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EPtalk by Dr. Jayne 12/1/16

December 1, 2016 Dr. Jayne No Comments

Breaking Up is Hard to Do, or Caveat Emptor

I’ve been doing change management work for longer than I care to admit, so I’ve seen firsthand that change is never easy. It’s human nature to be risk-averse to some degree, and many people have deep-seated feelings that change is risky. I’ve enjoyed my work helping physicians and their staff members through the challenges of implementing EHRs and expanding their use of technology, moving them from the “no way” group to the “I can’t manage without it.”

I’ve watched some physician friends move through that transition and it’s been gratifying even though I haven’t been involved in their projects. As an EHR proponent, I’ve been on the receiving end of a lot of complaints about technology, and seeing people reach the point where it enables their work instead of causing heartburn keeps me going. Relying on EHRs has its own challenges, though, particularly when a practice breaks up.

One of my closest friends has spent the better part of the last three years going through such a breakup. Her group of three surgical subspecialists had been stable and productive for years when one of the partners became disabled and could no longer perform surgeries. They held it together while they recruited a replacement physician, taking on extra work to cover the portion of the overhead no longer funded by the departing partner. Unfortunately, the new physician didn’t work out and debts mounted. The remaining partner simply decided to stop working, forcing my friend to terminate the partnership rather than take on debt trying to keep the doors open.

The stress has been significant, but she was starting to see light at the end of the tunnel as she agreed to join another group in town. Since they were on the same EHR vendor, her hosting team promised her an easy conversion. She ran the pricing past me and I thought it looked low. Digging into the agreement, I noticed that it was only a demographic conversion and no clinical data was to be converted. Instead, the clinical data was going to be converted to PDF and added to the imaging portion of her new practice’s EHR. We talked through the ramifications of that, and whether she would rather have the data converted or abstracted. Due to the episodic nature of most of her patient relationships, she was willing to risk it.

I expected her to call after a week or two in the new practice, asking for an abstraction vendor. It wasn’t two hours into her new practice before she was inundating me with text messages and emails. The conversion wasn’t the problem – the EHR was the problem, along with the practice staff.

In a small practice, there may be only one or two super users. In this case, both of them had quit since the last time a new physician joined the practice. No one in the office knew how to add her to the provider master file, so they simply added her as a user since that’s all they knew how to do. As a physician, she didn’t know that was an issue until she started trying to issue prescriptions and apply her electronic signature to office notes. No one in the office knew how to contact the help desk, so she called me, knowing that I’ve worked with her vendor before.

I gave her the help desk number and some pointers on what to ask for and hoped for the best. I felt so bad for her. The average physician looking for a new practice situation is more focused on questions about the call schedule and how expenses are shared than he or she might be on asking about the number and availability of super users or system admins. Especially if we’ve come from a highly functional EHR support framework, it might never cross our minds. We take it for granted that things just work, not remembering all the hard work and setup that it took to get the system to the place where we could see patients.

We may also take it for granted that every installation of a given vendor’s system is the same. Although there may be core modules that are the same, practices and hospitals often customize and configure many portions of their system, unknown to the average end user. Additionally, not every installation is on the same version of a given piece of software. In my friend’s situation, her new practice was on an older version of the system. The visit documentation templates were nearly unrecognizable to her, as they pre-dated her previous system by several major releases. I’m sure asking for their release version and the number of their most recent content patch wasn’t part of her interview questions, either.

Fortunately, I was able to call in a couple of favors and get her some immediate help, although we haven’t been able to get her set up with electronic prescribing or updated letterhead for her patient plan documents. She’s not yet present in the patient portal and can’t order labs, but at least she can print prescriptions, document her visits, and bill out her charges.

Although the old adage about “buyer beware” certainly applies, these are uncharted waters for most physicians. Most physicians that are making moves are consolidating into larger groups or are being acquired by hospitals and health systems. It’s not as common for them to move from one small practice to another, but even in that situation, groups may be on a hospital’s community EHR offering or on a fully hosted solution. It’s rare to see a small practice trying to maintain their own client-server system and I think many physicians would fail to deduce that arrangement if they were in her shoes.

Back in the day when EHRs were just coming on the scene, I started my “on the side” consulting business by helping small practices with system selection and implementation. I’m thinking I may need to consider a new business line helping physicians on the move who need help teasing out potential EHR pitfalls during the practice selection process. It would definitely be a niche offering given the number of new grads joining hospital-owned practices, but for those physicians faced with a situation like hers, it would be worth it. Once the match was made, it would lend itself nicely to conversion and/or abstraction services.

My friend has given me permission to use her experiences to create checklists and questionnaires to help prevent other physicians from going through similar circumstances. I’m sorry she had to go through it, but I’m going to be ready for the next physician who needs help evaluating a practice opportunity.

How do you onboard new physicians? Email me.

Email Dr. Jayne.

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December 1, 2016 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 11/28/16

November 28, 2016 Dr. Jayne 2 Comments

It was a busy holiday weekend for me, with several days of patient care. I saw several extended families with a “stomach bug” that was more likely to be food-borne illness. It’s never fun to suggest that Aunt Tillie’s cooking make everyone sick, but it does happen. At one point, we had so many patients receiving IV fluids that we had to call for more supplies to be sent from another location.

Although I think I won the prize for fluid administration, several other locations broke records for the number of patients seen in a single day. Not every patient was in need of such urgent attention, though. Dozens had conditions that could have waited or didn’t need to be seen at all. I’ll have fun analyzing the statistics once we complete our month-end close, but the potential root causes are interesting.

Over the last several years, we’ve seen greater patient empowerment, which is generally a good thing, especially when you’re talking about shared decision-making and improved health through greater patient involvement. But it’s less of a good thing when patient empowerment loses the “patient” piece and becomes more of an exercise in instant gratification.

To be clear, I’m not talking about patients with urgent medical needs, such as shortness of breath, chest pain, lacerations needing stitches, strep throat, etc. I’m talking about the folks who have had a cough for one day, who haven’t tried any over-the-counter remedies, and who expect the physician to work magic and get mad when we don’t have much to offer.

We had one patient come in as we were closing on Friday who stated that she was “miserable” with her symptoms, yet she came in at closing time because she was too busy with her Black Friday shopping to be seen earlier. Even her $50 co-pay wasn’t a deterrent. She could have called the after-hours line at her primary care office and received the same advice that I gave her, which was to treat the symptoms using over- the-counter remedies since it was most likely a viral infection. She ended up being upset with my treatment plan and demanded an antibiotic, which I refused to give her. I’m sure she’s going to call our administrators and complain.

I used to become more aggravated at situations like that, but they’ve unfortunately become par for the course. When my administrators look at the overtime that was paid out handling her care, I’m sure they’ll be a bit less sympathetic to her complaints.

I also had several patients who were there because they were worried about symptoms they did not yet have. One was a college student planning worried about getting sick before finals, because she had been having a runny nose for a few hours. Her mother was more concerned about “what could possibly be causing those dark circles under her eyes?” than listening to my discussion of needing plenty of rest, plenty of fluids, and some over-the-counter medication from Target. I recommended that she obtain a flu vaccine when she gets back to school on Monday (we have already exhausted our supply) and she stated that she refuses to go to the student health service because they didn’t have “real doctors” there. Her mother heartily agreed. I knew at that point there was no reasoning with them.

Some of these situations are the unforeseen consequences of shifting healthcare policy. My practice is big on price transparency. That’s part of our marketing since we’re significantly more affordable than the local hospital emergency departments. We’re not cheap, though – self-pay physician visits are right around $100 with testing and treatment on top of that.

Patients paying out of pocket tend to have better judgment when deciding to come in, and most of them have conditions that legitimately need a prescription treatment or other intervention. The majority of patients who don’t really need to be there have insurance and are somewhat insulated from the real cost of care. Even those with high-deductible plans tend to come to care a little more frequently than I’d expect, knowing that the charges will be billed through to insurance first so there isn’t a direct correlation between care and payment.

My dad recently found some old physician office fee tickets from the 1970s that made for interesting reading. I remember going to those physician offices. They didn’t have big billing staffs or revenue cycle management agreements or contracts experts or any of that overhead. They had a physician, a nurse or assistant, and a receptionist who also collected the payments at the time of service. Even adjusting for the wages of the day, the charges were reasonable.

I look at my practice (which is right at MGMA benchmarks) and see how many people are supporting me from a revenue cycle standpoint compared to how many are actually helping me deliver patient care and it’s disheartening. We have so many layers between the patient and the payment that are contributing to costs, and yet no one seems intent on reforming the insurance industry or their extreme profits. Back when I ran my own practice, I once calculated that the costs of managing the payer-related workflows in my practice (charge entry, payment posting, working denials, collections, office management functions related to those workflows, etc.) were nearly 30 percent of my overhead.

People are working hard in the realm of healthcare technology to streamline those processes and make them efficient as possible. The practice management system I use now leaves the one I had in 2005 in the dust and it’s significantly easier to use as well. We’re automating ways to get the most out of the healthcare system, but the underlying problems aren’t getting much better. In some ways they’re becoming more complex, as we now have to manage prospective payments, capitated payments, fee-for-service, increased patient-pay amounts, and other arrangements.

I recently watched a practice spend nearly $100,000 in staff and consulting hours on a project to address write-offs and refunds largely related to inefficiencies in payer processes. I guarantee that practice had more patient-centric priorities they could have spent that money on, but they were hemorrhaging money with their previous process and needed to fix things so they could move forward.

Even with our major shifts in healthcare policy, it often doesn’t deal with some areas of urgent need. I saw one patient who was actively delusional, yet had nothing to offer her because she wasn’t a danger to herself or others. Mental health services are so strapped in our community that unless you meet the latter criteria, it may take months to see someone. I spent nearly an hour trying to come up with a plan for her, which ended up being pretty pathetic compared to the care she really needed. But at least I was able to refer her electronically and with an associated C-CDA so when she does finally have an appointment, the receiving care team will have my data.

My next few patient care shifts are in non-holiday, non-weekend time blocks, so maybe I’ll see more typical urgent care cases that will help reset my psychology around the work I do and how it plays into the grand scheme of things from a healthcare reform standpoint. In the mean time, I’ve got some last minute HIPAA-related security risk assessments to work through for consulting clients that like to wait until the last minute to get things done. After that, I’ll start helping clients get ready for end-of-year data gathering and preparing their attestations for various payer programs as 2016 winds to a close. The end of the year used to be a slow time, but no more.

What’s your busiest time of the year? Email me.

Email Dr. Jayne.

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November 28, 2016 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 11/21/16

November 21, 2016 Dr. Jayne 5 Comments

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One of the challenges of running a business is managing your brand. While branding is associated historically with artisans burning their marks onto products and with ranchers applying brands to livestock, modern brand management can be a tricky thing. While we often associate brand management with consumer goods, an increasing number of healthcare organizations aggressively manage their brand identities.

Where many faith-based organizations traditionally named themselves after saints, the last decade has seen those identities give way to more broadly-appealing concept-based names: Memorial, Dignity, Unity, Mercy, Ascension, and more. Corporate initials have become prefixed to the names of even more facilities, a change that is deliberate and belies a deeper strategy. Health systems have gone beyond the traditional mission and vision statements to create marketing taglines that are specifically designed to evoke a certain feeling about the facility and its services. As “patients” have become “consumers,” we’ve seen more and more health organizations that are looking at market share, competitive intelligence, and brand differentiation.

Hospitals often have aggressive marketing campaigns around their emergency department wait times, the luxury of their labor and delivery suites, the availability of hotel-like accommodations, and more. The competition for market share has long trickled down to individual physician practices, where being affiliated with a given health system can generate more business or greater prestige. Although these may have been loose affiliations in the past, they’re becoming more solid as groups of providers shift into Accountable Care Organizations and other risk-sharing arrangements. Organizations that understand their brand and how they are perceived by the community can make stronger plays in the market than those who can’t.

As I work in physician offices across the country, the differences in brand awareness are striking. Many physicians don’t understand how important having a corporate identity can be, or conversely what a disaster it can be if you don’t have one. Does the staff wear uniforms that match and have a practice logo? If there isn’t a uniform, is there a dress code? Or do staff just wear whatever scrubs are at the top of the clean laundry? It amazes me when practice leadership hasn’t given this any thought. Having a uniform appearance (which doesn’t necessarily mean there must be uniforms) can convey to the patient that their experience is going to be organized and predictable.

Even though my practice has a strict dress code, we sometimes struggle with this. Different team leaders have different levels of tolerance for deviation from the dress code, which can result in consequences when the CEO, COO, or a medical director arrives unannounced. The fact that there are penalties associated with failure to adhere to the standard makes a difference, though, and it quickly becomes clear that if leadership isn’t going to tolerate straying from the dress code, they’re not likely to tolerate deviation from our customer service or patient care standards, either.

I see physicians who struggle with their own idea of a dress code – white coats that are filthy at the cuffs and elbows, rumpled clothes, dirty scrubs, and shoe covers with holes worn through them. They may be brilliant in their field, but they’re missing the fact that their personal brand screams “messy” and “disorganized” rather than “capable” and “professional.” This concept of personal branding becomes even more concerning when it extends to a physician’s social media presence. Where some are skilled at keeping personal and professional personas separated, others offer up a confusing mix of messages that may be concerning to patients or potential patients.

Even those physicians who may do a good job managing their own personal branding and social media presence often struggle with managing how their employees present themselves. Do employees use the practice platform to promote their own interests? Does the practice have any say in how physicians and employees present themselves on platforms such as Doximity and LinkedIn? I’m seeing more organizations that are interested in trying to get a handle on these external platforms, making sure their employees help support the professional perception of the organization. Some may require employees that blog to add a statement that the opinions featured in the blog are not those of the employer. Others don’t seem to notice that their employees have social media profiles. Case in point: the marketing director of a local Catholic healthcare organization was wearing a shirt that said “sex, drugs, and rock & roll” in his LinkedIn picture while prominently featuring his employer’s logo on his profile. I’ve also seen plenty of non-clinical people wearing scrubs in their photos, which always baffles me.

Hospitals and healthcare delivery organizations aren’t the only ones in our world that are spending significant resources managing their brands externally. Many healthcare IT companies are actively managing their brands, even though those that may not admit to having a marketing department. Although some efforts can be counterproductive (remember the Siemens Healthineers debacle?), others have had significant success. HIMSS is the big game of healthcare IT marketing and it’s clear to see who brought their A game to the exhibit hall.

In dealing with many vendors in the course of my consulting work, however, I wish more of them would pay attention to internal branding and ensuring employees other than the marketing team can deliver a consistent message. I work with one vendor that often communications information directly to their client base without communicating the same information to their employees, which as you can imagine results in a lot of misunderstandings, particularly when the communications include release dates or break/fix information. Even though they’re a relative start-up, there’s no excuse for not having a communication plan that allows your internal team to be educated before you start sharing information with your customers.

There’s also no excuse for not having consistent, professional website bios for your senior leadership, but I can’t say I didn’t warn them. When nine of 10 execs have professional headshots and the other has a selfie from his most recent fishing trip, that’s probably not the image you want to convey, unless you are a vendor that runs a fleet of charter fishing boats.

What’s your brand? Email me.

Email Dr. Jayne.

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November 21, 2016 Dr. Jayne 5 Comments

EPtalk by Dr. Jayne 11/17/16

November 17, 2016 Dr. Jayne No Comments

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I heard from a couple of clients that CMS has started to notify practices of their selection for the Comprehensive Primary Care Plus initiative. Although the web site says that they updated the Region and Payer lists on November 15, I was unable to find the updated lists on the site. I’m assuming they’ll be putting out a press release shortly, but it would be nice to get the information from the source before clients start calling. The program starts January 1 and there is much work to be done for those selected.

Some of my clients who applied don’t have experience with prospective payments and may need retraining on their practice management and accounting systems to ensure they know what do to with the money and how to manage it. Fortunately my partner has a lot of experience in this regard, but it’s a learning opportunity for me as well. In urgent care, the only prospective payments I deal with are our occupational health contracts and that’s a different kind of accounting altogether.

I’m receiving a lot of requests for support from organizations that are relatively new to value-based care. One in particular has received reports from their ACO and the numbers don’t line up with what they are seeing in data from their EHR vendor. Reconciling competing reports isn’t one of my favorite pursuits, but I’m fortunate to work with a great data analyst who is going to start digging in. I’m suspecting that the ACO data might have issues since there are measures that have the same population and one is showing a zero denominator where the others clearly have denominators. One would think the ACO would have reviewed that and completed some data integrity checking before sending their participating practices into a scramble.

I think we’re going to start to see some buyer’s remorse as practices realize what ACO membership really means for them. I’ve seen quite a few independent practices that felt pressured to join organizations or risk being left out of referral networks. Some independent practices don’t have the most business-savvy people making decisions and may gave gotten more than they bargained for with regard to their responsibilities as part of the ACO. In this particular situation, the ACO agreement didn’t address the idea of what happens when there are data reconciliation issues. Even when we complete the analysis, my client might still be penalized based on the faulty data. These types of issues are going to continue to surface as more organizations move into the value-based care space but might not have the expertise to fully manage what they are trying to do.

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I spent several hours this week completing mandatory Maintenance of Certification activities for my primary board certification. It was a depressing activity since many of the questions covered minutiae that is hardly germane to the realities of practicing medicine. The format was an online “knowledge assessment” with provided citations for the information behind each question and answer. Notice I said “citations” and not “links” because finding the references was a manual process, and for some, a Google search failed to locate the materials. Other materials were fee-based and many were more than a decade old. I began to distrust whether I was spending my time wisely trying to find the right answer to pass the assessment vs. knowing that I was reviewing current information.

One of the questions were around the 2008 Physical Activity Guidelines for Americans, put out by the US Department of Health and Human Services. I’m not sure I need to know whether the Guideline officially recommends the frequency for alternating various types of activities in order to be a good physician. What I do know is that most of my patients need to eat less and move more. Splitting hairs with them on whether they prefer moderate-intensity exercise at a weekly minimum of X minutes vs. vigorous activity of Y minutes doesn’t play out in the six-minute office visit. If they’re overweight or have diabetes, hypertension, or metabolic syndrome, I need to focus on telling them that if they’re exercising they’re moving in the right direction and that they should consider doing more.

Maintenance of Certification is particularly difficult for those of us that work in non-traditional capacities or limited practice situations. For example, the modules where I am supposed to do practice improvement activities don’t necessarily apply to me because I don’t follow patients in continuity. Rather than giving me opportunities to do something relevant to my work, I have to do the same activities that traditional physicians do but with simulated data, and the learning value is pretty low. It’s particularly low because I’ve already done the exact activity before, in my last recertification cycle, because there are so few options for non-traditional physicians.

We are forced to maintain our primary board certifications for a couple of reasons. First, to be credentialed by payers, you generally have to be certified. Second, even to practice clinical informatics, we have to maintain a primary board certification. It’s a catch-22 for many of us who might consider dropping clinical practice altogether but want to stay certified in clinical informatics.

Speaking of that certification, the American Board of Medical Specialties approved a five-year extension on the so-called “practice pathway” to clinical informatics certification. Physicians who are currently practicing clinical informatics but who have not completed a fellowship can apply for certification through the 2022 examination cycle. I am grateful to AMIA for keeping everyone informed. The announcement cited continued workforce demand and opportunities for physicians seeking a full-time informatics career as contributing factors. Now we need a pathway for those of us who don’t want to maintain a primary certification to go “all in” for clinical informatics.

I’m way behind on my email due to some back-to-back travel and trying to get my board certification activities done. I was interested to see a request by the Food and Drug Administration for submissions on “Emerging Issues and Cross-Cutting Scientific Advances.” The FDA regulation process takes years, creating a need to assess how to regulate advances that are just now being thought of. The blog piece mentions ideas like intraoperative hibernation and brain-computer interfaces as examples. Submissions to the Emerging Sciences Idea Portal will be public, so I’ll have to make a reminder to follow up.

I’m taking a long weekend to recover from the chaos of the last several weeks. It put a dent in my frequent flyer and hotel points, but it’s exciting to have a trip planned that I’m actually looking forward to.

What’s your favorite long weekend getaway? Email me.

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November 17, 2016 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 11/14/16

November 14, 2016 Dr. Jayne 1 Comment

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Since I’m working both as a consultant and as an employed physician/CMIO, I have the opportunity to interact with quite a few different hospitals, health systems, physician organizations, and vendors. Maybe it’s the Supermoon effect, but it feels like some of the organizations and teams I’ve been working with have lost their rudder. It’s resulting in unpredictable situations that create challenges all the way around.

With one organization, I feel like I’ve been immersed in a spy novel. They’ve been planning to switch EHR vendors for quite some time and are well down the contract negotiation pathway with another vendor. Still, they keep stringing the legacy vendor along, demanding that executives be flown to the client site to address the issues and the relationship so that they can demand discounts and credits for perceived software inadequacies. I say perceived, because I’ve been working with them for well over a year and know firsthand that they haven’t implemented the legacy system correctly and refuse to take my advice or the advice of the other two consulting firms they have on site.

I wish there was some kind of whistleblower hotline to let the legacy vendor know they’re being played, as well as to warn the incoming vendor of the kind of people they’re dealing with. Maybe there is already some level of understanding of the situation, but in working with the earnest and dedicated sales and client management teams, the individual folks working hard to save the client don’t seem to have been clued in and are taking it personally when they figure out the client is lying to them. Client leadership is open about how much they can get out of the legacy vendor on their way out the door and it’s sickening. I’m grateful my contract with them expires at the end of the year because I won’t be offering them a renewal.

Another organization recently engaged me to do some coding education with its providers. In the decreasing world of fee-for-service, they’re eager to get every last dollar out of their problem-oriented encounters. The first thing I did was to look at the coding distribution across their providers, which was fairly close to what I expected. There were two physicians who were significant outliers, but the rest fell nicely along a curve that didn’t vary much by patient mix or payer mix. I figured my task was to first work with the high-end outliers, to find out whether they were over coding and putting the organization at risk. When groups get caught in that situation, the penalty is calculated by extrapolating the overage as if all visits had been handled that way. It’s to an organization’s benefit to rein that in so they don’t have a huge penalty in an audit.

In fact, the group wanted me to address those they perceived as under coding and get them up to the level of their outlier peers. I’m sorry, but if you’re a walk-in primary care clinic that isn’t even addressing complex chronic conditions or significant comorbidities, it’s hard to get a viral upper respiratory infection up to a 99214 E&M code without at least documenting the chronic conditions and how the infection might impact them. Just because you add a prescription medication to the plan or perform a 40-point physical examination doesn’t mean it was medically necessary or that the higher level of coding was justified. I was happy to provide the nuts and bolts coding education. but if they want to encourage up-billing. they’re going to have to use their own physician executives to explain how they want that done.

Another group who engaged me to do a workforce evaluation is being crippled by ineffective management and poor human resources policies. Workers routinely fudge their time cards to make sure they reach 40 hours a week, even though they’re exempt employees who aren’t necessarily required to document 40 hours a week. Unfortunately, they’re damaging their team’s reputation and creating risk for their company. Some of the workers are adding the time to administrative buckets, which negatively impacts the team’s productivity. The worst offenders are padding time on client-facing projects, in effect stealing from their clients six minutes at a time as they increment the billings almost imperceptibly to make up for their own shortages. I recommended that the 40 hours requirement be removed and time be monitored over the next few months to see if there are weeks that people are working more and weeks that people are working less, and to see if they were averaging 40 hours a week as expected. HR cited company policy for the 40 hours requirement, and failed to address the outright dishonesty by their client-facing employees.

I was raised in a world where people should be prepared to face the consequences of their actions, but in these situations, it’s clear that there have been no consequences to date and that those involved don’t even worry about the potential consequences. My business career has been under leadership that expected people to deliver what they said they would deliver, but to do it ethically and in a way that keeps the client at the front of their thoughts and actions. I’ve worked for leaders that were tough but fair, and were honest about the decisions they were making and the potential impact on downstream employees and clients. It’s what I’ve tried to be in my work, but sometimes I feel like the idea of “greed is good” has come back into vogue.

I don’t want to think that so many organizations are spiraling into the muck, and just as I was starting to feel that way, I had a company impress me with its integrity. I helped them with an extremely sensitive project and they made sure that as it unfolded I was in no way compromising my principles or proceeding in a way that didn’t make me comfortable or interfered with my other clients or responsibilities. They didn’t assume that just because I was a consultant and being paid a good amount of money that I was on board for anything they requested. I’ve never worked with a group that was quite that deliberate in how they handled their business relationships, but it was certainly refreshing. It was the kind of engagement that makes a consultant hope that if they eventually want a full-time resource, they’ll keep you on their short list.

I like working with people who say what they mean, mean what they say, and do what they say they are going to do. Are you fortunate enough to have that in your workplace culture? Email me.

Email Dr. Jayne.

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November 14, 2016 Dr. Jayne 1 Comment

EPtalk by Dr. Jayne 11/10/16

November 10, 2016 Dr. Jayne 3 Comments

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Most of the physicians I have interacted with over the last two days have commented about potential healthcare impacts from Tuesday’s election. Although the potential repeal of the Affordable Care Act was at the top of multiple conversations, there were many local and state questions with a health-related focus.

Colorado voters failed to pass Amendment 69, which would have allowed for a single-payer healthcare program to replace the state’s insurance exchanges and also private plans. Voters there approved Proposition 106, which would allow physicians to prescribe lethal drugs to terminally ill adults who are certified by at least two physicians as having less than a six-month life expectancy. Colorado voters also said no to increased tobacco taxes, with similar rejections in North Dakota and Missouri. The latter had two tobacco tax issues on the ballot, which likely caused confusion.

Regarding other smoking options, medical marijuana was legalized in Arkansas, Florida, and North Dakota, while Montana amended its existing regulations. Recreational marijuana use was approved in California, Maine, Nevada, and Massachusetts. Those eager to partake will have to wait a bit longer while states finalize the details around the actual sales and dispensary processes.

California voters approved a tax of one cent per ounce on sugar-laden drinks in Oakland, San Francisco, and Albany, while voters in Boulder, Colorado approved a two cent tax. California voters also elected to continue fee assessments on private hospitals, with the proceeds being used to fund Medicaid.

The most interesting ballot questions I saw were in Florida, with two non-binding referendums on the release of genetically modified mosquitoes to reduce disease. It’s an interesting idea as a public heath intervention and passed in Monroe County, but not in Key Haven. I’m a big fan of Jurassic Park and I can’t help but wonder if voters thought about what happened with those genetically modified dinosaurs when they made their decisions.

California was certainly a leader in the number of health-related questions, although voters failed to pass Proposition 61, which would have blocked pharmaceutical companies from charging state payers more than they charge the Department of Veterans Affairs. Not surprisingly, big pharma spent more than $100 million to oppose the measure.

Although the president-elect promised to repeal the Affordable Care Act as part of his platform, Republicans failed to earn a filibuster-proof majority in the Senate. The ACA was a long time in the making and had support from both sides of the aisle, so efforts to reverse are sure to be interesting. Filibusters are always attention-grabbing as well as a way to hear some interesting literature and potentially pick up some new recipes.

There is a chance that a budget reconciliation maneuver might be used, which only requires a simple majority, but this requires a review of the parliamentary process around budgeting to ensure that the process is compliant. This process was used earlier this year, but the bill ultimately suffered a Presidential veto.

Changing the ACA might be more difficult than people think, as more than 20 million people would stand to lose insurance coverage. Additionally, many Americans have been pleased with the portions of the law that protect patients with pre-existing conditions and extend the length of time that dependents can remain under their parents’ coverage. This enthusiasm has been tempered, however, by concerns over high coverage costs and rising premiums.

Trump has also mentioned allowing the import of prescription drugs from outside the US, as well as allowing Medicare to negotiate drug pricing directly with pharmaceutical manufacturers. Similar efforts have been blocked by the GOP in the past, so it will be interesting to see what’s different this time. It’s likely that a Republican-controlled legislature will take up the issue of funding for Planned Parenthood and perhaps other regulations related to reproductive healthcare.

The issue of filling the existing vacant Supreme Court spot was also the topic of several discussions. I’m sure the nomination process will be interesting once our new president takes office. We’re certainly in for an interesting ride over the next several months.

What chatter are you hearing about the future of healthcare after the election? Email me.

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November 10, 2016 Dr. Jayne 3 Comments

Curbside Consult with Dr. Jayne 11/7/16

November 7, 2016 Dr. Jayne 2 Comments

One of the key tenets of the shift towards value-based care is the idea that physicians are increasingly graded on patient outcomes. Not surprisingly, this grates on many physicians.

There are complex issues involved when trying to get a patient to change behavior, even when it’s a relatively straightforward recommendation such as taking a medication. Conventional wisdom and multiple studies have demonstrated that close to half of all prescriptions aren’t taken as directed and many are never even filled. There are many factors involved: cost, convenience, commitment, side effects, etc. Additional factors related to specific patient populations may also include transportation, safety, health literacy, cultural barriers to care, and more.

When a significant lifestyle change is recommended, the factors involved become exponentially more complex. We live in a society that focuses on instant gratification. Health-related lifestyle changes typically challenge that paradigm and require ongoing hard work that results in slow change that can sometimes feel imperceptible. People want quick wins. Any clinician who has tried to discuss the pros and cons of moderation in diet and increased exercise vs. various celebrity-endorsed weight loss programs knows what I’m talking about. Patients see the claims of a dropping significant weight in a short time period and find the contrast of a slow, sustainable loss of a pound a week to be off-putting.

Other lifestyle changes are impacted by socioeconomic factors, including food insecurity, variable availability of healthy grocery options in the urban core, joblessness, homelessness, abuse, and more. Although physicians can refer patients to community supports and programs (assuming that the programs exist in your area and can maintain their funding in the face of increased need), there are limits to what we can do. That is where the idea of being graded on patient wellness starts to feel unwelcome.

Once you’ve considered the logistical issues involved in a change in patient health status, you have to contemplate the ethical ones. Autonomy and personal freedom are major issues in America today. Governments from the national level to the local level are trying to address issues such as the consumption of high-calorie drinks and the inclusion of unhealthy ingredients in foods. I still miss the trans-fat in my Oreo cookies, but I understand why it’s no longer there. But when you try to convince a patient to make a change, things can often get challenging.

Physicians are at the front line of trying to drive outcomes, but often our advice is often challenged. When I recommend diet and exercise for weight loss, patients want a pill. When I recommend a pill for high blood pressure because diet and exercise failed, I’m accused of being in the pockets of the drug companies. Even though 95 percent of the prescriptions I write are for generic drugs and many of those are on the $4 list at the local supermarket, it’s assumed that we’re getting kickbacks and are part of the healthcare cost problem.

Physicians have long been in a position of paternalism, although that is changing with the focus on patient-centered care. Still, there are patients who want to choose their treatments based on what I would do for myself or a family members. They don’t want to be part of their own decision-making, they just want to be told what to do.

But the next room you enter might have a patient and their entire extended family, all of whom have been all over the Internet researching treatment options, and want to discuss each one of them independently. It certainly makes one feel scattered when trying to see patients as well as a bit fragmented when you have to shift back and forth between two completely different frames of mind. Not to mention that it’s difficult to get payers to compensate physicians for the time spent in those conversations, and patients aren’t eager to pay for it out of pocket.

Then, there’s the principle of beneficence. By pushing patients to comply, are we still doing right by the patient? Where is the boundary between trying to engage your patient to take charge of their health and being pushy? At what point do you agree to disagree on the colonoscopy order the patient is never going to complete? I’m on the hook for the patient’s performance regardless of whether they go or not and regardless of how many times I’ve tried to get them to go or how persuasive my arguments might be.

Under the new healthcare payment schemes, our incomes are directly tied to our ability to motivate our patients to do what we recommend. A recent study may shed some light on which approaches are more productive in moving patients towards change. It confirmed the results of a previous study that identified potentially effective strategies for supporting patient self-management:

  • Emphasizing patient ownership
  • Partnering with patients
  • Identifying small steps toward change
  • Scheduling frequent follow-ups
  • Showing care and concern

Researchers created a scale to measure where primary care clinicians stand and found that performance on the scale was associated with patient efforts. I found it interesting that they only looked at primary care physicians. Although everyone assumes we’re “most responsible” when trying to attribute certain elements of care, it really does take the proverbial village to care for patients. The study found that primary care providers who spent more than 60 percent of their time “counseling, educating, and coaching” their patients scored higher than those who spent less time in those activities. For most of us, being able to spend that portion of the visit motivating our patients would be a luxury.

I also found it interesting that some of the strategies they cite are challenging under new reimbursement schemes. Frequent follow-ups aren’t going to happen for patients on high-deductible health plans. The usual response to that concern is telemedicine, but most payers still don’t cover it. That translates to unreimbursed physician work, which is less likely to happen than actually reimbursed work.

Even something that seems relatively simple such as showing care and concern is increasingly difficult under payment reforms and technology incentive programs. Many physicians are stressed to the breaking point. Scarcity of primary care physicians in traditional continuity practice makes for long waits and short visits. When you have to spend time trying to hit as many metrics as possible in as little time as possible, it doesn’t make it very easy to get to know your patient. Adding the stress of technology issues doesn’t help.

Another factor that doesn’t help is the assumption that patient engagement is a software problem. The reality is that patient portals and online interactive education are just part of the toolkit, but it takes time to help physicians learn how to best use those tools, how to best encourage their patients to use them, and how to put processes and policies in place in their offices so that their use doesn’t increase the burden of physician work.

I’ve done formal training in motivational interviewing and healthcare coaching and know that physicians struggle with finding the time away from their practices to get that kind of training. Some of my rural colleagues have difficulty getting coverage for even a few days out of office. Regardless, having those as options for practice improvement activities under some of the regulatory requirements might have been additional motivation to move clinicians in that direction.

What are your plans for greater patient engagement? Email me.

Email Dr. Jayne.

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November 7, 2016 Dr. Jayne 2 Comments

EPtalk by Dr. Jayne 11/3/16

November 3, 2016 Dr. Jayne No Comments

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Although many are focused on the Presidential election, it’s important to remember that Congress is responsible for appropriations. Many professional and advocacy organizations are busy at work, encouraging both parties to keep the government funded. The American Academy of Family Physicians continues to ask Congress to continue funding for the Agency for Healthcare Research and Quality (AHRQ) and other programs tied to primary care and public health. One would think that those kinds of efforts would be relative no-brainers for our leaders, but if there’s anything that we’ve learned during this election cycle, it’s that brains are sometimes in short supply.

A recent Advisory Board daily briefing noted that “Most docs are Dems” according to data from Yale University research. Surgeons, anesthesiologists, and urologists are more likely to be registered Republicans, where pediatricians and psychiatrists were more likely to be Democrats. Contributing factors may include salary, age/sex demographics, and specialty culture.

In the “no surprise” department, a recent piece in the September issue of Health Affairs identified a decrease in the number of small practices, defined as those with nine or fewer physicians. Small practices dropped from 40 percent in 2013 to 35 percent in 2015, while the number of large practices (over 100 physicians) increased by a 5 percent margin. Increasing regulatory and administrative burdens will continue to drive physicians to larger groups or employed practice situations.

The meeting season is in high swing, with MGMA just having wrapped up and various vendor user groups including NextGen and Cerner about to take place. The AMIA Annual Symposium starts on the 12th in Chicago. I’m sad that I’m missing AMIA this year due to other responsibilities, but I have a couple of friends going who promised to fill me in. If you’re attending any of the user groups or AMIA, feel free to share your pictures of good times, great shoes, and groovy entertainment.

I’m often overwhelmed by my Twitter feed, but when I see something that is mentioned by both Atul Gawande and Farzad Mostashari, I take note. Both mentioned this Washington Post piece addressing the practice of enrolling non-terminal patients in hospice care. The Office of the Inspector General found that many patients signing up for palliative care weren’t told that it meant giving up curative treatments. Hospice care has grown to a $15 billion industry and patients that require fewer services are more profitable due to the flat fee structure. Hospice care can provide real relief for patients and their families during very difficult times and it’s appalling that shady characters would choose to profit from it.

Speaking of people operating on the fringes, I’m sometimes amazed at the things people say in the course of trying to make a deal. I may be young and my consulting company may be small, but that doesn’t mean I’m clueless. A prospective client that I’ve been meeting with has repeatedly asked me to do some things with my proposal that I’ll call “irregular” for lack of a better description. I’m no stranger to dealing with convoluted corporate accounts payable processes, but if you ask me to do things that require legal fees to determine whether they’re legitimate, we’re unlikely to do business together.

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I came across an interesting statistic today that 20 cents of every dollar in consumer spending goes to FDA-regulated products, including many foods, drugs, medical devices, cosmetics, dietary supplements, and tobacco. Being in healthcare IT, we often think about the FDA in regard to device regulation, but may forget everything else they do.

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The “Mr. Yuk” award of the week goes to Kareo, whose “premium content” Medical Economics piece completely ignores the volume-to-value transition, admonishing physicians that “if you are not seeing enough patients each day, you will never be able to grow your practice.” Their guide gives “three key ways to increase the number of patient visits and the revenue that comes with them,” including an effective recall program, an online presence, and encouraging referrals. I was surprised to see someone pushing a clearly fee-for-service model without even remotely mentioning value-based care. It does talk about adding ancillary services such as a dietician, but mostly in the context of increasing the physician’s bottom line rather than as a quality maneuver.

I loved their advice to “don’t bring a dietician on payroll until they are at least 80 percent contracted with your payers. You don’t want to be paying that extra salary while they are unable to bill for seeing patients.” It seems they need a better understanding of how providers enter into employment arrangements. I’ve never met a provider who was willing to sit it out unpaid until the often unpredictable credentialing process reaches a certain threshold. Although you may delay a start date to allow for the paperwork to move through, clinicians will often begin delivering services to build their patient base or to start contributing to quality efforts. There are many things that providers do that aren’t about the bottom line, but apparently Kareo doesn’t get that.

They go further to suggest that practices should limit the slots for capitated patients “while leaving same-day and extended hours open for fee-for-service patients.” A couple of pages later they mentioned that providers can encourage referrals by “offering low wait times and great access.” I guess that’s just for the fee-for-service patients, though. Although many of their suggestions may appeal to the business side of our brains, I found the piece generally tacky and hope they’re more in tune with emerging software needs than they are with clinical transformation.

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November 3, 2016 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 10/31/16

October 31, 2016 Dr. Jayne No Comments

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There has been a fair amount of swirl and churn with my clients this week as they begin to digest the recently-released MACRA Final Rule. It was released with a comment period, which seems to be having some unintended consequences. Some organizations are interpreting the presence of the comment period as a license to continue to stall in their preparation efforts, as if some magical MACRA Fairy is going to swoop down and change the requirements.

It’s been tough to get some of them moving again, because they stalled after the Proposed Rule and took on other projects. I keep preaching the idea of taking baby steps. Even if we don’t think it is truly final, just pick some subprojects and get moving. It’s a hard sell for some groups, however.

Being in the trenches with small to mid-sized practices is tough. There are a fair number of groups out there who still can’t manage to tackle the basics that haven’t changed in years, particularly on the business side. I see groups with high days in accounts receivable, low net collections, and more. Most of the issues are due to process problems such as being unable or unwilling to adopt essential revenue cycle best practices.

You wouldn’t believe the number of organizations that still haven’t grasped the concept of collecting the co-pay up front, which results in a lot of chasing after the fact. Others aren’t performing insurance eligibility checks so that they know whether the patient needs to be self-pay or not. Yet others don’t have their contracts loaded into their practice management system, which makes it difficult to know whether insurers are paying as expected.

These business processes are fairly cut and dried and haven’t changed in quite some time, so when you see organizations that can’t handle them, it throws up red flags about their ability to handle change in their clinical operations. Medical billing systems were among the first pieces of automation added to the medical practice and quite a few vendors have extremely mature platforms. Compared to the relative immaturity of some clinical platforms and the constantly changing federal requirements, it feels like the business piece should just be more solid.

I also see a fair number of practices that don’t have disaster recovery figured out. No part of the country is immune from natural disasters and there are always the “small things” like power outages, disrupted data lines, water line breaks, etc. to potentially disrupt practice operations. At this point, everyone should have a business continuity plan and disaster recovery plan. For those practices that are still stalling around MACRA requirements, I’m trying to push them to go ahead and address those issues so at least they are doing something and creating some kind of positive momentum for their organization.

One of the practices I’m working with right now that is stalling the most is one where the owner is contemplating retirement just to get away from it all. He’s in his late 50s, so I wouldn’t exactly call him retirement age, but he isn’t sure he wants to move forward with all that is being asked of him. It would be one thing if he was waffling and he only had himself to consider, but there is a relatively new physician who joined his practice in the hopes of possibly buying it in a few years. They’ve dabbled in Meaningful Use in the past, but barriers like not having a patient portal block their progress. Even though their vendor offers one, the owner isn’t willing to spend the money while he debates his future.

I don’t have insight into their contract arrangement, but the junior physician has let me know he has been having second thoughts about staying in the arrangement vs. looking at other employment options. They are both aware that there are a number of large groups and health systems that have open opportunities that I suspect offer comparable working conditions, salaries, and benefits, at least for the younger physician who is still building his patient panel. Unless he’s similarly committed to practicing outside the federal incentive / penalty scheme, one of those opportunities may start to look pretty attractive, which I think is adding to the stall factor in this case.

I’ve been spending a lot of time with the both of them trying to create a strategic roadmap for the practice. Does the senior one plan to retire? Will he sell to the junior one or to a health system? Will they close altogether? Will the junior one eventually make a move to force his employer’s hand? It’s like a soap opera and I’m caught in the middle of it. It’s a blend of change leadership training and relationship counseling but hey, it pays the bills.

On a personal level, my own practice has been reviewing the Final Rule as well. Even though we’ve opted out of Meaningful Use, it’s prudent to review the next iteration and determine whether we still want to stay out of it. I’m fairly confident we’re going to continue to just say no, but it’s refreshing to know that you are working with leaders who consider the options at various turning points so that you don’t wind up simply doing things because you’ve always done them that way or because that’s how you decided to do them before. Our owners are very deliberative and data driven and it’s been refreshing to work in that kind of an environment compared to the highly reactive environments I see with most of my consulting clients.

We’re currently focused on growth and have three new locations under construction, poised to open monthly from now through January. It’s been an interesting ride. I’m not entirely bought in regarding some of the locations they’ve picked for expansion, so we’ll have to see whether their forecasts actually play out. In the meantime, it’s been fun to work with people that are so focused on processes and outcomes, independent of any regulatory shackles.

What’s your favorite Halloween candy? Email me.

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October 31, 2016 Dr. Jayne No Comments

EPtalk by Dr. Jayne 10/27/16

October 27, 2016 Dr. Jayne 2 Comments

Hot on the heels of the MACRA Final Rule, CMS announced expanded opportunities for physicians to participate in Advanced Alternative Payment Models. One of the opportunities includes reopening applications for the Comprehensive Primary Care Plus (CPC+) program. This is a coordinated initiative that involves the participation of multiple commercial payers in addition to Medicare and Medicaid across specifically identified regions across the nation.

Although they initially said they would take up to 20 regions for the program, they only announced 14. It would be an easy thing to open applications for providers, but they’re also opening it for payers, which makes me wonder if they’re going to select additional regions for this new 2018 cohort. They’re also calling for new participants in the Next Generation Accountable Care Organization model for 2018.

I was on a CMS Quality Payment Program Overview webinar today. Although I give them props for nice classical hold music, it would have been better if they didn’t start late and then run over time. I’ve been on several CMS webinars lately and they tend to be overly scripted. As someone who does a lot of presentations, I appreciate their desire to make sure they deliver all the information, but there’s definitely an opportunity to be more engaging.

Because of the number of questions and the late start, they didn’t answer many of the questions posed by attendees. I understand that there were more than a thousand people on the call, and with that many questions, it illustrates how complicated these programs are and the level of concern felt by providers.

One attendee asked how CMS is going to manage the idea of patient free will and the fact that physicians are being held liable for patient behavior. The attendee gave the specific answer of a patient with lung disease who leaves the hospital and immediately starts smoking, which has the potential to skew quality numbers. She went on to ask what preparations are being made to address the possibility of patient dumping, where physicians refuse to treat patients who fail to comply with treatment plans and recommendations. Dumping (and cherry-picking, where clinicians go after the healthiest patients) has been a real issue in the past as various payer programs penalized providers for being quality outliers.

The Medicare Learning Network offers their version of a Quality Payment Program call on November 15th and interested parties still have the opportunity to enter comments on the Final Rule. Registration is open and space is limited. This is in addition to their “How to Report Across 2016 Medicare Quality Programs” call that is being held on November 1.

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There are so many things that primary care physicians must advise their patients on that it often feels like there’s not enough hours in the day. This month, one more thing has been added to the list, and it’s an item that isn’t going to be a quick conversation. The American Academy of Pediatrics has endorsed new safe sleep guidelines that recommend that infants sleep in the same room as their parents (although not in the same bed) for the first year of life. Despite recent interventions, there are still 3,500 sleep-related infant deaths each year and the new recommendations aim to reduce that number. These are the kinds of conversations that take more time than the typical office visits allow, creating additional time pressure for clinicians.

Those time pressures challenge physicians who are  being graded on how we’re doing with patient engagement. My office uses a Web-based patient engagement platform that surveys each patient or caregiver who provides an email address at check-out. Our scores (on a scale of zero to five) are part of the formula that determines whether we receive a bonus and how much it might be. Usually my scores are fives with the occasional four. The scores roll in real time and I’ll often see results from patients I saw just a few hours earlier.

Today I got a three, which was strange because all the comments associated with the score were strongly positive. Our office calls each patient who gives us less than a four, so I’ll get additional feedback on the reason for the low score. Looking at the schedule, she was seen during a patient rush when our wait time was over an hour and while I was in the process of transferring two patients to the hospital for life-threatening emergencies. It’s likely that the wait time played a role in the score, but it’s certainly discouraging for physicians who provide high-quality care but don’t carry a magic wand.

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Speaking of magic wands, I definitely need one for a current client. I’m doing some governance work for a mid-sized health system that has been struggling with their EHR to the point where they’re ready to start looking for a new vendor. They realized how expensive a system replacement might be, so they brought me in to do a thorough review and to see if anything can be salvaged.

I found an extensive list of issues ranging from defective hosting to absent physician leadership. There are also some configuration issues with the EHR, but nothing that can’t be fixed. I’m in the middle of a follow-up consulting engagement trying to get their leadership organized around a common vision and mission. I’ve struggled with one of their clinical leaders who keeps focusing on perceived EHR issues (which are largely self-inflicted) to the exclusion of everything else. I’ve been trying to get the leadership to focus on strategic planning and creating prioritized action plans, but it’s hard to get the clinical leadership to show up, let alone participate.

Today one of the most difficult clinicians graced us with his presence after several weeks absence and proceeded to try to hijack the agenda and pull us back into a discussion of EHR issues, most of which have already been corrected. I used my best facilitator skills to try to redirect him, to try to engage the group to self-police, and to place his various rants on my “parking lot” for later discussion. He insisted that “we can’t get strategic until we get past the issues.”

That definitely wins my quote of the day award, especially since under his approach, they’ll go nowhere fast. It’s hard to make a roadmap when you haven’t decided where you’re headed. And if you don’t know whether you’re driving to the beach or to the mountains, it’s going to be hard to plot out the fuel stops and tourist attractions along the way. I was ultimately able to thwart his attempts to block the group’s progress, but it wasn’t easy.

How do you handle people who are constantly stuck in the weeds? Email me.

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October 27, 2016 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 10/24/16

October 24, 2016 Dr. Jayne 5 Comments

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One of the family medicine journals recently published an editorial on preventing diagnostic errors in primary care. It advocates using diagnostic checklists and clinical decision support tools to make sure an appropriate differential diagnosis is considered. Although checklists can be helpful to make sure you arrive at the most likely diagnosis, sometimes physicians just want to know whether we were right and what happened to our patients.

Now that the MACRA final rule is out, we know that HHS plans to continue monitoring to see if EHR vendors are guilty of information blocking. I know I’ve mentioned this before, but I’m still waiting for someone, anyone, to come after the hospitals and health systems that are guilty of information blocking. Especially when treating a patient with an uncommon presentation or a rare diagnosis, follow-up is needed to understand whether the diagnosis was accurate and whether the treatment provided was appropriate or whether there was something more beneficial that could have been done. It’s also important for me to know whether my patients have any complications as a result of my treatment.

This week, I had a couple of rare cases and wanted to track down what happened. In both cases, I had to transfer the patient for further care – one went to a local community hospital where I was an attending physician for many years and from which I continue to receive (erroneous) patient test results. The other patient was refused by the community hospital due to the nature of his condition, so I had to send him to a tertiary referral center where I haven’t been on staff but where I know for a fact that I am in the referring physician database.

In each case, I called report to the facility, giving my name and the pertinent information on the patient’s condition. I also sent copies of the patient’s urgent care evaluation note and the CT scan performed at my facility, both with my name and credentials.

In both cases, when I tried to call for follow-up, I was stonewalled. One facility had the audacity to tell me that, “We have no idea of knowing you are who you say you are” despite the fact that I could accurately give them the patient’s name, date of birth, time of the transfer, and name of the nurse I spoke to when giving report. I urged them to look at the transfer and admission documents to verify my status.

The other facility told me they couldn’t even verify the patient had been admitted “due to HIPAA,” again despite my providing all the information including the name of the attending physician who agreed to assume care.

Last time I checked, HIPAA allows the disclosure of protected health information for treatment, payment, and healthcare operations. Even if you wanted to argue that I was no longer treating the patient, the definition of healthcare operations clearly includes: conducting quality assessment and improvement activities, including outcomes evaluation; care coordination; evaluating provider performance; and certification activities. Despite it being around for two decades, HIPAA is still misunderstood and various entities continue to cite it as a reason to prevent information sharing.

How is this not information blocking? Sharing information verbally and in writing is the precursor to interoperability. And in areas of the country like mine, where there is no consistent platform for EHR-based interoperability, it may be the only way to get information. Where are the HIPAA police when you need them?

If healthcare entities cannot understand a regulation like HIPAA after 20 years, how can there be any hope of everyone understanding MACRA and all its successor requirements that go into effect in a little more than two months?

Hoping that I was just dealing with overworked floor staff who may not understand the nuances of clinical follow-up, I decided to go up the chain and see if I could find another way to get the information I need. I ran a couple of reports out of my EHR and found out how many patients I personally referred to the hospitals in question, as well as how many patients our practice overall had referred in the last year. Knowing that the hospitals have programs where community physicians can have access to their clinical data, I decided to ask for courtesy access. If that failed, I planned to cite the transfer volumes and make a compelling case to be able to access the records in the name of practice-related quality improvement activities. We’re the largest independent urgent care in our metropolitan area and we generate substantial referral volume, so I was hoping they’d bite one way or the other.

Both of them gave me the same response. Unless I apply for and obtain medical staff privileges at the hospital, they have no way to give me access. Being on staff means that you have to actually admit or otherwise attend to patients in the hospital, which isn’t covered under my medical liability insurance since I’m no longer practicing traditional primary care. It’s the reason why I resigned my privileges during my most recent reappointment process to the previously mentioned community hospital, because I couldn’t meet the ongoing requirements.

Hearing the tertiary referral hospital cite the medical staff requirement was especially funny since I know for a fact that they have hundreds of students, researchers, and quality review staff who have access to their clinical data repository, as do payer claims auditors and others. I’m familiar with the fact that they have robust methods for auditing chart access since I helped lead the consensus-building around those methods in my former life. I may also know where the proverbial bones are buried since at least one of their executives worked to stymie our efforts to build a health information exchange.

Yet regulators are going after EHR vendors rather than going after hospitals that refuse to share information with relevant physicians and even with patients themselves. The same hospitals that have accepted countless millions of EHR incentive program money in recent years and who hope to continue drawing down federal dollars continue to be part of the problem despite some feasible solutions.

I’m not letting this go, but plan to continue working may way up the chain at both hospitals. I’m also going to ask at a couple of other area hospitals that receive our patients to see if they will bite and therefore create a precedent. I have a feeling I’m more likely to be blocked then allowed access to the clinical information superhighway.

How does your hospital handle records access and follow up for referring physicians? Email me.

Email Dr. Jayne.

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October 24, 2016 Dr. Jayne 5 Comments

EPtalk by Dr. Jayne 10/20/16

October 20, 2016 Dr. Jayne No Comments

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It’s been a busy week as people begin to digest the contents of the MACRA Final Rule. Most of the physicians I’ve spoken with are worried specifically about what they need to do in order to meet requirements for 2017. It would be a mistake, however, to not spend some time planning for 2018 and beyond. CMS will increase the number of outcome metrics as time passes, while also increasing the weighting applied cost measures. CMS is also making changes in the Medicare Shared Savings Program. Although 2017 may seem to be a low-risk year where providers can take it easy, in reality 2017 should be a year where providers work to maximize their performance in preparation for future years.

Providers are going to be increasingly graded on performance and if they’re not honing their skills they’re going to be behind. Our favorite Geek Doctor, John Halamka, weighed in on the Final Rule as well:

Think of MIPS not as four separate categories (quality measurement, cost control, practice improvement, and wise use of IT) but as a single program focused on rewarding clinicians for improving quality and penalizing clinicians for non-participation. There are only a few ways to change clinician behavior – pay them more, improve their satisfaction and help them avoid public humiliation (like poor quality scores posted on a public website). MIPS pays them more, consolidates multiple other government programs, and provides flexibility to give clinicians every opportunity to make their quality scores look good.

As much as everyone has been waiting for the Final Rule, it’s not entirely final. It was released as a final rule with comment, which means that we have 60 days to continue to weigh in. There’s still the opportunity for our feedback to be heard by those who will make subsequent rules and those who will tweak this Rule as it is applied. We’ve seen from previous iterations with Meaningful Use and other federal programs that the only constant is change.

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I had the privilege this week of lunching with some former co-workers. We all worked together on a large health system’s EHR implementation project starting more than a decade ago. Although we try to get together quarterly, it gets more and more difficult unless we plan it months in advance. We’re all still in healthcare, although we’ve branched out into consulting, quality improvement, program management, and interoperability roles. Two of the group have come full circle and are again helping the large health system with an EHR implementation as they perform a massive rip-and-replace of all clinical and financial systems.

It was gratifying to learn that although much time has passed and it’s a different system, many of the processes we created are being dusted off and used to help the practices navigate the transition. Regardless of the type and scope of the project, the change leadership and governance pieces are essential and fairly timeless. It sounds like it’s been a bit frustrating for my colleagues who are on the ground, as the organization has lost some of its institutional memory. The current project is being handled as an IT project that has a couple of clinical advisors, rather than as a clinical / operational project with IT support as we had done in the past. They’ve already experienced massive scope creep, delays, and cost overruns.

There are also issues with IT leadership not understanding the needs of a large provider organization. They actually tried to tell the provider group that they “won’t be allowed to onboard any new physicians or practices during the transition period,” which is over 18 months long. That statement alone shows a fundamental lack of understanding of what is going on in healthcare today, as providers are being consolidated into larger organizations either willingly or in response to fear. I can’t imagine telling a CEO he can’t onboard new physicians, but apparently it happened. I’m betting the follow up phone call to the CIO was interesting, to say the least. When you’re spending upwards of a third of a billion dollars on a project, impeding strategic growth probably isn’t the best idea.

Back when we were doing our original implementation, we needed a full-time person to go around and do some periodic retraining for providers. We had the opportunity to hire a retired IT staffer who had been a physician liaison and was dearly loved. The powers that be told us we couldn’t justify a full-time position, so we brought her on as a contractor. I laughed out loud when I heard today that she is still there, eight years later. Maybe that position would have been justified after all.

The health system is wrangling with the same issues that we fought with the original EHR, including how to handle private/community physicians that want to be on the platform but don’t want to pay for it, as well as how to support the infrastructure. Where we were worried about making sure everyone had adequate bandwidth via DSL or T1, now they’re working to upgrade everyone to fiber. They’re still dealing with patient consent around interoperability as well as difficulties with patient matching and provider attribution. Although they’ve made some headway on those issues, the core problems still remain tricky.

Another theme with the group was trying to maintain some kind of work-life balance given the continuing chaos that healthcare reform and ensuing technology requirements has created regardless of role. I remember when we started, the understanding was that we’d do this rollout for 18 months and then go back to our original jobs. The organization quickly realized that it was unlikely for that scenario to play out. A decade later we’re not only still at it, but most of us are leading teams of people dedicated to the ongoing support of healthcare IT and clinical transformation. Some of us are still burning the candle at both ends, which although sustainable for a few years, starts to wear on you when you’ve been doing it nonstop.

By the time we get together again, it will be 2017 with all the MIPS and APM-related excitement that brings. It will be a new year for penalties and incentives, with new clinical quality measures, new carrots, and new sticks. It’s been great to have a core group of friends who can support each other as we go through this, venting about our respective situations and the challenges we face. Looking at what’s coming down the road, we’re going to need each other to stay sane.

Email Dr. Jayne.

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October 20, 2016 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 10/17/16

October 17, 2016 Dr. Jayne No Comments

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Everyone in informatics circles has been buzzing about the release of the MACRA Final Rule. As is typical for CMS, it came out on a Friday afternoon. I know a lot of people were hunkered down reading it, me included. I did what I could with it Friday, but on Saturday I had a previous commitment to teach some team-building sessions as part of a local outdoor classroom program.

The type of change that MACRA is trying to drive and the stresses it is going to place on healthcare delivery organizations will require that organizations have high-functioning teams. They’re also going to require intense project management and active management of resources and outcomes. Although many organizations have already figured this out and have robust programs in place (or have hired consultants to do the dirty work), there are numerous organizations that are just trying to figure out what their first steps should be.

When you place stress on teams like these MACRA-related projects are certain to do, teams will either rise to the occasion or they will fall apart. Although some people throw their hands up and just watch things devolve, there are active ways to manage team dynamics and to get your people in the right place so they’re well prepared to take on new challenges.

The program I staffed this weekend brought out many of the types of issues that organizations need to be thinking about as they evaluate how they will handle MACRA-related tasks and who will be responsible for executing them.

Our program brings together people from different backgrounds and throws them into a situation that is unfamiliar for most of them. This year’s group had about 50 participants from all different disciplines – healthcare, manufacturing, communications, technology, and a couple of college students. Even if we have participants coming from the same organization, we mix them up so they’re not working together.

They’re placed in group of five to eight with people they’ve never met and they have to handle a variety of objectives. It’s outdoor classroom with camping and survival skills. Some of the participants may not have done so much as roasting a s’more, so we provide several coaches for each group to help them through the process.

The course starts with an indoor session with a few outdoor elements where they practice basic team skills, and then we follow up with the actual outdoor weekend portion. Their first task was to come up with a team name and motto. We use a variety of exercises to work them through the stages of team development – forming, storming, norming, and performing.

My team definitely had some forming issues because only two of them had arrived by the time the session started. The ability to get to meetings on time continues to be a major issue for a lot of people, which makes it challenging to be a high-performing team. Once the rest arrived, we had some rehashing and revising of the team name, but the team was able to eventually move forward once the late arrivals understood that they couldn’t complain about decisions that were made when they failed to perform.

The teams learned some basics of outdoor cooking and assigned members to roles, identifying leaders and supporting members. When you’re headed out into the woods for a weekend, it’s key to know who is responsible for what. Just like complying with federal regulations, if someone drops the ball, everyone suffers, and having clear chain of command and documented responsibilities makes things easier. The teams are provided with a series of tasks that they have to complete prior to the outdoor portion, and I thought I lucked out when I had someone who immediately volunteered to set up conference calls and meetings to get everything taken care of in the interim.

They met once by phone and once in person during the two-week gap, learning some important lessons on logistics when only half the group showed up in person. The other half was at another meeting place, because leadership failed to recognize that “meet at the XX restaurant by the mall” wasn’t specific enough since there were four different locations of the chain in close proximity, including one actually in the mall. How many times do we have situations like this in healthcare IT? The team thinks they have a clear plan and everyone voices understanding, but it turns out there were multiple ideas about how things were actually going to happen. Although it wasn’t that big of a deal when you’re just dealing with a voluntary team-building program, it’s a huge deal when you have miscommunications around federal requirements and regulations.

There was some last-minute planning, but it appeared they had everything figured out prior to their arrival for the weekend. Unfortunately, one-third of their team was late, leading to delayed setup since people were bringing different pieces of equipment. Across the meadow, the other team I was cross-coaching had arrived and began to set up in a disciplined fashion. Their only glitch was not having their team tee shirts done on time, which they remediated with some ad-hoc spray painting. I was doubtful when they pulled out the cans as to how well it would work, but when they pulled out a drop cloth, rubber gloves, and pre-cut stencils, my doubts were laid to rest. It may have been last-minute, but it was well planned and well executed.

In working with both teams, it was clear that one was more successful. In trying to dissect the reasons behind that success, the major factor was that they put the good of the team beyond their individual needs. They were up early each morning to take care of team tasks, where my team had issues getting out of their tents. I definitely earned my coaching stripes this time around since I had to roust grown adults out of their tents two mornings in a row. I also had to pull out some camping magic when my team failed to follow some of the cooking instructions and their dinner was in jeopardy. Luckily my other team had prepared extra charcoal and had extra supplies, which I was able to borrow to bail my team out. Again, in most of our organizations, we’re running so lean we can’t count on a bail-out. We have to be organized and in command of the situation.

I was hoping that my primary team would see what was going on with the other team and rise to the occasion. Although some team members started to get the message and get with the program, others either didn’t see the possibilities in front of them or maybe just didn’t care. Sometimes we see that, when organizations have enrolled wary participants. Hopefully those that didn’t fully embrace the program learned something along the way and can find elements of the program to take back to their home organizations. I know I learn something every time I put on this program and there are always different challenges to be overcome and different personalities to work with. I come back to my work energized with new tricks and techniques to try to motive my teams.

We’re definitely going to need energy and motivation to make it through MACRA-related reforms and all the sub-projects that will entail. Although I was tired from a couple of nights of sleeping on the ground and herding cats, I’m ready to tackle the rest of the Final Rule.

What kinds of strategies do you use for team-building? Email me.

Email Dr. Jayne.

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October 17, 2016 Dr. Jayne No Comments

EPtalk by Dr. Jayne 10/13/16

October 13, 2016 Dr. Jayne No Comments

Several of my clients applied for the CMS Comprehensive Primary Care Plus initiative. One reached out to me after receiving a letter from CMS that required a response in an extremely short time frame. It sounds like practices that offer services other than just straight primary care may have been flagged in the application process to provide additional information. CMS was concerned about whether they could isolate their primary care providers and data if they were selected to participate in the program.

I understand the need to make sure applicants can meet the requirements, but the short turnaround time and unexpectedness of the letter created a lot of stress for my client. We were able to gather the required information for the response, but it was a good example to remind them that if they’re selected, they will be even more at the beck and call of CMS.

Speaking of CMS, a friend of mine who works for a vendor mentioned her concerns about the Social Security Number Removal Initiative. This is a big deal for people who are worried about identity theft since Medicare patients have long been identified with their Social Security Numbers. During 2019, Medicare will issue new identification cards to all beneficiaries. This also means that vendors have to adjust their systems to accommodate the new numbers while preserving the old numbers for historical purposes, rebilling, etc. Depending on the timeframe for mailing the new cards and what portion of a practice’s payer mix is made of Medicare patients, we could see some serious check-in delays and billing issues. I’m not sure if contractors have been selected to deliver the cards, but I hope it goes better than Healthcare.gov did.

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Pet peeve of the week: I had mentioned previously that people who try to share Web addresses verbally (unless they’re really short, like “Amazon.com” or “CMS.gov”) drive me crazy. I was on a conference call this week where the panelist not only read enormous Web addresses aloud, but also didn’t know the difference between slash and backslash. I hope the people who were on audio-only connections wait for the slide deck to be distributed before they try to reach any of those sites.

The Wall Street Journal published a piece this week about physicians “deprescribing” when patients are taking too many medications or risky combinations. For all the pressures on physicians and other healthcare providers to cut costs, this is an often overlooked solution.

There are many cultural factors at play with individuals preferring to take a pill to making the effort to change their habits and lifestyle. Patients don’t want to believe that they have a virus that will take 10 to 14 days to run its course — they want it cured now. Some of our love of pharmaceuticals is also generational, with older patients who came of age with the advent of penicillin and other lifesaving medications believing that pharmaceutical advances are heaven sent.

Unfortunately, there are too many people who are overmedicated. My grandparents, who are almost 90 years old, are on multiple medications for diabetes prescribed by a physician who advocates tight blood sugar control even in their age group and even with newer literature saying this might not be a good idea. It doesn’t make sense medically and they could certainly benefit from a reduced prescription bill each month, but they don’t believe in questioning their doctor.

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Speaking of technology advances, there have been tremendous strides in caring for premature infants over the last several decades. A friend of mine who works for Proctor & Gamble clued me in to the recent release of a new diaper for micro-preemies who often weigh in close to 500g. That’s roughly one pound. Years ago I laughed when my friend, who is a mechanical engineer, took his job at P&G right out of school and told me enthusiastically, “You would never believe what goes into a diaper.” Having changed quite a few, I thought that was funny at the time.

It’s definitely true of the new release. The P-3 diaper is three sizes smaller than the regular newborn size and was created after three years and 10,000 hours of research, including input from over 100 neonatal intensive care unit nurses. Sometimes it’s good to be reminded that often technology and innovation brings us new problems that we never even thought of and that require solutions that are outside of our expertise.

Pet peeve, part 2: I was on a call this week waiting for key attendees to arrive. One participant announced that another would be “at least 30, maybe 40” minutes late for the meeting, which was only scheduled for an hour. I appreciate that the delayed participant called someone to say she was going to be late, but since she was the CIO and this was an executive briefing, it would have been helpful for her to indicate whether she wanted us to go ahead without her, wait for her, or reschedule. Instead, we were left guessing and trying to reach her by phone, which went straight to voice mail.

From Nurse Engineer: “Thanks for the heads up on the Healthcare Data Analytics course (Free!!) through OHSU. I am through four modules and thoroughly enjoying the class. I went into informatics way before it was chic – so far it has been a good review with very timeline information. I hope to complete the course next week before work travel interferes.” I appreciate the way they have it formatted. You can either watch the videos or read from a transcript, which allows people who learn in different ways to leverage the content in the way that most meets their needs. It also lets students make progress while traveling on flights with abysmal Wi-Fi.

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One of the joys of being a consultant is experiencing life in different parts of the country. Sometimes that involves trying new foods (cheese curds anyone? Nashville hot chicken?) and sometimes it involves trying to translate the local vernacular. My Texas client shocked me this week by mentioning that in their city, “You can’t swing a dead cat without hitting a barbecue place.” I must have had a horrified expression on my face because they asked me if I was OK while I sat there trying to figure out if I really just heard what I thought I heard or whether I was on Candid Camera or being set up by PETA or something like that. I’ve traveled a lot but somehow missed that phrase before now. There are various theories on its origin and my client spent the next ten minutes schooling me on other colorful expressions they felt I needed to know. My thoughts go out to any cats, real or imaginary, who might have been swung.

What’s your favorite local or regional expression? Email me.

Email Dr. Jayne.

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October 13, 2016 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 10/10/16

October 10, 2016 Dr. Jayne 3 Comments

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I picked up an additional clinical shift this weekend to help out one of my partners whose travel was interrupted by Hurricane Matthew. Weekends in the urgent care world are always busy, especially on Sundays when people who have put off care earlier in the week decide they can’t wait until Monday to try to get an appointment with their regular physician. Others don’t have a regular physician and just see us when they’re sick. Another subgroup of patients tries to use us as their primary care home even though we’re really not equipped to do so.

When you’ve seen 40 patients in the first six hours of a shift, that’s a bad sign. Even with a scribe I couldn’t keep up, so we had to send up the bat signal and try to get more reinforcements. Flu season is moving into high gear, overlapping with a bad run of hand/foot/mouth disease for kids in our area. Most of our patients were acutely ill and we always try to move patients into exam rooms rapidly so that they’re not cross-contaminating each other in the waiting room.

For a while, things were backed up, though. Looking at the roster of patients in the waiting room, I couldn’t help but think that telemedicine would have been a good option for quite a few of them.

There are many conditions we treat regularly that can be diagnosed with accuracy based on the patient’s history and some targeted questions. Important data points are the duration of the illness, the specific symptoms, anything that has made it better or worse, and the patient’s health status and other existing conditions. Although the physical exam can confirm a working diagnosis, it usually doesn’t make a difference in the treatment plan for these patients.

Offering telemedicine services would have keep these patients at home where they could be recovering rather than potentially exposing them to other communicable diseases. In my area, however, insurance doesn’t cover telemedicine services, so they’re not being offered.

Assuming insurance would cover the services, our EHR isn’t equipped to handle telemedicine. It’s not just this system, though. The last three platforms I have used for patient care wouldn’t have supported it very well, either. The closest workflow they could offer was to couple the documentation pathway for a telephone call with some of the elements of a standard office visit. It certainly wasn’t a streamlined workflow and there wasn’t a good way to include video links or patient-provided pictures of rashes or other findings.

Although the new federal programs seem to encourage these types of alternative visits, it seems to me that many EHR vendors are just trying to keep up with all the reporting requirements and specifications of the new certification scheme and don’t have many development resources to shift into these kinds of nice-to-have workflows.

Some of the cases I saw today really made me think about how our country is addressing (or not addressing) healthcare delivery. We’re so focused on cost reform that we’re missing other significant factors that influence care-seeking behavior.

Many of our patients come to the urgent care due to access issues – they can’t get a timely appointment with their primary care physician or they can’t leave work during the hours the office is open. Although many employees have sick time benefits from their employers, the reality for many of the patients we see (as well as many of my friends and colleagues) is that it’s often difficult to use that sick time.

Employers put a variety of strategies in place to keep people from abusing the benefit, but those strategies can also function as a barrier to care. The rise of high-deductible health plans is also a barrier to care, and we sometimes see people with serious illnesses who have deferred coming to care because they can’t afford the deductible. It’s not an overall cost savings if the patient has to have an amputation because they didn’t have a $90 visit that could have mitigated the condition weeks ago.

We try to engage our patients and encourage them to follow up with a continuity physician, providing them View/Download/Transmit access to their note as soon as the physician completes it. We also have nearly-real-time surveys of patient satisfaction, which can be a bit unnerving when you receive an email with your rating before the patient is even out of the parking lot. It’s definitely a different world than what I thought I was getting into when I went into medicine.

I’m not sure how many patients actually engage via a records download, though. Although we can accept and consume inbound records, I’ve not seen any in the two years I’ve been working with this organization. I have had a couple of patients who have personal health records that they access on their phones during the visit and many who have accessed their pharmacy records to tell me about previous treatments if I can’t download them via our EHR’s pharmacy management link. But I’ve never seen a C-CDA and I’m betting that my staff would be confused if one turned up.

Our organization is growing steadily. We’ve doubled in size in the last two years. Although it’s great from a business perspective, when you really think about it, it’s terrible from a patient care strategy standpoint. Although patients come to us because it’s convenient and we’re fast and economical, we’re not a primary care office and we don’t handle preventive screenings or other universally recommended services.

I firmly believe that patients do best when they’re cared for by a physician and/or care team that knows them well and can manage their issues over time, looking for trends or linked events. This is what old-school family physicians used to do, before insurance companies pushed patients into networks based on costs and contracts. When I was in solo practice, I had patients who were forced to change primary physicians every year or two because their employer would change insurance plans or the insurance plan would change their roster of contracted physicians.

With the rise of the medical home movement in the last decade, you’d think this trend would be somewhat reversed, but we’re not seeing as much change as we need to solve the healthcare delivery problem. Physicians are stressed and don’t want to provide after-hours services without additional compensation and patients don’t want to pay for it.

We’ve thrown billions of dollars of technology at it, but it doesn’t feel like we’re much better off than we were before. Physician practices have been disrupted. Once they settle in, there is a tremendous opportunity to harness the technology, but now we’re seeing a second wave of disruption as providers and organizations change EHR vendors, often sending provider workflows back into chaos.

Programs such as the Comprehensive Primary Care Initiative and its successor CPC+ are trying to shift care delivery to the medical home model through additional payments and support, but it’s still tremendously difficult for organizations to make these changes, especially since they’re already coping with additional federal and payer regulations.

I’m not sure what the answer is, but it feels like we’re reaching the breaking point. Is anyone building the killer app that will help providers and care delivery organizations truly transform how we care for patients in the 21st century? Or will the regulators just keep tightening the screws? As we sit here on the edge of our chairs waiting for the next Final Rule, it feels more like the latter.

What do you think is the answer to truly reforming healthcare delivery? Email me.

Email Dr. Jayne.

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October 10, 2016 Dr. Jayne 3 Comments

EPtalk by Dr. Jayne 10/6/16

October 6, 2016 Dr. Jayne 1 Comment

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At my clinical practice, we frequently use scribes to document in the EHR while we focus on patients. While most of our scribes are cross-trained emergency medical technicians or medical assistants, some are college or graduate students who are looking for experience in the field while they apply to medical school.

My favorite scribe was recently admitted to medical school. Since he doesn’t have any family in town, he invited me to sit in for his family at his school’s white coat ceremony. We didn’t have that ceremony when I went to medical school, but quite a few schools have them now. Often in their first year of training, students are presented with the traditional white coat and may take an oath.

Schools have gotten away from the traditional Hippocratic Oath (mine used the Declaration of Geneva), but his school encourages each class to write their own oath. It was quite moving to see the students promise to keep the patient at the center of care and to deliver care equitably regardless of gender, race, religion, or sexual orientation. I didn’t hear anything about sacrificing patient care time to address burdensome regulations and reporting requirements, but they’ll be learning about those aspects of medicine soon enough.

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October is Health Literacy Month, aimed at helping promote the importance of understandable health information. Greater health literacy can lead to improved health status and may be more of a contributor than other factors such as race, ethnicity, or socioeconomic status. Although many EHR vendors try to increase health literacy by making sure their patient education materials are at an accessible reading level, there are other factors at play. The National Patient Safety Foundation is promoting its “Ask Me 3” program that encourages patients to ask three questions to better understand their health: 1) What is my main problem?; 2) What do I need to do?; and 3) Why is it important for me to do this? I’d love to see more EHR-generated patient plan documents that address these questions in a readable format rather than just spitting out codes and canned phrases that may not make sense for patients.

The rising cost of health care and subsequent attempts at reform are impacting care delivery across the country. My local school board just voted to investigate the possibility of onsite health clinics for employees and their families. They’re not ready to address health clinics for students, but the employee clinics are seen as a possible way to not only get employees back to work more quickly, but to control costs. We perform similar corporate health services at my clinical practice and can generally get patients treated and back to work with their medications in under 45 minutes. I’ll be interested to see how it turns out and whether the promise of efficiency and cost-control outweighs any privacy concerns.

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Nearly 180 members of the House of Representatives sent a letter to CMS claiming that recent payment reforms announced by the Center for Medicare and Medicaid Innovation (CMMI) exceed the authority of CMS and are therefore illegal. The legislators contend that voluntary programs are acceptable, but mandatory participation in programs such as bundled payment programs can “commandeer clinical decision making and dramatically alter the delivery of care.” They go on to “insist CMMI stop experimenting with Americans’ health.” I’ve spoken with many of my peers who feel that MU and other programs are out of control experiments with no requirement for institutional review board approval. It remains to be seen if using financial incentives against providers will really drive the needle on patient outcomes.

I wrote earlier this week about some downtime/disaster recovery adventures I had with one of my clients. A reader commented on my mention that “since crossing to the IT dark side, I’ve had more late night phone calls for database disasters than I’ve had for patient care issues, but the steps are surprisingly similar,” wanting to know more.

  • Getting to the root cause of an information technology misadventure can be a lot like trying to diagnose a patient who presents with vague symptoms or a complex condition.
  • Like a person with a stroke, it’s important to know when was the last time that the system was normal, what the presenting symptoms were, and how quickly it progressed.
  • Similar to a person having a heart attack, you have to act quickly within a limited time frame so that more extensive damage doesn’t happen.
  • You have to assimilate data from a variety of sources and try to put it all together in the hopes of figuring out what happened, what is currently going on, and how you can identify the best intervention.
  • Sometimes you try maneuvers that are both diagnostic and therapeutic. They may or may not work depending on the status of the patient/system.
  • It’s important to have a skilled team that can work well together and has common goals.
  • When we teach CPR and advanced cardiac life support, we talk about closed-loop communication and following algorithms for prescribed interventions. Both of those apply to downtime and disaster recovery situations.
  • Not unlike medicine, sometimes you lose a patient. But when you make a save, it’s extremely gratifying.

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Mr. H recently polled the reader base on desirable qualities for sales team members. He mentioned that military service ranks #1 on his list. I work with numerous veterans and have to say they’re high on my list of desirable employees and co-workers as well. I recently finished reading a book called CONUS Battle Drills by Louis J. Fernandez. Subtitled “A guide for combat veterans to corporate life, parenthood, and caging the beast inside” it also offers good perspective for those of us who hire or work with people who have been through situations we can barely imagine. I’m grateful for all the men and women who have served and who have continued to serve and look forward to having them on my team.

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I’m going to put my physician hat on for a minute and remind everyone to get a flu vaccine. There was some buzz earlier this year about whether receiving the vaccine too early can reduce its effectiveness, which may have led some people to wait. Although some think the flu is no big deal, it kills nearly 24,000 people in the US every year, including 100 children. It can also cause life-threatening complications. The vaccine used to be recommended only for high risk patients, but now vaccination is universally recommended for everyone over six months of age. Let’s roll up our sleeves and get the herd immunity going.

Does your employer mandate flu vaccinations? Email me.

Email Dr. Jayne.

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October 6, 2016 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 10/4/16

October 4, 2016 Dr. Jayne 1 Comment

The last 43 hours has been some of the most agonizing time I’ve spent in the IT trenches in recent memory. I’ve been working with a client on a small CMIO augmentation project, mostly helping them get organized from a governance and change control standpoint. It’s a mid-sized medical group, roughly 80 physicians, but none of them want to take time away from patient care to handle the clinical informatics duties. I suspect that this is because they’re mostly subspecialists and there’s no way the group would be willing to compensate them for the time they would miss from their procedural pursuits.

Until I arrived on the scene, the IT resources would just build whatever the physicians wanted, regardless of whether it made sense for everyone. This in turn led to a whole host of issues that is impacting their ability to take the upgrades they need to continue participating in various federal and payer programs.

I’ve been spending eight hours a week or so with them, mostly on conference calls as they work through a change control process. Much of my work has been in soothing various ruffled feathers and in trying to achieve consensus on issues that have to happen regardless, but I hope to get them in a good place where they can be well positioned for the challenges of shifting to value-based care. Nothing at their site has been on fire from an operational standpoint, and other than telling the IT team to stop building whatever people ask for, I haven’t had much interaction with them.

I stayed up late Saturday night working on a craft project (curse you, Pinterest), so I was awake when they called me in the wee hours of Sunday morning. It was the IT director. I could immediately tell he was in a panic. It took several minutes to calm him down. I was able to figure out that something had gone very, very wrong with their ICD code update.

Hospitals and providers have to update their codes every October 1 to make sure they have valid codes that can actually be sent out to billers. Most cloud-based vendors do the updates themselves and push it out to their clients, while non-cloud vendors that I have worked with provide a utility that allows the client to update their systems. Usually it’s no big deal, except for the vendors who are habitually late sending out their update packages and whose clients are cringing on September 30.

This particular client is on a non-cloud format and had planned to run the utility on their own. Although they had a solid plan with a lead resource and a backup resource, they never really anticipated having to use the backup resource. On the evening of the 30th, the lead resource became seriously ill and wasn’t able to do his duties. They decided to wait it out a day since they weren’t open on the weekend and see if he could handle it later in the weekend. When he was admitted to the hospital with appendicitis, it was clear that they would have to engage Plan B.

Although the backup resource had gone through the documentation, he had never run the utility or even seen it run. Apparently there was some confusion with a downtime playbook. Users were supposed to be dropped from the system before the backup cycle started and then were to be allowed back on the system after the code update was complete.

Somehow the users weren’t forced to exit and ended up being on the system while the backups started. Once the analyst realized users were still on the system, he attempted to halt the backups, but instead, the ICD update was started. I’m not sure what happened next, but the bottom line is that the database became unresponsive and no one was sure what was going on. To make matters worse, the fail-over process failed and they couldn’t connect to secondary/backup database either.

A couple of analysts had tried to work on it for a while and couldn’t get things moving, so they tried to reach the IT director, who didn’t answer. I can’t blame him since it was now somewhere near 1:00 a.m. After working their way through the department phone list, somehow I got the call. I’m not a DBA or an infrastructure expert, but I’ve been through enough disaster recovery situations to know how to keep a cool head and to work through the steps to figure out what happened. Since crossing to the IT dark side, I’ve had more late night phone calls for database disasters than I’ve had for patient care issues, but the steps are surprisingly similar.

Things were a bit worse than I expected since they couldn’t tell if the transaction logs had been going to the secondary database since we couldn’t connect to it. Even worse, I looked at the log of users who were on the system when it crashed and the senior medical director had been in, potentially documenting patient visits for the day. It took me at least 20 minutes to talk people down and get them calm before we could make a plan. The next several hours were spent working through various steps trying to get access to the secondary database to preserve patient safety. It was starting to look like a network switch might also have given up the ghost.

What surprised me the most was that they really didn’t have a disaster recovery plan. There were bits and pieces that had clearly been thought through, but other parts of the process were a blank canvas. Although there are plenty of clinical informatics professionals who are highly technical, it’s never a good sign when the physician consultant is calling the shots on your disaster recovery.

We engaged multiple vendors throughout the early morning as we continued troubleshooting issues. The IT director finally responded to our messages around 8:00 a.m. I realize it was Sunday morning, but he was supposed to be on call for issues due to the ICD code update and he frankly didn’t respond.

By 4:00 p.m. things were under control, with both the primary and recovery systems up and appearing healthy. My client created a fresh backup and decided to go ahead with the ICD code update. We weren’t sure how much of it had actually run given the aborted process from the night before. It appeared to be running OK initially, but after a while, it appeared that the process was hung. By this point, the team was stressed out and at the end of their proverbial ropes and there wasn’t any additional bench to draw from.

I finally persuaded them to contact the EHR vendor, thinking they would have had resources available since this was the prime weekend for ICD code updates even though my client was now more than a day late. It took several hours to get a resource to contact us back and then we had to work through the various tiers of support. Eventually midnight rolled around again and things still weren’t ready, increasing the anxiety as the team knew they’d have billing office users trying to access the system starting at 5:00 a.m.

Once we arrived at the correct vendor support tier (aka, someone who knew something), the team was run through checklist after checklist trying to figure out what was going on and whether we should continue to let it run or whether we should try to stop it.

The IT director finally made the decision at 6:00 a.m. that the practices should start the day on downtime procedures, and thank goodness they had a solid plan for that part of the disaster recovery game. The practices were given access to the secondary database in a read-only capacity for patient safety purposes and each site was said to have a “lockbox” with downtime forms. The group subscribes to a downtime solution that creates patient schedules, so they were quickly printed in the patient care locations along with key data for the patients who were already on the books for the day. Anyone who presented as a walk-in could be accessed through the secondary database.

At least on downtime procedures, users weren’t assigning any ICD codes to the patient charts since the utility hadn’t completed yet. It was restarted a couple of times and finally got its act together, completing around 4:00 p.m. Monday. After an hour or so of testing, we were able to let users back in the primary system to start catching up on critical data entry and billing.

Most of the day, though, was extremely stressful, not only for the IT team, but for everyone in the patient care trenches. It was also stressful for the patients since the group has a high level of patient portal adoption and there is no backup patient portal. Anyone who sent messages or refill requests or tried to pay their bills today was simply out of luck.

When an event like this hits your organization, all you want to do is just get through it. That’s not the hard part, though – the challenge is just beginning with the post-event review and attempts to determine the root cause of various breakdowns. It usually takes at least a couple of days to untangle everything and the work is not yet over. I’m happy to report that the analyst with the appendicitis did well in surgery and was discharged home before the EHR system was back online. I’m not sure having the primary analyst would have made a difference in this situation. I hope he continues to make a speedy recovery.

You never know when something like this is going to happen in your organization, and if you haven’t prepared for it or practiced you plan, you need to do so soon if not today. Similar to the practice of medicine, sometimes the most routine events can have significant complications.

Are you ready for a downtime? Is your disaster recovery plan solid? Email me.

Email Dr. Jayne.

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October 4, 2016 Dr. Jayne 1 Comment

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