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Curbside Consult with Dr. Jayne 9/15/14

September 15, 2014 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

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September 15, 2014 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 9/8/14

September 8, 2014 Dr. Jayne 2 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Are you a CMIO on the brink? Email me.

Email Dr. Jayne.

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September 8, 2014 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 8/25/14

August 25, 2014 Dr. Jayne 6 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

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August 25, 2014 Dr. Jayne 6 Comments

Curbside Consult with Dr. Jayne 8/18/14

August 18, 2014 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

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August 18, 2014 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 8/11/14

August 12, 2014 Dr. Jayne 2 Comments

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

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August 12, 2014 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 8/4/14

August 4, 2014 Dr. Jayne 5 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Have a transformative vacation story? Email me.

Email Dr. Jayne.

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August 4, 2014 Dr. Jayne 5 Comments

Curbside Consult with Dr. Jayne 7/28/14

July 28, 2014 Dr. Jayne 5 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

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July 28, 2014 Dr. Jayne 5 Comments

Curbside Consult with Dr. Jayne 7/21/14

July 21, 2014 Dr. Jayne 4 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

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July 21, 2014 Dr. Jayne 4 Comments

Curbside Consult with Dr. Jayne 7/14/14

July 14, 2014 Dr. Jayne No Comments

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I wrote a few weeks ago about my adventures with the CMS physician portal. Since the reporting of payments and gifts from drug and device manufacturers to physicians is now mandatory, physicians are wise to make sure the information is accurate because it is going to be released to the public.

I had gone on the site and registered for basic portal access in June, but had read that I would have to return in July to register specifically for access to the Open Payments data. Once I went to the Open Payments link (thank goodness the website at least has a decent breadcrumb trail at the top), it asked me to create my profile. It also allows physicians to nominate “authorized representatives” to handle physician information.

It also requires entirely too much other information that CMS should already know about us from our NPI, Medicare, and other applications: NPI, license number, practice type, specialty code, DEA number, etc. The first words that popped into my head (of course in a snarky voice) were “administrative simplification.”

Rather than have the specialty codes on a pick list, I had to launch a 359-page PDF to figure it out. Finally, Page 212 had a link to Appendix C, where the answer was still nowhere to be found; the appendix had a link to the CMS taxonomy crosswalk. I’m not sure why they couldn’t have hooked up the link on the actual application to the crosswalk in the first place.

Even though the crosswalk lists my specialty code as “08” in the column that says “Medicare Specialty Code,” what they actually wanted was the code in the “Provider Taxonomy Code” column. Don’t bother trying to cut and past the 10-digit code into the form because it won’t work right. I was able to finally get through all the steps, only to learn that I won’t be able to do anything else until my profile is “registered” after my identity as a physician is confirmed. I’m surprised they didn’t ask for my blood type.

When I write about my initial experience, I also asked for a good martini recipe to help me get through it. Weird News Andy was happy to oblige with one that plays to my literary passions:

Charles Dickens Martini

1) Make a martini as you see fit

2) Add an olive or twist

I’m still laughing. There are so many Dickens titles that seem appropriate for healthcare IT: Great Expectations, Hard Times, and Bleak House, to name a few. It looks like my attempts to see my Open Payments data are turning into either a serial or a novel.

Have a literary suggestion that meshes with our lives in the IT trenches? Email me.

Email Dr. Jayne.

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July 14, 2014 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 7/7/14

July 7, 2014 Dr. Jayne 2 Comments

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I enjoyed some R&R over the holiday weekend. It was good to have a break from the normal routine. As an added bonus, most of our IT staff disappeared the day before the holiday, whether sanctioned or not. I had a grand total of one email after noon on Thursday and it had to do with something administrative.

I know this reprieve will be short-lived since we start implementing practices again tomorrow. At least we’ll be heading into the fray well rested.

Quite a few readers chimed in on last week’s Curbside Consult discussion of poor-quality EHR documentation. Several readers mentioned the purpose of the note as a key concept. While visit notes were traditionally for the benefit of the provider in documenting the patient’s condition, exam, and what was done, they have been co-opted by payers and regulators who equate documentation volume with value.

Notes are increasingly the purview of patients. Our health system does release visit notes directly to the patient through our patient portal. Most of our primary care physicians do a great job with patient documentation because they know the patients might actually be reading it. Our subspecialists who have been on EHR a long time also do fairly well.

The new practices are struggling more than those groups. It’s hard to tell how much they’re struggling with the actual documentation process vs. the concept of being part of an employed medical group and being told what to do.

As to who has the authority to take corrective action against “bad actors,” in our organization, it isn’t the CMIO, but rather the CMO and the president of the physician group. Both of them received formal notification of the specific concerns I found during the special project. I also included a request to authorize a more thorough and comprehensive audit by our internal Compliance department. If some of the documentation is as bad (and potentially fraudulent) as it seems, we’re going to need a better sample size and multiple independent auditors to prepare the documentation ahead of disciplinary maneuvers.

When I created my CMIO role here, I intentionally excluded physician discipline from my purview. To be successful within our culture, I needed to be seen as an advocate rather than someone who could get them in trouble. Additionally, I felt that in the case of EHR misuse, I would be seen as inherently biased towards defending the EHR and the IT group whether or not it was true.

Our leadership agreed. So far, the splitting of authority has worked. I think it will work well in this case also once we have evidence of documentation patterns across the group.

I laughed at SpoonEHR’s suggestion to create a macro “Signed but not read.” It’s unfortunately all too true. Back in the days of in-house transcription, I quit using a consultant whose letters came back “Dictated but not read, signed by transcriptionist to expedite” or some similar nonsense. If I can’t trust someone to read, edit, and sign their notes, I certainly don’t trust them to care for patients.

Reader Zafirex receives similarly ridiculous notes addressed to “Dear Dr: No Referring Doctor.” The paradox here is that the referring physician receives the referral note. Therefore, the practice at least knows how to address the envelope correctly.

I also loved Jedi Knight’s comment that, “We’ve sped up the process of sharing data without considering that the data is no longer worth sharing.” I do hope that the OpenNotes movement and the resulting opportunities for patients to read their notes will spur some providers to clean up their acts. Over the weekend, my dad asked about some information that was in his recent encounter note that didn’t make sense. I hope he calls his doctor on the carpet about it.

The idea that gives me the most hope, though, is Richie’s mention of a “Data Kidney” that can review text for “cleanliness.” In the newspaper world, that would have been the editors and proofreaders. All kinds of imagery comes to mind, including the proverbial red pencil. We’ve got grammar check in our word processing software, so why not for EHR output text?

What gives you hope that documentation will get better? Email me.

Email Dr. Jayne.

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July 7, 2014 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 6/30/14

June 30, 2014 Dr. Jayne 11 Comments

I spent most of this weekend doing a special project. Our coding and compliance officers approached me about how some of our providers’ notes look in EHR. They had seen some notes that were “really awful” and naturally assumed that something was going on with the EHR to cause them to be that way.

Our ambulatory vendor offers checkbox-style documentation templates, so I figured the complaints were about how their documentation was being output now that we’re dealing with SNOMED and other factors.

I asked my team to pull a sampling of notes from each of our specialties so that I could look at them myself. We’ve seen issues where the behind-the-scenes verbiage engine generates some subject/verb disagreements. Additionally, when a large number of positive and negative symptoms are documented, sometimes that can get a little strange.

Since our analysts are not clinical, I know that I can’t exclusively use their review to identify good vs. bad notes. Sometimes the documentation might be technically accurate, but would actually be something a receiving physician would laugh at.

We have a lot of subspecialists who do a lot of procedures, so I had the team pull a variety of those notes as well. They’ve been problematic in the past, especially when multiple procedures are documented. Most of those issues have been easy fixes. Still, considering the variety of specialties and all the different kinds of documentation, I had well over 100 visit notes to review.

By the time I was done, I could barely contain my aggravation. The largest subset of “awful” notes came from our providers who are heavy users of voice recognition. Some of the notes were downright incoherent. The problem however wasn’t with the technology – it was with subspecialists dictating sheer nonsense that normal humans (even those with medical degrees) would have difficulty comprehending.

The next subset of bad notes came from providers who have created their own documentation macros. The idea of providers having their own saved text blocks is generally a good one. We all know that there are some parts of the note that are the same over and over again: “regular rate and rhythm, no murmurs, rubs, or gallops, lungs clear to auscultation bilaterally, abdomen soft non-tender and non-distended with normal active bowel sounds.” From years of dictation it just rolls off the tongue, so it would make sense to save it as a block for EHR.

The problem comes when providers save text that either doesn’t make sense or has gender-specific findings that winds up being reused on the opposite gender. The point of saved text is to be able to quickly add documentation with little work. Some of our providers take the idea of efficiency too far, with so many acronyms and abbreviations it’s impossible to figure out what is going on with the patient.

Even with the subject/verb disagreement and some of the typical template issues, the group that most heavily uses check-box powered documentation did the best. They were easy to sort out due to the way the history blocks format and I was surprised at how much clearer their notes were compared to those done via other methods. Those that used the templates, however, had a much higher propensity to document Review of Systems items that I’m sure they didn’t actually perform.

For your amusement, I’ll share some of the highlights:

  • General surgeon sees a patient to remove a skin cyst. She documents a gynecological review of systems with seven negative elements. I confirmed that it wasn’t from a paper form the patient completed and staff keyed in. She also documented the procedure as “EXC TR-EXT B9+MARG 2.1-3cm.” What does that even mean? I could extrapolate “benign” and “margins” from that, but it makes no sense for the type of cyst excised.
  • The same surgeon documented a 21(!) point male urinary review of systems for a similar visit. The procedure document was the same except it was 0.6-1cm. At least she’s consistent. And apparently thorough, since she documented that she examined all 12 cranial nerves and the cyst was on the shin.
  • Orthopedic surgeon documents a physical exam that includes a normal fundoscopic exam. I’d pretty much bank that the last time an orthopedic surgeon touched the instrument needed to look at the back of the eye, it was in medical school.
  • Chief complaint of “bx results” which was saved to a provider custom list. Could we not have spared the extra characters to have it read “biopsy results” so that when the patient receives the note on our patient portal it makes sense?
  • Not capitalizing the names of other physicians on the team. Nothing says “thanks for the referral” like addressing the letter to “dear dr jayne.”
  • A “follow up back pain” visit with a (no kidding) 91-point review of systems including “changes in shape/size of moles” and “breast lumps.” I can’t wait until that one gets pulled for a CMS audit.
  • Detailed discussions of radiologic studies pulled into the note from other practices. I guess in addition to being “one patient, one chart” the EHR also lets us time travel because the same CD with the MRI results that the patient hand-carried from shoulder surgeon was simultaneously imported to the orthopedic consultant’s May visit note and also to the nephrologist’s note with a date stamp two months prior to the visit.

I could go on, but it would just make me frustrated and likely make you angry. More than anything, it just makes me sad, especially since the providers electronically signed all of them and indicated that they were read and reviewed.

You might ask who had the best documentation. Hands-down the most coherent, thorough, and clearly non-padded were the notes done by one cardiology group using a mix of voice recognition for the history and plan and template documentation for the physical exam and review of systems. I didn’t identify any gratuitous documentation and the notes were high quality. It probably takes them longer to document since they’re speaking most of the note vs. clicking. However, their documentation was so pretty I wish I could clone them. But CMS says cloning is bad, right?

Got documentation problems? Email me.

Email Dr. Jayne.

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June 30, 2014 Dr. Jayne 11 Comments

Curbside Consult with Dr. Jayne 6/23/14

June 23, 2014 Dr. Jayne 2 Comments

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The pile of medical journals on my desk has been growing steadily over the last several months. It’s hard to keep up with all the reading required for my informatics role (Federal Register, anyone?) let alone make time for clinical reading.

Summer hit full force this weekend and the prospect of going out in 90 percent humidity didn’t sound too enticing, so I decided to play catch up. One of my journals has a dedicated public policy section and of course the IT-related items always grab my attention.

CMS apparently released a mobile app to help physicians track payments and gifts received from drug and device manufacturers. My journal stack must have been older than I thought since the requirement for manufacturers and group purchasing organizations to collect the data kicked in last August. Separate apps were created for physician and industry use. Maybe being behind on one’s journals is a good thing, however, since it would allow me to do a post-live assessment of the app.

Looking at the FAQ for the app (only CMS would release an eight-page document for a smart phone app) it didn’t look that promising, although I liked the feature that would allow physicians to send profile information from the physician app to the industry app. That would have been helpful last year when I had to provide my NPI number after a colleague bought me a drink. He realized as he was signing the bill that as an employee of a medical device manufacturer, he was obligated to report it.

Knowing that I have no idea what my NPI is, I’d rather have bought him a drink as opposed to having to email myself a reminder to dig it up and send it to him. In case you’re interested, the threshold for reporting is $10. The martini in question was $12.50, having been purchased in a hotel bar at HIMSS. Had we both had the app in play, I could have stored my NPI in my profile and simply beamed it over.

Other than that, the apps don’t communicate with anyone. They are designed to make tracking easier, which probably benefits the manufacturers more than it does individual physicians, except for those who habitually mooch off of every vendor rep they encounter. In the interests of full disclosure, I didn’t accept drug samples in my primary care practice and generally don’t attend industry-sponsored events. I would probably have less than a dozen items to track over the course of a year and they would probably all be related to drinks at HIMSS, MGMA, or another trade show.

The physician app (which is also for other professionals subject to the reporting requirements) also features the ability to create or import QR codes to share information with others involved, although separate codes are needed for profile and payment data. A summary of transactions can be downloaded and the app is password protected. The information is stored locally and will auto-erase after multiple failed access attempts.

If you get a new phone, you might be out of luck since there’s not an easy way to transfer the information. Just looking at the FAQs, it seemed like more trouble than it was worth, but I headed off to download it nevertheless. It requires an eight-character password although it didn’t require me to use anything other than lower case. The cheesy stock images of physicians and industry staff were a turn-off however. Data entry was completely manual, so my initial reaction was right. I’d rather email myself the information and auto-route it to a folder in Outlook.

I agree it’s important for physicians to keep track of their data since it will be made public this fall. I decided to visit the CMS website to see what information was available and whether that martini from HIMSS was now visible to the public. Apparently it’s more complicated than I thought. There are two phases of registration. Physicians can register in the CMS Portal, but then they’ll have to come back in July to register in the Open Payments system itself.

The CMS website links to a “Step-by-Step” registration presentation.  Seriously? CMS expects us to demonstrate Meaningful Use in a variety of ways but has to provide a presentation on how to complete a registration to an online repository? No kidding, it was 42 slides long.

I did learn that the registration just started June 1, which seemed somehow validating that maybe procrastinating on my journals wasn’t a bad thing. Had I read about this last August when it was released, I probably would have forgotten by now.

I also learned that I’d have to go through an identity-proofing process that was even more stringent than what I had to go through to be an e-prescriber of controlled substances. I’ll be asked questions about my employment history, mortgage lender, and other “private data” and information from my credit report. The identity-proofing process is being run by Experian, but CMS wants to assure me the information isn’t going to be stored anywhere. The registration process will result in a soft credit inquiry.

By Slide 11, I was ready for a martini even if I had to make it myself. CMS requires the password to be changed every 60 days, so I’m sure I’ll become familiar with the reset process. I’m not familiar with this CMS portal, so I was intrigued by its promise to “present each user with only relevant content and applications” yet “provide ‘one-stop shopping’ capabilities to improve customer experience and satisfaction.”

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My satisfaction wasn’t much improved by the popup that appeared when I tried to read the FAQs to see what else I could do on the Portal while I wait for Open Payments registration to open next month. I did find quite a few new acronyms I hadn’t seen before, but left before discovering anything I thought might be of use. I finally figured out that I had to request access to Open Payments specifically. Maybe I should have paid more attention to Slide 28.

At that point, I went through the actual identity proofing, only to be told I need to set up another profile to register to see my data. I got blocked at that point, since the “Physician” option is still inactive. I’ll have to try my luck in July, when I can not only see my data but experience a yet-to-be-determined dispute process should the need arise. At least that will give me plenty of time to find a new martini recipe. Have a good one for summer? Email me.

Email Dr. Jayne.

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June 23, 2014 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 6/16/14

June 16, 2014 Dr. Jayne 3 Comments

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I’m sure those of you that follow me on Twitter were wondering what could possibly have happened last week to make it one of the strangest days of my career. In retrospect, it wasn’t just one of the craziest days of my IT career, but of my physician career as well.

My hospital is part of a larger health system. When have to have a representative on some kind of IT-related committee, I am usually tapped to attend.

We’re a decent-sized organization with plenty of employed physicians. One of my CMIO friends in a similar situation has employer-paid medical co-payments to encourage staff to see the physicians in their group. Another offers their “associates” early access to office appointments that aren’t available to other patients. Theoretically, when you’re caring for your own people, it should be like a miniature accountable care organization and might give you insight into the best way to maximize health and lower costs for a defined patient population.

I have to admit I am way behind on my email and didn’t read the agenda for our Emerging Technologies meeting prior to heading uptown for the session. I’m barely keeping my head above water and didn’t think it was a big deal because usually the topics are things I can handle on the fly. This time, however, I was seriously wrong.

The meeting happens over lunch and I was trying to grab a quick bite while scanning the agenda as people arrived. One of my IT colleagues thought he was going to have to perform the Heimlich maneuver after I started choking on my salad.

Apparently our brilliant “ET” group decided to bring in a third-party solution for “advanced access” to physicians. Unfortunately, it’s a telemedicine solution staffed not by our own physicians, but by others in the market. As the meeting started, a glossy marketing slick was passed around. I thought it might be some kind of Friday the 13th prank until I realized they were serious.

Our human resources department wants to roll this out as part of our benefits package in the fall. They wanted to vet it with our group as far as our thoughts on HIPAA and other regulatory issues. The health system would pay a fee to the vendor, which offers “doctor visits anytime, anywhere!”

I’m not opposed to the concept of virtual visits, but I’m truly surprised that we wouldn’t give our own physicians the opportunity to not only serve the employee community, but to maybe make a little extra cash as “advanced access” physician resources. Given the recent draft policy from the Federation of State Medical Boards regarding telemedicine, we would be ideal. We’re licensed in the states where most employees live (and are usually located), so that’s easy. We already have unified medical liability coverage, so that’s easy, too. We also have a vested interest in keeping our collective employees healthy as a means to strengthen the community.

I also like the idea of employees being able to receive care without disrupting work schedules, although the service promises access to physicians “at home, at work, or anywhere you need care.” We have enough issues with staff using cell phones to take care of personal business in patient care areas and don’t want to encourage them to talk about their medical issues in the workplace. There aren’t a lot of private places in most of our ambulatory practices (the physicians don’t even have private offices any more) so I’m not sure that’s a benefit.

What really got me was the assertion that the third-party physicians would become “your doctor.” Are they really advocating conducting a longstanding patient-physician relationship established via smart phone? Are they going to be accessible 24/7 to handle all the health issues that typical patients should be addressing with their personal physicians? What is their plan for continuity of care?

I was trying to see the other side of the equation. Maybe they were worried about patient privacy. Employees might not want to see network physicians because their records would become part of our central database. That’s certainly valid. Maybe they were worried about accessibility and that’s a factor, although more and more of our employed practices are extending their hours and providing walk-in accessibility. Maybe they think offering this will differentiate us as an “employer of choice,” as the HR people like to describe it.

One of the other physicians at the table who wasn’t distracted by lunch managed to access the telemedicine website and find out more about it. Apparently they’re willing to partner with healthcare organizations to involve their own physicians, but our HR department didn’t think that was important. They figured they’d just offer it to our employees with the existing provider network because that would be faster.

I wonder if they seriously considered the public relations and morale repercussions of offering our staff having virtual visits with providers from a competitor health system. I’m sure the various medical executive committees at our hospitals will have a field day with this if it moves forward. That’s likely to happen since HR didn’t seem to understand our objections or find them valid. One of the physicians actually got up and walked out. The rest of us stuck it out, if for nothing else than to gather information to help inform our next steps.

Since we’re a technology committee and we couldn’t find any significant technology objections (I have to admit their setup looks pretty slick), it’s likely to move forward. I’m interested to see what the hospital administrators will think since it will likely have an impact on their bottom line.

I’d be interested to hear from organizations who have done something like this, including whether your providers participated or whether you used an existing or external network. We’re having a discussion with the vendor in a couple of weeks, assuming roadblocks aren’t thrown up in the interim. I’m putting together my list of questions and “what if” scenarios for the meeting.

Got ideas? Or alternatively a potential job with a seaside location? Email me.

Email Dr. Jayne.

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June 16, 2014 Dr. Jayne 3 Comments

Curbside Consult with Dr. Jayne 6/9/14

June 9, 2014 Dr. Jayne 5 Comments

I mentioned that I was planning to start working in an urgent care that documents patient visits on paper. I fell into an opportunity with an independent facility and worked my first shifts this week. A reader asked if I had mentioned during the job interview that I would be blogging about my work and whether I’ve been able to remain anonymous in my various work roles.

The answer to the blogging question is “no.” I enjoy my day jobs and wouldn’t want to jeopardize them. Although I share many stories about my work, there are a great many stories that don’t get told because they might result in specific people or organizations being identified. Some of the best tales will go with me to the grave.

A reader once said that as a CMIO, I’m still a doctor, but my patients are sick hospitals and physician offices. That’s true to a degree and I guard their information as I do with patient information. Often my material reflects events that are so common they could apply to many organizations across the country, so camouflaging the events and players isn’t necessary.

As far as my clinical duties, I do think I’ve been able to remain anonymous. Frankly most clinicians in the trenches are too busy keeping their heads above water to even know that there’s an entire health care IT community out there. They may not know who their own CMIO is or what he or she does, let alone that there are scores of us who know and talk to each other. The idea that there would be blogs talking about EHRs and the people who use them to torment physicians isn’t even remotely something that would cross their minds.

If I use photos from work, it’s often months after they were originally taken or in a slightly different context than where I obtained them. I have a veritable treasure trove of photos I’ll never be able to use because they would be easily identifiable or involve people that I know read HIStalk. I also use photos that have been sent to me by readers when they can help embellish something I’m writing about. Hopefully if anyone recognizes those, the story is different enough from their reality that they don’t make the connection.

Back to the world of paper records. I arrived at the office ready to go. It’s a little different vibe from working the ER. The lack of a metal detector and security guard was refreshing, although I admit after my first procedure, I missed wearing scrubs.

The physician I worked with was quick to show me the processes and systems. Staff does the intake interview, gathers the history, and performs any needed pre-testing based on a written standing order. The clipboard goes in the door with a magnet to indicate which patient should be seen next. Simple and elegant, although low tech.

The physician sees the patient, documents on a paper template (they have a dozen or so templates for their top conditions plus some more generic versions), then comes out and order whatever additional tests are indicated. If there aren’t any, we prepare the discharge instructions and prescriptions, which are done via computer. The prescription ordering system isn’t sophisticated, but it does have hard-coded selections for the most common drugs, sortable by body system and diagnosis. If you can’t find them, there’s a search dialog, and if you get in a real bind, there’s a paper script pad in the drawer.

I have to reiterate that this is obviously not a practice that is trying to achieve Meaningful Use. As an opt-out site, we’re not asking super-detailed questions about smoking history or the types of tobacco used. We’re not asking race and ethnicity. We’re not codifying problems in SNOMED. Since we’re not part of a hospital system or accredited by The Joint Commission, we’re also not spending time assessing suicide risk, nutritional status, or any number of possibly irrelevant scenarios on all our patients. This leaves us time to actually see our patients at a reasonable pace.

Even though the first part of the shift was fairly busy (5-6 patients per physician per hour), the pace didn’t seem extreme. I think mostly it felt like I was able to focus on the patient’s current needs and not feel expected to address unrelated issues just because someone made a regulation that said I needed to.

Once the provider is finished, the nursing staff then takes the discharge instructions and scripts, goes back in the exam room, counsels the patient, and addresses follow-up needs. Then the patient gets to go home. Their plan may not have all their medications printed on it nor their list of historical diagnoses, recent vitals, or a host of other things, but it does have the information they need to care for today’s problem and to follow up with their primary care physician.

Up to this point, I’ve focused on the things that made today easy. Let’s talk about what made it difficult.

The first thing that jumped out at me was the fact that there is no drug or allergy checking when we write prescriptions. Although physicians have used paper scripts for years and there are plenty of people who argue that we were better on paper, I can’t help but think that I’m going to harm someone because I don’t have technology backing me up.

I calculated most of my weight-based pediatric prescriptions two or three times because I didn’t trust myself. I had one pharmacy call-back for prescribing a drug that might have had a mild to moderate interaction with a patient’s current medication. I know it would have flagged in an electronic prescribing system, but I’m wondering if there is a chicken vs. egg phenomenon going on. Did I miss the interaction because my vigilance was weakened by my reliance on technology? Or would I have missed it anyway?

I ended up customizing 80 percent of the patient education materials to include additional precautions or information that I like to provide for my patients. Most EHR systems would allow some level of saved customization. but our discharge system doesn’t. I’ll likely create a text document of common phrases that I can use to populate them in the future and just keep it open on my desktop.

Unlike some chain or pharmacy-related urgent cares, we don’t have an easy way to send information back to the primary care physician. It’s something that definitely merits discussion with my new employer.

Looking at the workflow with a critical eye, there were other inefficiencies. Staff had to transcribe lab data to the chart that might have been interfaced with an EHR. Patient education topics had to be searched manually rather than linked from diagnoses. These inefficiencies were virtually unnoticed, though.

Having done more than one stint as a science fair judge, I can’t say this was a valid experiment of any kind. Comparing this practice (regardless of whether it uses paper or EHR) to any other place I’ve practiced in the last several years would be like comparing apples to unicorns.

One major difference is the ability to focus on the patient’s presenting problem rather than extraneous but required information. Another is the encouragement to rely on support staff for tasks like order entry and diagnosis code lookup. It’s been so long since I was just able to articulate a diagnosis without codifying it that I didn’t know what to do with myself.

Whether it was due to the workflow process, the patient acuity mix, or other factors, I noticed one thing. Even after 12 hours of non-stop work, I felt like I had spent more of my day being an actual physician than in doing other tasks. We’ll have to see if I still feel this way in six months, but right now I’m cautiously optimistic. I’m still going to lobby for e-prescribing, though.

Have a story about going back to the basics? Email me.

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June 9, 2014 Dr. Jayne 5 Comments

Curbside Consult with Dr. Jayne 6/2/14

June 3, 2014 Dr. Jayne 3 Comments

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I haven’t been on a job interview in years, so I didn’t really know what to think when I found myself getting ready for one a few weeks ago. Since giving up traditional practice, I’ve worked in a variety of part-time and locum tenens primary care situations. I’ve also done part-time work in several emergency departments. I’ve worked directly for hospitals and also for staffing companies hired to populate the ED. It really doesn’t matter where my paycheck comes from – patients are patients and we care for them the best we can.

Due to a couple of regional shakeups with ED staffing companies and posturing by competing health systems, I recently found myself without a place to hang my clinical hat. My own hospital has decided that unless you are board certified in emergency medicine, you can no longer cover the ED (unless you’re a midlevel provider — then you’re OK to work as many shifts as you can cover.)

I find it ironic that they’d rather have a nurse practitioner straight out of training then a seasoned physician who happens to be certified in a non-emergency specialty. It’s less ironic, though, when you understand the real reason, which is as it always is, the bottom line.

Anyway, to take any kind of leave of absence is a pain. Unless you have an active practice address, you’re expected to surrender your state controlled substance license. They won’t let you just transfer it to your home or to an administrative office. I know this well because I got caught in the trap before and it took months to untangle. We received a 90-day notice that our contracts would be ending, so the race was on to find new positions.

Unfortunately, there were about a dozen other physicians in the hunt. Most were looking for full-time positions, though, so I had a bit of an edge being willing to work the odd shift here and there rather than needing a primary income.

I also have the edge of being sassy and single, which means I don’t mind working holidays or providing late-night coverage. In fact, I like the late nights. Usually the nursing staff has a better sense of humor and there are definitely great stories that come out of the ED after 11 p.m. As long as it doesn’t interfere with my CMIO duties, I’m up for it.

In a turn of serendipitous events, I was cold-called by a recruiter who was given my name by a friend of a friend. He vetted my profile using LinkedIn and thought I might be a reasonable candidate. A local urgent care was preparing to open a second location and needed additional coverage while they recruit full-time staff. Just my speed: low acuity, reasonable patient volume, not a terrible commute, and fair pay. And so it was that I found myself on my way to a job interview.

I explained my situation to the owner – that I have a full-time job but enjoy seeing patients on the side and am looking for a way to continue doing both. He asked me a lot of questions about being a CMIO. We talked about his PACS and the patient education system.

I became a little suspicious when the questions about standalone e-prescribing systems started, so I finally just asked what system they’re using. He kind of laughed and told me not to worry, the learning curve is about 30 seconds. I wish I could have seen my face when he handed me the clipboard.

I haven’t used paper in what seems like forever. Even during downtime I didn’t do formal paper documentation, but rather took a few notes to document in EHR later. I suppose it’s probably like riding a bike, although I think the combination of computerized PACS and discharge system with paper charting might feel a little strange. Part of me decided I wanted to work there just to see what going back in time would be like. At least they use templated paper forms, so it’s not like I’ll be writing SOAP notes from scratch.

I start in a couple of days, picking up a few hours after work one night to get used to the system while they’re fully staffed with other physicians. I’m most worried about getting to know the staff, figuring out the informal processes that aren’t documented anywhere, and trying not to make rookie mistakes.

I admit I’m a little nervous, though, not to have the backup of prescription error checking and clinical decision support, not to mention the convenience of e-prescribing. I had to dig through my storage area to find the leather prescription pad holder I received as a medical school graduation gift. Maybe to go full circle with the old-school vibe I’ll have to get myself a fountain pen.

Here’s to new adventures and hopefully a slow first shift. I’ll let you know how it goes. The monogrammed white coats have already been delivered, so there’s no turning back. I hope everyone stays well, but if you happen to find yourself at an urgent care with a sassy physician carrying a hot pink clipboard, you might want to do a double take.

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June 3, 2014 Dr. Jayne 3 Comments

Curbside Consult with Dr. Jayne 5/26/14

May 26, 2014 Dr. Jayne 1 Comment

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Several readers emailed about last week’s EPtalk, where I shared my frustration with CMS and the constantly-changing game of Meaningful Use.


Dear Dr. Jayne,

I’m sorry for how you feel about CMS and long for days of old when $5 got you a doctor visit at home. I’m 76 and have been on Medicare for over a decade. From a patient viewpoint, it beats big payers hands down. One little card with a red, white, and blue stripe gets you everything from any healthcare system, any physician, no referrals, no one ever asks a question, and, if you have a gap insurer, you almost never pay a nickel. As I recall, CMS gave every doctor $44,000 to buy an EMR and every hospital a lot more. I’m sure over $50 billion was given to providers and now CMS wants something in return. Sounds reasonable to me and almost rare that the government can’t be accused of a giveaway.

I think a lot of MU requirements are off target as to need and value. Most EMRs are off the mark in architecture, workflow, and value. So, we have the equivalent of a 1.0 standoff, but at least it is a start. Hopefully by 2.0 both the MU and EMR will have both evolved to a better place. This will take at least a decade and the practice of medicine and the technological advancements during this period will make the current systems look like stone age work.

Don’t give up on Medicare and CMS; make it better. The alternatives are much less attractive.

Sincerely,
Spirit of ‘76


Dear Seventy-Sixer,

Speaking as an Eligible Provider, I can confidently state that CMS hasn’t “given” us anything. It’s true that up to $44,000 each was available to eligible providers over a multi-year period. For most providers in my community, however, it cost far more than $44,000 to dot the “I” and cross the “T” of each Meaningful Use requirement. Even in the first iteration of Stage 1, providers had to meet 22 objectives (several of which have multiple subcomponents). For many physicians, this meant overhauling practice operations. Unfortunately, I’ve seen a lot of box-checking at the expense of clinical quality. When providers go to file their attestation, it’s all or none in nature, which creates a great deal of stress on caregivers and staff.

I’m glad you have had such a positive experience with Medicare. Patients in my community aren’t as fortunate, as many physicians have stopped accepting Medicare assignment or are limiting the number of Medicare patients they see. CMS has many coverage and medical necessity rules and my patients are spending a lot more out of pocket than some of them think is fair. We’re still in a recession and quite a few patients have been forced to drop their supplement plans or have chosen barebones coverage that they don’t like. Those who have gone on Medicare Advantage plans hate the narrow networks and further limitations, but like the cost.

Speaking of cost, going back to what it costs to implement an EHR. Looking at HealthIT.gov for numbers, they list the five-year total cost of ownership (estimated average) as $48,000 for an in-office system and $58,000 in a software as a service model. That doesn’t include practice losses during implementation or ongoing loss of efficiency, the need to add additional staff to manage all the metrics, or hiring contractors and attending classes just to make sure one understands all the maze of rules.

I agree with you that necessary change will take a decade. Unfortunately, CMS only gave providers half that time to accomplish ever-changing (and sometimes obscure) goals involving elements beyond their control before the penalties kick in. I hope there are some primary care providers left when the dust settles. I’m seeing my peers retire in droves and there aren’t enough new hires to fill the gaps, increasing patient wait times.

Sincerely,
Jayne


Dear Jayne,

What do I think? Well, I’m glad you asked. I have just spent about four hours reading, digesting, and summarizing in a document I can share internally what this could mean. Then again, it might not mean any of what I have summarized. Theoretically depends on public comments.

This has been such a frustrating process for everyone. I work with providers and healthcare organizations. There was so much confusion with the 2014 CEHRT requirement already. This will undoubtedly make it so much worse. For some EPs, it could be a life preserver – several vendors aren’t CEHRT yet. Maybe the 62-year-old provider I met with last week (whose EHR vendor wants him to sign a 10-year contract for their patient portal) will be able to delay and shop some more. Perhaps another client I work with won’t be forced to purchase a CQM module and sign a three-year contract by June 1 or be faced with missing MU Stage 2 this year because the vendor won’t have them upgraded in time.

Waiting the 60 days for public comment, however, will be like trying to fly stand-by the Wednesday before Thanksgiving. If you get the flight, all will be well and you’ll spend the day smiling and toasting your good fortunes. If you don’t, you had better be scrambling to figure out how to thaw a turkey overnight. MU and a turkey – it’s a good analogy!

Sincerely,
Apple Pie Fan


Dear Pie Fan,

Thanks for writing. Your thoughts reflect those of many people I’ve spoken with this week. The potential delay doesn’t mean anything if it doesn’t go through. If you wait for the final rule and you didn’t guess right about its content, you’re going to be caught short. In the mean time, everyone has to push forward as if there will be no delay.

I really like your turkey analogy. In contrast to CMS, however, Butterball has a turkey hotline you can call for actual answers.

Sincerely,
Jayne


I’m not sure how many readers we will have given the Memorial Day observance. I hope you were able to spend time with loved ones and took the opportunity to remember those in the armed forces that made the ultimate sacrifice. If you’re wondering about today’s picture, it’s courtesy of Smithsonian.com and was taken at the site of the Battle of the Somme. There are several other haunting images that show the scars that remain even after 100 years.

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May 26, 2014 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 5/19/14

May 19, 2014 Dr. Jayne 1 Comment

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Outside of healthcare, very few people understand what a CMIO does. Usually when I meet new people I explain that I’m a doctor, but I work in the information technology world. If I get a totally blank stare, I might go on to say I work on the electronic records systems that hospitals and physician offices use.

Some will ask why I’d want to give up the money and excitement of being a physician. I suspect they don’t have any idea of what being a primary care physician actually looks like. Occasionally someone will ask me if I can help them with some home networking problem, which I find pretty funny that people assume that everyone “in IT” knows how to do desktop and network support.

Inside the hospital, I’m not sure that many physicians actually understand what we do either. They know we’re the people to call when they have complaints and that we’re usually the figurehead telling them they have to do something for Meaningful Use or CMS audit purposes. Physicians may not understand the role we play as their advocate or the depth of the battles that we fight on their behalf.

I’m not sure our role is always fully understood by the IT teams either. Some analysts think we’re just super-nerdy physicians or that we had to leave full time practice for some reason. Others are afraid that having a physician on the team means that we’re going to try to call the shots or be the boss all the time. Frankly there are some days that I’m not even sure what I do. Teams work more effectively when they understand where the various members are coming from. In that spirit, here’s a week in the life of a CMIO.

I started Monday with a half-day of teach-back training for a couple of our new implementation team members. Our organization is a stickler for making sure that training is consistent and reproducible so that no one can complain that he or she didn’t have every opportunity to learn the material. As part of that process, I deliver train-the-trainer sessions for the team.

Some of our team members come from non-clinical backgrounds. It’s important that they understand the training scenarios and clinical pearls we incorporate for our end users. Having that knowledge helps them build credibility and trust with the end users. They’ll also shadow other members of the training team so they can see various presentation styles before it’s time for them to start deliver their own sessions independently.

Over lunch, I returned a couple of phone calls from cranky colleagues who don’t understand why we won’t customize the system for their individual needs. Although our EHR is template-rich, it lacks content for some of our subspecialty physicians. They all have access to voice recognition so they can dictate narrative as part of their notes, but some are insistent on wanting click-the-box type templates.

From experience, we can build them whatever they ask for and they still won’t like it, so our bent has been to steer them to using dictation, but creating macros and templates to make it even faster. One of them agreed to try our standard approach but the other was more skeptical, so I convinced him to shadow one of his colleagues and see how well it can work. I’m cautiously optimistic.

The afternoon was filled with a mountain of email that had built up from taking Friday off. I make it a habit to not work on the weekends unless it’s an upgrade situation or a critical outage. I hope setting that example for our team means something, but I still see entirely too much correspondence originating during the off hours. Maybe it’s time for another work-life balance discussion with a couple of them.

Tuesday began early with the hospital credentialing committee, which is always somewhat of a snoozer. I appreciate the need to have medical staff committees, but they can be pretty dry. In a world where I preach the gospel of working to the top of the license, it’s hard to justify having 10 physicians sit in a room and make decisions that would be quite amenable to the committee equivalent of a refill algorithm or a standing order.

After that, I had a meeting with one of our physicians who is interested in our open associate medical director of informatics positions. He’s qualified, but reluctant to give up any of his current duties to make it a reality. Somehow he thinks he can just fit it in, and that’s not going to be the case. I keep trying to explain that we’re not going to put someone in a position where they’re destined to fail, but he isn’t getting the message. I’d really like to add him to the team, but you can’t just squeeze 16 hours a week of informatics work in between patient appointments.

I met in the afternoon with our project team to run through the presentation we’d be doing for our bi-monthly steering committee meeting on Wednesday. The budget numbers looked a little funny, so we had to dig into the reports and the time-tracking system, which is never fun. It turned out to be some operating expenditures that should have been capitalized, but it took forever to find the discrepancy.

In between meetings, there is a steady stream of email, requests to visit practices, and occasionally help desk tickets that providers want escalated directly to “a real doctor who will understand.” Most of the time those end up being user error or training issues, but they take a lot of time to explain, reassure, and arrange for retraining when needed.

Wednesday can only be described as Meet-a-Palooza. We started with the steering committee. One of our hospital VPs must be reading some kind of leadership book because he was all over asking hard questions just for the sake of asking hard questions. Although no one of them stumped us, it drives me crazy when people use meetings to try to make a name for themselves. Following that was our regular project leadership team meeting, followed by an implementation team meeting, which I usually sit in on so I can stay on top of any practices that are having difficulty with EHR.

I hid in my office with the door closed during lunch because one of our junior analysts has decided he wants to go to medical school and is driving me crazy. I think he’s watched too many episodes of “Grey’s Anatomy” and his expectations are completely unrealistic, but he’s persistent. Unfortunately he didn’t like biology or chemistry in school, and although he has a masters in health information management, his undergraduate major was political science. He’s not willing to concede that he’ll have to go back and take all the science 101 classes, so until he does, I’m avoiding him.

The afternoon’s scintillating meetings included: monthly clinical quality measures review; MU status review; new provider on-boarding; and a red-hot discussion of whether or not we should pay our providers to attend training (we don’t, but they always ask us to).

Thursday is my work from home day, which is the only day I can get anything done. I had a couple of presentations to prep – one on change leadership that I’m submitting to present at a conference, the other for a local residency program on the business of healthcare. I was able to get them mostly done, but I like to let them rest for a week or so then revise, so I’ll be back at them again. In the afternoon I worked on performance reviews. Although I don’t have any direct reports, our organization believes in a 360-degree evaluation, so I end up doing reviews of most of the implementation team and support analysts. I can only do a couple at a time before my brain shuts off, so I punctuated them with some gardening, which was pretty therapeutic.

Friday I met with our testing coordinator to review the test plan for a new specialty we’re bringing up. She’s going on maternity leave soon and I suspect she won’t be coming back, so we’ve been spending time making sure we document the process we use to evaluate new content, build scripts, and ultimately test new content. Although that will make on-boarding her replacement easier, I hate to see her go. We’ve had too much turnover in that position and I’d like to find someone who will stay for the duration.

Next it was on to our monthly ICD-10 update for senior leadership. The delay has taken the wind out of our sails. I wish someone would just cancel the meeting for a couple of months and then we can pick it up full steam, but instead it languishes on the calendar and doesn’t have a real purpose. It’s not my meeting, though, so all I can do is suggest a different path, and when we run out of agenda items, be the one to recommend we adjourn early.

Friday afternoon I came full circle with the implementation team, this time being the student instead of the teacher. I have to say I was impressed with how quickly they were able to pick up the material and how well they did. We cleared them both to go out into the field and work with seasoned trainers. They’ll initially just shadow and assist with the hands-on portions, but over the next month they’ll start teaching parts of the new employee sessions until they’re eventually teaching the entire course with another trainer as backup. By mid-June they’ll be out of the nest and on their own.

I always end Friday by looking over my calendar for the next two weeks. It gives me an idea what I need to focus on for the coming week and lets me see any conflicts or major issues in the one that follows. Sometimes our administrative assistants get a little cavalier with our schedules, so if we want to be able to breathe or eat during the day, it pays to be proactive. I realize they’re trying to squeeze every minute out of the day and respect what they do, but ultimately I’m the one who looks bad when I’m absent or late due to an overcommitted schedule.

Some weeks are different, but many are the same but with just different meetings and different cranky colleagues. When we’re close to a major upgrade, it looks completely different, with much more focus on the new version but with all the same standing meetings continuing. It can be quite the juggling act at times. Nevertheless, I enjoy doing what I do. But sometimes it’s just easier to be “the doctor who works in IT.”

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May 19, 2014 Dr. Jayne 1 Comment

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