve got a bad feeling about this.

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AMIA has announced its InSpire 2016 event, which is specifically dedicated to informatics educators. Expanding beyond the Academic Forum, the conference is seeking submissions around education innovation. Additional topics include academic career advancement, informatics for curriculum developers, research, and data science.

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DocuTap is hosting its annual user group June 15-17 in Sioux Falls, SD. It should be an interesting meeting since they were just acquired by private equity firm Warburg Pincus. The event is free for clients and includes sessions on telehealth, analytics, and target-marketing to payer specific patients. I got a kick out of their “20 reasons to attend” document which included the ability to take extra time off to visit Mount Rushmore and the Black Hills, noting that it is an additional five-hour drive across the state.

Next week is National Nurses Week, held May 6-12. Being in clinical informatics, I’m proud to work with quite a few informatics professionals who are nurses, as well as nurses who specialize in nursing informatics. I’m also eternally grateful to the nurses at St. Somewhere who saved my backside repeatedly during my first rotation in the coronary care unit as a resident physician. They taught me a tremendous amount of real-world medicine.

They also taught me the value of respect – they knew I respected their judgment and knowledge, so they batched their questions for me throughout the night so I could get a little sleep (unlike my counterparts who got paged every 15 minutes because they were jerks).

Has a nurse made a difference in your career? Email me.

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May 5, 2016 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 5/2/16

May 3, 2016 Dr. Jayne 3 Comments

Since the release of the proposed rule for MACRA, many of my colleagues have been heads down trying to digest the content and figure out how to operationalize the requirements. While some organizations are taking the proposed rule and running with it, others are adopting a “wait and see” approach given the anticipated volume of negative comments from the public. They’re hoping that things will change prior to it becoming final, which is always a possibility given this crazy environment in which we all now operate.

Although CMS talking heads have said MU is dead, it must be zombie-dead. It’s just been reinvented as “Advancing Care Information,” which although more flexible than MU, is still too daunting for many practices. Physicians will not be accountable for cost category measures from claims data as well as being pushed towards further tracking and reporting on PQRS.

There are two tracks for physicians, with CMS expecting that most providers will be in the MIPS track vs. Alternative Payment Models. The numbers I saw estimated were 700,000 vs. 60,000, respectively. Unfortunately, providers will have to decide wither to submit under MIPS before they know whether they qualify for the APM track. Many organizations will be doing a belt and suspenders approach.

Several of my friends that work at vendors are extremely stressed out, realizing that federal requirements will dominate development efforts over the rest of the year. Just when they had breathing room to work on usability and customer-requested enhancements, they’re going to be forced back to the grindstone to crank out code that may or may not be what their customers want or need. Vendors have to walk a fine line between speculating on what will be dropped from the final rule and running full speed to get it all done.

Some vendors will start working on the requirements whether or not they think they’ll be modified. Given the way the last few rulemaking cycles have gone, even if a particular element gets taken out of the final rule, it will likely rear its head in a subsequent rule or in another program, so this might be a wise approach. On the other hand, if the rule is substantially modified, there is a risk of significant wasted development efforts. Once the comment period closes, it will be several months before we have a final rule. My friends with crystal balls tell me we’ll have the final rule in October with it taking effect in January. If that timeline holds, there won’t be much time for vendors to shift gears if the modifications are significant.

In the provider space, there is a tremendous amount of chatter about this being the last straw for small or independent practices. The requirements are daunting, especially for practices who haven’t been at the forefront of payment reform efforts. Just trying to read and understand all the rules and keep track of all the FAQs we’ll undoubtedly see could be a full-time job. As CMS goes, so go the commercial payers, and I expect we’ll see them ratcheting down on physicians as well. I’m still trying to fully absorb how this will affect my own practice given that we opted out of MU and haven’t looked back.

One of my colleagues brought up a good point. Although providers may not be ready to go to a direct model practice or all the way to a concierge / retainer model, providers have been slowly transitioning out of Medicare. It’s tricky for these non-participating providers when they want to continue to care for Medicare beneficiaries. Another option is to opt out of Medicare entirely. The complexity of the choices make it difficult for providers to consider leaving, especially when they consider that commercial payers will have matching requirements of their own that the providers will still have to deal with. The seemingly-onerous nature of the proposed rules might be a catalyst for providers to consider moving to direct models.

When you think about it, direct payment models would go nicely with some of the goals of all these efforts. If the goal is to put the patient at the center of their own care and to engage them, what better way to engage them than with their pocket books? Patients who start to see the true cost of care (rather than being shielded by their co-pays) might start choosing their therapies more wisely. Perhaps the generic drug that’s been around forever but doesn’t have sexy marketing will start looking more attractive.

We’ve experimented with that to some degree with tiered co-pays and that has driven patients to ask about cheaper alternatives. I’ve seen some patients question their hospital-employed physicians when the patients start getting bills from both the provider and the facility through provider-based billing arrangements. A couple of organizations in my region have done away with the practice based on negative community feedback.

Understanding the cost of care may encourage patients and families to make end-of-life choices that are ultimately more compassionate – choosing palliative care or hospice rather than expensive interventions that may not prolong life and may even damage the quality of life. Patients may begin to analyze whether the expensive (and life-altering) cancer treatments that may only extend life a few months are really worth it for them or for their families. Maybe we’ll stop ordering CT scans for things that really could be diagnosed with a good history and physical exam.

Of course, this wouldn’t solve all our problems. The cost of care is still prohibitively high for many treatments. Patients would still need insurance against catastrophic medical bills and we would still need safety net facilities and arrangements for patients who have limited ability to pay.

It also doesn’t address the real origins of healthcare costs. Lifestyle and behavior-related factors are 40 percent of the pie compared to medical care, which is a mere 10 percent. Human biology is 30 percent, with social determinants of health at 15 percent and environmental factors at 5 percent. Although patient engagement may help the lifestyle and behavior-related category, there’s still much more work to be done.

I still have several hundred more pages to get through, but I’m not sure I’ll make it. It’s too depressing.

Have you finished the proposed rule? What do you think? Email me.

Email Dr. Jayne.

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May 3, 2016 Dr. Jayne 3 Comments

EPtalk by Dr. Jayne 4/28/16

April 28, 2016 Dr. Jayne No Comments

My phone started going into shock Wednesday afternoon with the release of the 962-page proposed rule for the Medicare Merit-Based Incentive Program (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models.

Vendors and providers alike have been eagerly awaiting the details hinted at by MACRA when it was passed last year. Providers were hopeful about the potential for consolidation of the alphabet soup of PQRS, VBM, and Meaningful Use.

It starts with the customary glossary of acronyms, which numbers nearly three pages. It also includes an overview of current reporting programs and regulations. For people who haven’t been immersed in the federal regulatory stew for the better part of a decade, it must seem like so much gibberish.

The provisions regarding the “Sunsetting of Current Payment Adjustment Programs” starts on page 35. A section on “information blocking” caught my eye on page 41 despite the fact that information blocking as defined by Congress seems much more theoretical than actual for most of the organizations I’ve encountered. Page 44 brings nearly three pages of new terms which require definitions. I gave it my best effort, but I couldn’t make it more than 100 pages. For those with longer attention spans, the comment period is open through June 27.

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Registration is open for the AMIA 2016 Symposium, to be held at the Chicago Hilton. The Student Design Challenge, now in its fourth year, will focus on engaging providers and patients in precision medicine. Proposals are due by June 30 with notifications to authors on August 15.

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For those who can’t wait until the fall for your next informatics meeting fix, the 2016 ONC Annual Meeting will be held May 31 through June 2, with the last day being focused on consumers. Agenda details are still forthcoming, so I’m not quite ready to commit just yet.

I enjoy attending conferences and connecting with colleagues across the country to discuss best practices and innovative ways to move healthcare forward. In my own world, though, I’d settle for healthcare that met the bare minimum.

I’ve been in a downward spiral, with several negative ophthalmology experiences over the last several years, but this week’s visit took the cake. My physician (the third in that I’ve seen in the practice) recently went on an indefinite medical leave, so I was called to reschedule with one of her partners. I always book the first appointment of the day so that I can be on time for the rest of my schedule. Unfortunately, my new physician was stuck in traffic.

He phoned the office five minutes after my appointment started. The practice has an open front desk, so I could hear the receptionist talking with him. I was dumbfounded when she told him that he didn’t have any patients in the office yet, especially since I had been checked in with my co-pay posted for 15 minutes.

About five minutes after she finished the call with him, she called me up to tell me what was going on. After another 10 minutes, a technician took me back to an exam room to get things started so I’d be ready when he arrived. She asked my reason for visit, and when I told her, she promptly asked why I was seeing Dr. X because he doesn’t treat patients with my chief complaint.

I reminded her that the practice is the one that scheduled me for the physician and should have known from my original appointment reason in the scheduling system what I was coming in for and that it was going to be a problem. I then got to hear through the open doorway as the staff called the physician in his car to ask what to do about me.

He agreed to see me, which I thought was odd if it was outside his area of expertise, but I decided to keep the appointment so I could get my prescription, which had expired due to the rescheduling with my previous physician’s departure.

When he arrived, he was apologetic, and told me “How great that was that the office was able to get in touch with you and have you come in later so you didn’t have to wait for me?” That’s certainly a creatively editorialized version of what happened, but by this point, I wasn’t surprised by anything. He performed only part of a typical exam, pronouncing my eyes “healthy” and then sending me to the front desk with a paper superbill that included charges for services he didn’t actually render.

I hadn’t mentioned that I was a physician. I wonder if he would have performed the way he did had he known that I was? It shouldn’t matter, though – the things that happened during this visit shouldn’t have happened to any patient anywhere. The fact that this occurred at a major academic medical center was particularly distasteful. Although the office manager was appropriately horrified, I’m still waiting for a call back from the department chair.

I have no idea whether his behavior was a result of his being late or generally poor practice. I’m waiting for a copy of my visit note to see what he documented in comparison to what he actually did and what he attempted to bill. In the meantime, I have an appointment across town to see another physician.

If we can’t even get basic medicine right, what hope is there? Email me.

Email Dr. Jayne.

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April 28, 2016 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 4/25/16

April 25, 2016 Dr. Jayne, News 1 Comment

I wrote last week about my experience with a client who had been swindled by a practice administrator who had promised far more than he could deliver. A reader commented: “I would have loved to hear a few more specifics on what a practice might do to avoid hiring such an administrator or office manager. It has also been my experience that too many independent practices don’t seem to know what to really look for and consequently suffer down the road.”

I’ve certainly done more than my share of hiring and firing over the last decade. On my own, I’ve employed medical assistants, office managers, and partners. I also had to terminate at least one of each. As part of the corporate world, I’ve had to deal with vetting a host of positions including clinical staff, IT staff, managers, and operations execs. As a consultant, I’ve been asked to deal with errant members of the C-suite and upper management and also to assist in finding their replacements.

The best tip I can offer anyone in a hiring position is an old adage: trust your gut. Nearly every time I’ve gone against my gut, there’s been a poor outcome. Sometimes you can’t avoid it, especially if you’re in an employed capacity or part of a larger corporate entity.

For example, I once had to hire an analyst to run some lab interface work. The health system’s HR department (which usually left something to be desired) was only able to find two candidates who were remotely qualified. Although their resumes were decent, both of them interviewed somewhat poorly. I felt the first one didn’t understand the job we were offering, despite our attempts to explain it and talk about the work she would be doing. She kept going back to what she had done in the past and how good she was at it, even though we were trying to assess whether she’d be a good fit going forward.

The second one was too folksy right off the bat. Don’t get me wrong, I’m a folksy girl myself, but there’s a time and place for familiarity and it’s not in a job interview. I don’t want to hear about your children and your weekend plans – not because I don’t care, but because it’s too easy to get close to discussion topics that are normally a bad idea during the interview process. She seemed to be much more eager than the other candidate, but I didn’t really feel that she would be able to get the job done.

I wanted to go back to HR and ask them to look for other candidates, but was under pressure to fill the open posting immediately to ensure we could get someone in the position before a series of budget cuts that might force us to pull the opening off the board.

Although her interface skills were decent, it turned out that her overly casual demeanor was reflective of casual regard which she paid to all her work. When asked for status reports, it always felt like she was on the cusp of getting to the tasks that needed to be done, rather than actually doing them. She also liked to spend a lot of time chatting with other team members, which impacted not only her productivity, but that of others. It felt like she spent a lot of time doing nothing and then sprinted towards the deadline, which was a poor fit for our company culture.

Although I was involved in the hiring, I wasn’t her direct manager. He didn’t seem to have the wherewithal to deal with her because she interpreted every element of constructive criticism as “being mean.” Needless to say, she didn’t last very long. My failure to fight for my gut feeling in that situation bothered me for a long time.

Besides following your instinct, it’s important to watch out for people that seem too good to be true. Maybe they have a seemingly stellar record of accomplishments, but are willing to work for a salary that is lower than they appear to be worth. Sometimes you can get a bargain, but usually there’s a good story to go along with it. For example, a highly-skilled administrator who moves to a small town to care for aging parents or someone who needs a more low-key role to provide greater work-life balance. Usually these candidates realize that they may seem oddly matched for a position and will take the lead on explaining their desire to move down the ladder.

Other times, though, they might not have a good explanation for why they left their last position, or the references they provide don’t seem to make sense. I admit that it’s getting harder and harder to get a decent reference, particularly from past employers. Often organizations will simple verify the dates that the individual was employed. If you’re lucky, they might tell you if the person is eligible for rehire. Getting a true reference that you feel you can trust is like gold.

Other things that I sometimes don’t see smaller practices do: the consumer background check. They may do a criminal check, but not a consumer one. In this day and age, it’s important to know whether the people you are hiring have had any financial difficulties, particularly if they are going to be a position to handle funds within the office. Of course, that won’t tell you if the employee will make bad decisions, like the front desk staffer that I fired after finding $1,200 in co-pays in the sample closet. Why, you might ask, was the money in the sample closet? Because she didn’t have time to go to the bank and do the deposit each night, so she wanted to keep it somewhere “safe.”

Organizations should also make sure that candidates have valid experience for the position they’re trying to fill. Candidates might not have held the exact same job or title, but should be able to clearly explain how their previous experience will translate to the new position. Especially for higher-level roles, most organizations don’t have time to deal with someone who cannot hit the ground running. I do occasionally see it though, with groups that feel like they can mold someone into something that they may not be able to become.

Administrators should be able to talk about their achievements in previous roles and cite metrics for practices they’ve led. How have their days in accounts receivable been? Even if they weren’t stellar, did they show a positive trend? What initiatives did the candidate lead to try to move things in the right direction?

Potential employers need to have a list of solid questions to ask that relate to the needs of the organization. If you’re planning to become a Patient-Centered Medical Home, ask about that experience. If the candidate doesn’t have experience, ask him/her what he/she would do to get up to speed should they be hired. Anyone worth their salt should be able to articulate a plan to learn about a new discipline or new initiative, especially since the healthcare system we may be operating in over the next few years doesn’t exist yet. If they can’t come up with a reasonable strategy, they might not be a good fit.

Once an administrator or practice manager is hired, the practice should keep close tabs on their performance, not only in the initial hiring period, but in a regular ongoing fashion. Practice leadership (owners, partners, managers, etc.) should be having monthly meetings to review financials and potential problem areas in the practice. If the administrator says everything is rosy all the time, something is wrong. Even in the strongest practices there is always opportunity for improvement or some sort of personnel issue to make management aware of.

Owners or top leadership should also watch out for staffers that continuously spread blame around to vendors, payers, or other staff without showing even the smallest level of introspection about whether they could have done something differently.

Another good question to help assess a potential hire is this: “Given what you know about our organization, if you are hired into this position, what do you see the first six months looking like?” In my experience, candidates who plan to do a good amount of listening and observing before making too many changes are often the best. They’re willing to take their time to figure out what they have to work with, assess the team’s strengths and weaknesses, and make a careful plan rather than coming in with guns blazing.

What’s your worst hiring or firing nightmare? Email me.

Email Dr. Jayne.

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April 25, 2016 Dr. Jayne, News 1 Comment

EPtalk by Dr. Jayne 4/21/16

April 21, 2016 Dr. Jayne No Comments

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There has been a lot of buzz this week around the announcement of the Comprehensive Primary Care Plus (CPC+) model. CMS hopes to build on the previous Comprehensive Primary Care initiative, this time recruiting 5,000 practices into two tracks. The strongest candidates for participation will be practices that are already involved in care coordination and population management.

CPC+ differs from some of the other quality programs in that the incentive payments are prospective and the way in which practices manage their patients will determine how much of the incentive the practice gets to keep.

Practices will be selected after the identification of 20 participation regions which will be dependent on payer participation. The goal is for the majority of patients in the practice to be covered by one of the participating payers. Although physicians seem interested in the prospective payments, their enthusiasm was somewhat tempered by the need to wait until regions are determined. Payer proposals can be submitted through June 1, with submission of practice applications to follow. I attended one of the CPC+ webinars this week and actually enjoyed learning about some of the nuances of the program.

CMS also announced that those practices participating in the Bundled Payments for Care Improvement (BPCI) initiative can extend their involvement for an additional two years. CMS will use the extra time to evaluate outcomes and determine whether bundled payments are leading to better care while controlling costs. I wonder if their evaluation will also look at the stress levels of providers involved in the initiatives and the ratio of their patient-care hours to administrative time both before and after the initiative.

In other government news, our friends at ONC shared a comprehensive evaluation of the Regional Extension Center (REC) program. Highlights include data that 68 percent of eligible professionals receiving incentive programs under Stage 1 of Meaningful Use worked with a REC. If you don’t want to try to make it through the entire 124 pages, I’d recommend the Executive Summary, which is only six pages.

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I’ve been waiting for the HIMSS16 presentations to be available online so I can grab a couple of slide decks. Although I understand they’re trying to be hip with their screen layout, you can only see eight sessions at a time, which leads to a lot of scrolling. I had quite a bit of difficulty finding the sessions I wanted, until I realized that sessions starting with “The” were filed under T.

After locating my sessions and downloading the slides, I decided to watch a couple of the sessions that I missed. The first one had audio which I couldn’t hear despite maximizing the settings of my tablet and the streaming content. I could tell the people were talking, but couldn’t make out any of the words. Good luck to the rest of you hoping to watch the sessions.

Being on the HIMSS website also reminded me that I needed to submit my sessions for continuing education. After my experience with the streaming presentations, I was hoping for a better experience, but left disappointed. Although I liked the fact that it prevented you from accidentally trying to claim credit for two sessions in the same time slot, it did it by refreshing the screen which required the user to re-select the day each time before searching for the next session.

I eventually was able to get all of my sessions selected. HIMSS has to submit them directly to the American Board of Preventive Medicine for credit, so I’ll be checking back in a week or so to ensure they get posted. Given the cost of attending the conference, I want to maximize my returns.

I’ve started to plan my next couple of trips and am excited to report that there will be no healthcare- or IT-related educational components. One trip involves camping in bear country, which is a new experience for me. The other involves wine country, so it should be a good balance.

What are your travel plans for the summer? Email me.

Email Dr. Jayne.

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April 21, 2016 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 4/18/16

April 18, 2016 Dr. Jayne 1 Comment

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I recently concluded a long-term engagement with a client. Having started as a small private practice, they had grown to 20 or so physicians and wanted to get larger, but had been running in circles trying to figure out how to grow their business.

I was hired to do an analysis and conduct some strategic planning sessions. After my first call with them, it was clear that a multiple decisions had somewhat sabotaged their chances for success and that much work was needed before we could truly embark on strategic planning.

None of the physicians had really wanted to take the lead in managing the practice, so they hired an outside administrator. For lack of a better description, he was the Harold Hill of practice leadership. He had billed himself as an experienced administrator who could help them grow from 20+ physicians to over 100 in less than two years, so they hired him. I knew he was going to be an issue because he instantly opposed my involvement with the group, with some of his comments being red flags that he had something to hide.

It was clear early on that they had some serious issues with physician satisfaction and employee engagement that would make it difficult to grow at all, let alone quadruple in size. It’s hard to recruit physicians when the existing ones are disgruntled and when you’ve had turnover issues with staff.

When I tried to explore how their staffing ratios looked compared to various professional organization statistics, he couldn’t even cite his own ratios, falling back on the fact that, “Every one of our locations is a little different” over and over. The word “evasive” didn’t even begin to describe him at this point. He also kept going around and around about the fact that “we’re a family” and extolling the virtues of various team members.

In my experience, that’s a technique used to try to distract an observer from the fact that they are overstaffed, underproductive, or both. At many practices I’ve worked with, the sense of “family” often does not outweigh the fact that a staff member is dysfunctional or incapable, but it’s cited as a reason that the issue has not yet been dealt with. Family or longevity can also be a way to try to camouflage overcompensation of resources that haven’t been able to keep up with the evolution / revolution we’re seeing in healthcare delivery.

Once the administrator was hired, the physician partners gave him the reins and stopped checking in on management issues. There were some red flags on the revenue cycle side (lack of clean claims, increased denials, failure to track down slow-pay or no-pay accounts) and it was clear that some of the critical reports available in the practice management system had not been run recently.

The managing partners were shocked to hear that this was going on, although the audit trail data in the software was clear. If he wasn’t running the reports, he certainly wasn’t presenting the information to the practice. However, I had a hard time figuring out whether he was presenting bogus data or no data at all, because the physicians all just stared at each other around the table. When pressed about the lack of reports, he immediately threw the practice management vendor under the proverbial bus, but was unable to provide support tickets for the alleged problems.

In digging deeper into some of the employee satisfaction issues, it was clear that the new administrator had chosen his favorites and wasn’t doing anything to build relationships with the rest of the staff. He had given the favorites control of the other staffers and wasn’t monitoring the equity of shift assignments or the quality of work being performed. What I heard from the line staff didn’t match up with the inspirational posters he had placed around the office regarding the ability of employees to drive the success of the business.

Turnover was a significant issue with the clinical support staff. In working with the practice over several months, it was clear that they had no plan to engage the staff beyond just the day-to-day duties performed in a medical office. Those staffers that showed initiative and drive were quickly shut down by some of the favorite staff, who saw energetic young staffers as a threat. They quickly left.

Some of the remaining staff members were mediocre at best and were interested in punching the clock rather than making the practice great. While I was working with them, two staffers resigned. I asked if I could participate in the exit interviews and learned that they didn’t have them or see a need for them. I instituted them anyway and found that the employees didn’t feel like there was any room for them to grow in the practice, that they didn’t feel valued, and that they didn’t see it as a place they wanted to stay.

One mentioned that the administrator had done an employee survey which was supposed to be anonymous, but they suspected that their responses were identified and were shared with the middle managers who may have used the responses in a retaliatory manner. It’s a shame for an organization to fail to take advantage of employee feedback, but thinking that you can get away with creating a hostile / retaliatory workplace in this day and age is just shocking. Healthcare workers are in demand (particularly skilled ones who are energetic) and organizations should seek to cultivate them and empower them. This means really engaging with them and not just paying lip service to the concepts.

Apparently at least one of the partners had asked about turnover. The administrator’s idea was to put in place a bonus structure that was not clearly documented or well executed. Employees were told they would receive a bonus, and then it would be months before it was paid if it was paid at all (as was reported by two staffers). I’m not completely blaming the administrator for all of this, as the managing physician partners were also responsible for the situation. When hiring someone into a position of authority, organizations need to make sure the transition is carefully monitored and that outcomes are matching expectations. If they’re not, then there needs to be an intervention.

After receiving the results of my initial analysis, the practice decided to have me try to mentor the administrator to see if he could be salvaged. My gut instinct was that this was not going to be possible, but I was willing to give it a go. Working with him on a day-to-day basis, it was clear that he had no strategic plans for the practice and really had no idea what he was talking about in a lot of core areas. We tried to discuss managed care contracting as it relates to practice growth and he quickly became defensive, trying to cover the fact that he was lost in the discussion. We talked about physician incentive strategies and staff engagement and he had no concrete plans or goals. When asked to discuss the practice’s mission and culture, he popped out a canned response but could not elaborate.

After a couple of weeks, it was clear he wasn’t going to be part of their go-forward strategy, but the practice was on the fence about actually terminating him. Practices are often afraid of letting people go for fear of being sued. I explained to them that it’s really a fairly straightforward process, depending on whether you have an employment agreement or not and whether the job description is clearly documented. I suggested trying to document “non-performance of essential duties” strictly through the lack of diligence around the financial reporting requirements, which should have been a clean way to do things.

I was surprised that they didn’t want to go that way and instead wanted additional documentation. I explained that this would require some effort on the part of the managing partners as well as additional risk to the practice while the administrator was allowed to continue to alienate staff and fail to manage the practice. They disagreed, so we embarked on a four-week effort that ultimately did culminate in his departure, although not without a lot of angst among the partners and turmoil in the office.

My partner and I finally got them stabilized and spent quite a few additional weeks creating policies, procedures, and protocols to help take them forward. We took them through a search process and they’ve hired a new administrator who will be carefully supervised by one of the senior managing physicians, according to the steps we’ve laid out for them. My partner is going to continue to work with them on a weekly basis to make sure we can solidify their process and keep them moving forward. We’re planning to conduct the original strategic planning engagement down the road, but want them to show that they can at least keep 20 physicians and the accompanying support staff stable before they decide to try to grow again.

Given the changes in healthcare, I want to root for the independent practices and am happy that they are a large part of my consulting practice. It’s easy to throw up your hands and allow your practice to be purchased by a hospital or health system, but it doesn’t fix anything. Usually it creates more issues. I’m hopeful for this group, but we’ll have to see what the next six months bring.

Has your organization experienced their own Harold Hill moment? Email me.

Email Dr. Jayne.

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April 18, 2016 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 4/11/16

April 11, 2016 Dr. Jayne No Comments

Although the majority of my consulting work revolves around healthcare IT, I’ve done a fair number of practice management and operations engagements along the way. Many of the opportunities have bubbled up as a result of a practice or medical group trying to implement EHR.

Going through the process tends to highlight overall inefficiencies, role confusion, lack of management, financial issues, and more. Over the last six months, I’ve seen the requests for those types of services increase, which is part of why I joined forces with another consultant. We’ve written a number of engagements that don’t really have any information technology components.

As we’ve been exploring the different kinds of services we can offer and the needs of our potential customers, we’re seeing more organizations that are at a crossroads. It seems that quite a few primary care organizations are having what amounts to an identity crisis. Should they press ahead towards value-based care? Should they transform their systems and prepare to accept full-risk contracts? Or should they retreat towards their roots with personalized (and sometimes concierge) care? Two emails this week from the American Academy of Family Physicians highlighted this looming crisis.

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On one hand, the AAFP has launched what is describes as a “full-court press” to ensure that family physicians are ready for payment reform. Calling it a “ground-breaking, knock-your-socks off change that opens to the door to a whole new era of Medicare physician payment,” the AAFP is positioning itself to help physicians “reap the benefits of a new payment system that, unlike fee-for-service, values the training, skill level… and time that goes into taking care of patients in a family medicine setting.”

In order to prepare for the transition, they’re encouraging physicians to participate in the Physician Quality Reporting System (PQRS). They also recommend that practices review their Quality Resource and Use Reports (QRURs) which will show physicians where they stand as far as future payments for the MIPS track. Most of the primary care physicians I know have never heard of a QRUR and would be put off by the process one needs to go through to obtain theirs.

AAFP also recommends that practices embark on clinical practice improvement activities around access to services, patient engagement, care coordination, and more. Smaller practices (and some larger organizations) are often ill-equipped to try to make these changes on their own. Their articles are pushing physicians towards the new models with comments that the process won’t go away or be delayed, and that “this train has left the station.” There’s going to be a huge market for services around helping physicians make the transition and I’m sure the AAFP teams will be gearing up with offerings of their own.

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On the other hand, AAFP is hedging its bets by also marketing services towards physicians who are choosing to opt out of payment reform entirely. They’ll be hosting a Direct Primary Care Summit in July. The meeting is targeted towards not only physicians who have already converted to direct primary care, but for those who are thinking about it or trying to figure out how to manage the transition. They’ll be educating physicians on the legal aspects of operating a direct care practice as well as how to address business development around the new model. The conference promotion materials cite the “momentum” and “growing excitement” saying Direct Primary Care is “no longer a trend” and is being supported by positive legislation across the country.

I certainly don’t fault AAFP for playing both angles. Primary care is at a crossroads. The National Residency Matching Program “Match Day” was last month. This year’s match saw only 1,481 graduates from United States medical schools choosing family medicine. There were some other interesting statistics coming out of the Match:

  • Family medicine offered 11.7 percent of all positions in the Match.
  • The fill rate in family medicine for US seniors has decreased from 1996 (72.6 percent) to 2005 (40.7 percent) with a slight increase this year (45.4 percent).
  • The fill rate in family medicine for US seniors has been below 50 percent since 2001.
  • Aggregate primary care positions (family med, general internal med, general pediatrics, and internal med/peds) filled with US seniors at a rate of 50.7 percent.
  • Only 12 percent of US seniors participating in the Match selected primary care residencies.

Looking at non-US seniors who matched into family medicine, the numbers are climbing overall. Although I’m happy to see qualified international graduates matching into primary care specialties, I think the fact that US grads continue to choose other pursuits is very telling. Primary care salaries are among the lowest in the physician ranks and primary care physicians report some of the highest burnout levels compared to their peers.

The loss of autonomy brought by shifting healthcare policy over the last decade has hit primary care physicians disproportionately compared to specialists in many markets. Although payment reform may extend that loss of autonomy more fairly across the board, if feels like we’re moving towards the lowest common denominator rather than trying to elevate everyone.

Lots of people are looking at the decline of primary care. A recent JAMA article looks as the expanded use of the term “primary care provider” as having negative consequences for the future of primary care. It asserts that although increased use of the term provider “reflects the importance of a multidisciplinary approach to modern primary care delivery, extending beyond the traditional dyad of patient and physician,” it has also had negative impacts. Patients may not be reaching the appropriate member of the primary care team if they can’t distinguish between different types of primary care providers. A mismatch in care delivery can lead to both over- and under-performance as well as challenges to patient safety and the delivery of cost-effective care.

The article specifically cites the rise of Direct Primary Care as being from “the resultant uncertainty and insecurity about who is going to handle their medical problem.” It also mentions that not differentiating between providers may put some individuals into “situations beyond their level of training and competence.”

I’ve seen this with one of our practice’s competitors, whose push for their nurse practitioners and physician assistants to practice independently is causing them to seek employment elsewhere. Healthcare IT is cited as a potential bridge for providers in those situations, who may be able to use protocols and clinical decision support mechanisms to “help mitigate some of the front-line diagnostic and management challenges for team members facing situations beyond their level of expertise.” I leverage technology often in practice, but it’s not a substitute for experience.

The authors also mention that the provider designation ”risks de-professionalizing” physicians, NPs, PAs, and nurses “who value their specific professional identities.” My favorite part of the article says it all:

Using the “provider” designation in primary care also suggests that primary care is simple care that can be commoditized and delivered piecemeal in a variety of settings by less well-trained personnel operating interchangeably at low cost. As such, use of the term may promote low levels of compensation and diminishes respect for the field, compromising its fundamental mission. Although low-cost approaches to some very basic elements of primary care, such as immunizations and treatment of upper respiratory infections, make enormous sense, they do not apply to the resources, skill, and training needed to deliver the full spectrum of comprehensive primary care in personalized, coordinated fashion, especially to an aging population with multiple comorbidities. “Provider” belies the complexity and amount of effort required. Note that the designation of “provider” has not been applied to such fields as surgery or cardiology, even though these too entail multidisciplinary, team-based care structures.

It goes on to recommend that we “cease referring to and treating primary care clinicians (as well as all other physicians and health care practitioners) as “providers” and address and relate to them as the highly trained professionals they are. If only things were that simple, that we could change some terminology and things would improve. Healthcare seems to just keep riding tide after tide and grabbing after the next shiny object that they think will solve the problems. We hoped for the last decade that technology would solve all our problems, that if we just added automation to the practice of medicine that we’d solve problems. Unfortunately, automation was often poorly applied and shifted the work to physicians.

Now we think that if we make the data more accessible, we can fix the problem. It feels like we’re pinning our hopes on interoperability, but we’re not doing what we need to make better use of the data, whether by physicians and other care providers or by patients themselves. Professional and educational organizations are weighing in, but are somewhat hampered by the lack of details on how new care models will unfold.

“Providers” are tired of waiting and continue to leave practice or pursue alternatives such as Direct Primary Care or to opt out of Meaningful Use or Medicare/Medicaid. The giants of our industry are increasingly reactive rather than being proactive or innovative. Eventually, something will have to give, and I fear it will be the people on the front lines.

Do you think emerging payment models will fix the healthcare crisis? Email me.

Email Dr. Jayne.

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April 11, 2016 Dr. Jayne No Comments

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