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Curbside Consult with Dr. Jayne 3/30/15

March 30, 2015 Dr. Jayne 3 Comments

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I mentioned that we are having budget meetings this week. One of the hot topics is how we’re going to manage office space and various leases as we reorganize to consolidate onto a single vendor platform. The health system’s goal is to move everyone under the IT umbrella, so we’ll need more space at the mother ship.

We’ll also have to figure out what to do with existing office space leases at our regional campuses and how to transition people from one location to another in a timely fashion. Certain functions such as desktop support and provisioning will continue to be somewhat regional, so there’s going to be some delicate negotiating while we figure out which spaces to keep and which to let go.

I hadn’t given much thought to the new space they’ll be outfitting for the project. The last time I was involved in a significant office move was seven or eight years ago and we were going into a largely completed space. The biggest thing we had to decide was which staffers would be placed into which rows of cubes.

Late last week, I had the dubious pleasure of attending a half-day session to discuss design and construction of the upcoming office build-outs. Given some of the complaints we’ve gotten about the open office design at some of our newer facilities, I thought the topic might be contentious, but I had no idea just how much.

One faction came to the meeting armed with copies of a recent article in The New Yorker called “The Open-Office Trap.” It details the perils of the open office, citing examples of reduced productivity and higher levels of employee stress. Reports have also chronicled higher use of sick days and reduced cognitive performance. One study from Cornell University found that workers exposed to typical open-office noise had higher levels of the stress hormones that are typically associated with the fight-or-flight response. Another from Finland looked at whether younger employees did better with the open office platform and concluded that although they might seem to, there are trade-offs.

As we started the meeting, another attendee hastily emailed links to the Washington Post piece on the topic. The author mentions employees who have difficulty with the transition the open office paradigm and laments the lack of huddle rooms to be used when private conversations are required.

I know that the first time I had to transition from a private office to a cube, I had a hard time adapting. As a newly-minted medical director, I was given a “supercube,” which was essentially double sized with a small table for meetings. It was on a main thoroughfare in cubeland however, which seemed to invite people to plop around the table for impromptu conversations.

I was often interrupted with requests to borrow my chairs or by people just saying hello on the way to the bathroom, icemaker, elevator, or coffee pot. It was also difficult to have confidential conversations about physician behavior, especially since we didn’t have enough smaller meeting rooms. This led me to hide out in a poorly-lighted and recently-vacated office in the basement near hospital engineering, at least until that space was reassigned. The experience definitely strengthened my support for allowing staff to work from home.

Halfway through today’s already-rowdy meeting, another colleague emailed around a piece entitled “Open-Plan Workspaces Are the Work of Satan.” The meeting quickly spiraled out of control after that since it’s hard to take Formica samples and color swatches seriously after someone has invoked the Prince of Darkness. The design and construction team had brought along an intern and I’m sure she found the meeting to be highly educational, just not in the way it was originally intended.

I’m just glad I kept a low enough profile to avoid being volunteered for the subcommittee that will meet again to “continue the dialogue.” I’ve spent the last two months fretting about the future of my team and of my own career and it didn’t even occur to me that serious choices needed to be made on whether we want an aquatic color scheme or one that is desert-inspired or how many “rolling-wall” whiteboards we might need to order. I’m glad there are people that care and are thinking about these things, but at this point it feels frivolous.

The positions for our new clinical project were posted last week. It’s hard to watch my highly-qualified staff fret over whether they’ll be chosen. They’ve heard that they have to take a personality test and that there may be a preference for younger workers without “bad habits” gleaned from working with other vendors and systems.

I’m not part of the hiring decisions at all, but I certainly hope we don’t shoot ourselves in the foot by throwing away all the non-software knowledge we have amassed regarding how to effectively serve our physicians and their practices. In the mean time, I’ll have to amuse myself by running the betting pool on aquatic vs. desert color schemes.

What do you think about open offices? Email me.

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March 30, 2015 Dr. Jayne 3 Comments

EPtalk by Dr. Jayne 3/26/15

March 26, 2015 Dr. Jayne 1 Comment

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I read with interest Mr. H’s summary of Chicago’s April weather over the last several years. One of my friends was in Chicago this week and posted pics of snow. Right now I’m still planning a ball gown for this year’s Histalkapalooza, so I’m crossing my fingers against rain, snow, sleet, hail, and slush. I do have an opera length coat at the ready, but I am not looking forward to figuring out how to pack it all. The fact that I’m thinking about HIMSS planning right now underscores the fact that I’m procrastinating the continued reading of the Meaningful Use Stage 3 documents that were released last Friday.

I’ve only received a couple of pre-meeting mailers, but there have been a couple of ads in healthcare IT publications that caught my eye. Sponsor ChartMaxx is giving away some Chicago pizzeria gift baskets in their “Grab a Slice of the Windy City” promotion. Winners could receive a gift basket and pizzas delivered to their home – sign me up for that one. The two mailers I did receive both mentioned Apple Watches, but I’m not an iPhone girl, so they didn’t engage me. Additionally, one had my title wrong and another botched the address. It never ceases to amaze me when a mail merge goes awry or that people don’t proof things before they go out.

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Speaking of proofreading, I wonder if 1-800-Contacts realizes that their most recent mailing provides a possible time-travel option for customers? Although it was mailed earlier this month, it invited me to place an order through January 2013. I guess it’s not just conference marketers who can’t get it straight, but I’m wondering if I can call and see if they’ll honor their 2013 pricing.

Procrastinating on the Meaningful Use documents also means catching up on journals this week. I’ve been doing a better job of keeping the pile on my entryway table to a minimum, but still am not current. A blurb about using Fitbit devices to predict recovery from back surgery caught my eye, however. Researchers at Northwestern University, New York University, and the University of California-San Francisco are looking at patient activity four weeks prior to a procedure and six months after. Preliminary data shows that patients not only reach their pre-procedure activity level after about a month, but continue to increase to levels that weren’t possible prior to surgery. Although they’re only looking at a subset of spine surgery procedures, I like the idea of capturing that data to model real-world results.

I’m glad I went through the journal pile because nestled in the back pages of American Family Physician was a “Patient Oriented Evidence that Matters” (POEM) segment answering the question of whether computerized decision support systems linked to EHRs improve patient outcomes. The ‘not really’ response cites a recent meta-analysis and I’m glad I read the original article. It was a little less pessimistic than the “bottom line” summary provided in the POEM. I printed a couple of copies of the actual paper to keep on my desk because I’m sure someone will bring the summary in next week as support for why we should not have an EHR. I’ll be ready when they do because at this point EHRs are not going away, but I do love a good medical literature spitting match.

Going back to January in the stack, I also found reference to an editorial in the Annals of Family Medicine that talks about allowing medical students to use EHRs so that they’ll be ready for later phases of training such as residency. Our students get a lot of experience with EHRs in our academic hospitals, but very little when they’re on their community-based rotations. The barriers cited by our sponsoring physicians include licensing issues with EHR vendors, lack of dedicated training for students, inability to separate student documentation from rendering physician documentation, and the transient nature of clinical rotations. Most of these were echoed in the editorial, which also mentions the need for students to learn how to manage populations using registries and other analytic components of EHRs.

I’ll be interested to see how the current generation of medical school and residency grads use EHRs after completing their training. In many parts of the country, we’re to the point where students may not even be exposed to paper charts. In my area, even our community free clinics are using EHRs. I’d love to do a study of new physician interactions with patients in an EHR-enabled exam room vs. physicians who transitioned from paper charts.

Got grant money? Email me.

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March 26, 2015 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 3/23/15

March 23, 2015 Dr. Jayne No Comments

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Just when I was excited that spring had finally sprung, our friends at CMS and ONC have dumped a load of snow on my proverbial daffodils by releasing the Meaningful Use Stage 3 proposed rule along with the 2015 Edition Health IT Certification Criteria. Although it proposes to “simply the meaningful use program,” I find it hard to believe that the 301-page rule and corresponding 431-page certification criteria can be viewed as simple. As an example, there is a four-and-a-half page glossary of acronyms near the beginning.

Having sat through the first two parts of the trilogy, I know Hollywood would have helped me out by breaking the third installment into two full-length features. Alas, we aren’t that lucky with federal regulations and we’re squeezing it into three parts, much like Shakespeare’s Henry VI. I really did try to get through it, but I think the last five or so years of reading so many regulations have shortened by attention span. I hoped if I delayed into the weekend that Mr. H would read it and provide a pithy digest, but it seems he’s thrown in the towel as well.

Glancing through, they do note that, “Stage 3 of meaningful use is expected to be the final stage” which brings a sigh of relief. However, starting in 2018, all providers would report on the same Stage 3 definition of MU regardless of prior participation. Everyone would be on the same playing field regardless of their start date, which certainly does make things simpler. It makes it nearly impossible, however, for those who have not yet started to play the game.

I liked the proposal on page 15 to remove “topped out” measures, which they believe are “no longer useful in gauging performance, in order to reduce the reporting burden on providers for measures already achieving widespread adoption.” Sorry for the easy “A” grades, folks, you’re going to have to continue to work for it. There will, however, continue to be four categories of exceptions:

  • Lack of Internet access or barriers to IT infrastructure
  • Time-limited exception for newly practicing EPs or new hospitals
  • Unforeseen circumstances such as natural disasters
  • Exceptions for EPs with limited interaction with patients or lack of control over EHR availability for those of us practicing at multiple locations

The estimated federal cost to continue the incentive programs between 2017 and 2020 is approximately $3.7 billion. They do mention that “we do not estimate total costs and benefits to the provider industry” because those would be difficult to estimate. We all know that our EHRs cost far more than the $44,000 we might be receiving through Meaningful Use. Additionally, I’m not sure what the neck and back pain that some of us experience after hours at the computer might be worth if we asked for compensation. That’s not to mention the anxiety of dealing with all the virtual I’s that have to be dotted and T’s that have to be crossed to receive the incentive payment and/or avoid a penalty.

Pages 20-23 give a nice overview of the regulatory history and if you’re interested in the definitions they start on page 24. I admit, though, that my concentration started flagging around page 30 and I decided to call it a night. The 60+ patients I saw earlier in the day (will flu season never end?) started to catch up with me as did the glass of Simi cab. I’m going to have to work my way through it over the course of the next week, but I’m still crossing my fingers that the Cliffs Notes version will come out soon.

I feel for the vendors that have to read both the proposed rule and the certification requirement documents to be ready for clients who are going to start asking how vendors plan to handle the requirements before anyone has barely had a chance to digest them. Not to mention, this is still just a proposed rule and subject to public comment and potential revision. Although we don’t expect too many changes based on the historical track record, there still might be a few. I always enjoy reading some of the public comments and I’m sure those will be good for discussion in a few weeks.

I’m still a relative youngster in the medical trenches, but reading the proposed rule did make me nostalgic for the so-called good old days that I barely got to experience in practice. I was already nostalgic after a patient encounter earlier this week, when I had the privilege of caring for one of my medical school professors. He retired the year my class graduated and happened to need care while visiting his grandchildren in my city. When I saw the name come up on my census, I couldn’t help but think of my teacher. I’m sure I was beaming when I walked into the exam room and realized it was indeed him. I’m just thankful his issue didn’t involve his specialty of head and neck so I didn’t feel like I was on the hot seat again.

I do miss the continuity of traditional family medicine, so it was nice to make that kind of connection with a patient. I can’t help but think that my class gave him more than a little heartburn and might have contributed at least a little to his retirement decision back in the day. Luckily his problem was minor, but I have to say that seeing him made not only my day but possibly also my week and my month. I went into medicine to connect with people, but I feel that connection is being lost as the healthcare system evolves. After a bright spot like that, sitting and reading government regulations just makes me sad.

I’m sure lots of other CMIOs, medical directors, and informatics pros will be digesting the regulations this weekend. I’m going to finish unwinding and get ready for a big week of budget meetings and discussion about the further evolution of my team.

I asked last week how others unwind after a long day. Several respondents cited wine or other adult beverages, but an equal number mentioned physical activity as a stress reliever. Swimming, cycling, and horseback riding also made the list. As long as the snow stays away I’ll be out in the garden, marveling at the tender shoots and the promise of things to come. For tonight, however, I’m going to close my eyes and count not sheep, but pages in the Federal Register.

Are you ready for MU3? Email me.

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March 23, 2015 Dr. Jayne No Comments

EPtalk by Dr. Jayne 3/19/15

March 19, 2015 Dr. Jayne 1 Comment

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It was good to get away from my day job last week. I spent my days off seeing patients and intentionally not checking my hospital email account. I’m aggravated at how things are going with our upcoming EHR migration and how my team is being treated, so I thought unplugging would be therapeutic.

Initially we were told that our team would be transitioned to the new project and placed in similar job roles. Our ambulatory group continues to acquire new practices and a small team would remain to continue implementing at those sites as well as to support existing sites. We communicated this to the team and they were comfortable with the approach.

About a month ago, the plan changed. Leadership decided that they want to structure the team more consistent with what the vendor recommends. Now we’re looking for a fairly large number of project managers and plan to hire a completely new training team.

I’m reading between the lines and thinking that perhaps they don’t want people with experience because they’re worried about preconceived notions of how an implementation should look. New trainers will certainly be easier to mold to a new paradigm, but I have serious concerns about throwing away as much cumulative experience as our team has. In addition to being solid trainers, they understand our physician base and how our offices run. The offices trust them and see them as advocates.

Before I left for vacation, our leadership informed the staff of this new plan and essentially told people to get their resumes in order. If they want to move to the new project, they will need to apply for the project manager positions. Most of my team members thrive on the front lines and on working directly with users. If they had wanted to be project managers, there have been quite a few opportunities during the last couple of years. On the other hand, they don’t want to be stuck turning the lights out on a dying project and risk being let go at the end.

Because of flip-flopping by the leadership, the team is nervous and scared. At this point, I don’t know what to tell them. I’m still in limbo regarding my own position. I’ve seen at least half a dozen variations on the proposed clinical leadership structure and none of the positions have jumped out at me as being a good fit for my particular skill set. Like the team, I’ve been told to get my resume in order. Once the positions are posted, I can apply along with the rest of the CMIOs that are being consolidated.

We’ll have three days for internal candidates to apply before the positions are posted externally. It goes without saying that they’re going to hire a new system-wide CMIO who has experience with our new vendor, so at least we’re not all fighting each other for the top job. Postings are supposed to go up next week, but they’ve already been delayed several times, so I’ll be surprised if they are there before HIMSS. Once I see what is available, I’ll make my final decision on whether I’m going to stay or fly the coop.

Most people find uncertainty to be disconcerting. For me, it’s been somewhat liberating because I’ve given up on trying to figure it out. This might be the first time in my life that I haven’t had a plan. I’m starting to understand how my colleagues that fly by the seat of their pants feel every day.

After my week off, I came back to work much more relaxed and ready to see what the next curveball might be. We’ll see how long that lasts, based on the craziness that we’re thrown on a daily basis.

In the mean time, there’s always room for pastry therapy. In honor of St. Patrick’s day I made some outstanding cupcakes that a friend had suggested I make. I just may have found my new favorite buttercream frosting recipe. Slainte!

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March 19, 2015 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 3/16/15

March 16, 2015 Dr. Jayne No Comments

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I wrote last week about my new urgent care job. This week I worked a bumper crop of shifts to try to immerse myself in the new policies, procedures, and workflows.

From a clinical standpoint, it’s been terrific. The support team is top notch. I have the option to use a scribe, but I haven’t yet taken advantage of it.

Today was the second-busiest shift that my location had ever seen. I thought I kept my head above water despite having some really ill patients. I had several patients needing procedures or multiple diagnostic tests, so at times we were a little backed up.

I was so busy I barely had time to eyeball my phone. I headed home to put my feet up and was surprised to find multiple emails from patients waiting for me. Apparently my new employer subscribes to an online rating service that allows patients to submit feedback in an attempt to mitigate any negative feedback that might be otherwise posted to online rating sites.

I’m all for patient engagement and receiving feedback, but I wish I would have been warned. Although the email came from the rating service, it’s unclear whether patients can see my email address. Regardless, I would have set up a separate account to handle the traffic.

Even more unclear is what I am supposed to do about feedback that might be negative. At one time we had multiple very ill patients in the office and had even called EMS to transfer one to the hospital. I wasn’t surprised that one of my feedback submissions was about having a long wait. I called for backup when I felt it getting bad (we have flex staff that can swing over from our other locations) but it took time for the float to arrive and pitch in.

Our practice management system tracks all the different times in the patient cycle, from door to doctor to discharge and everything in between. I’m sure my numbers looked pretty bad at multiple times today, but the numbers don’t reflect acuity or case mix. They don’t give you the true picture of what might be going on.

I’m comfortable being rated on the timeliness of my care when I’m in a practice setting with scheduled appointments. I pride myself in running on time and I do well keeping up as long as the appointment slots are on a pretty standard schedule. If you want to grade me on that, I’m game.

However, being graded on being too slow is uncomfortable when you’re in a walk-in setting. It’s not uncommon to have a half dozen patients walk in right after one another. Maybe having multiple patients at the same time who should have really been in a hospital emergency department isn’t that common, but it was my reality.

Thinking through the day, I know I saw patients as quickly as I could, giving the best care possible. My team worked extremely well together, and although people’s lunch breaks were delayed and they were working hard, it felt good. One of the nurses was celebrating her 40th birthday and a member of the management team came to the office with treats. She also brought my official monogrammed scrubs, which made me feel even more like a member of the team.

Although the patients were served faster than they would have been at my hospital’s ED — not to mention that their primary physicians were unable to serve them at all — we didn’t meet their expectations.

I was facile enough with the EHR to run without elbow support, even figuring out a couple of shortcuts. For some reason, my favorite medications are all duplicated, though. With the mad rush we had, there wasn’t time to look at it or resolve it, so prescribing medications is much slower than I’d like it to be. I did get quite a few favorites built on the fly and picked up some tips from the staff at the end of the shift as things slowed down.

I’m waiting to hear back from the owner about what they want me to do with any feedback that wasn’t five stars. In the mean time, I’ve got a new Gmail account ready to receive patient comments rather than having it sent to my personal account. Since I’m only working a couple of shifts a month, I hope the follow-up they expect from me is minimal.

I’m also waiting to hear about their ICD-10 training plan. I’m hoping to get them to hire me to do their training when the time comes. I’ll definitely have the skill set and it might be good for them to be able to have one of their in-house physicians deliver it rather than having to contract it out.

In the mean time, I’m unwinding with a nice glass of wine and recharging before I head into the CMIO trenches tomorrow.

How do you unwind after a long day? Email me.

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March 16, 2015 Dr. Jayne No Comments

EPtalk by Dr. Jayne 3/12/15

March 13, 2015 Dr. Jayne No Comments

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I mentioned in Monday’s Curbside Consult that I took some time off from my day job this week to immerse myself in the routine at my new moonlighting gig. I also used some of the time yesterday to finish my tax return. As I went to put my documentation in the file cabinet, I realized that the drawer was full and I should probably spend some time dealing with some non-hospital document retention.

At work, we’re rabid about document retention. We keep everything exactly as long as required by laws or regulations, and then it’s off to the physical or virtual shredder. There’s a certain liability in keeping things longer than you need to, and as a risk-averse organization, we don’t want to shoulder any more liability than required. I definitely had files at home that were well past the need for retention, so I started culling through them. The amount of document detritus that can accumulate over a physician’s career is pretty impressive.

In addition to the usual household paperwork such as tax documentation, financial paperwork, mortgage paperwork, and important receipts, physicians have a host of other documents to manage. If you’re lucky enough to work for the same employer for most of your career it might not be too bad, but for those of us that have worked for several groups, the paper carnage can be impressive.

I’m not even talking about patient records or office-related information – just the personal ones. There are medical liability insurance documents, payer credentialing documents, hospital privilege documents, employment contracts, CME documentation, licenses, and DEA and state narcotics documents. There are college and medical transcripts, records of licensing exams, diplomas (and their certified translations if you went to a Latin-loving med school like I did), board certification documents, and now maintenance of certification documentation.

The pile was impressive. For conventional financial documents, there are retention standards. Some of the professional documents need to be kept for even longer, especially if they relate to liability insurance. I’m not going to rely on a former employer to prove that I had liability coverage if a claim occurs at the end of the statute of limitations. With the prevalence of identity theft, I’m not going to get rid of some of my original documents that relate to licensing or board certification. I was, however, able to weed out quite a bit of documentation and reduce the pile. Now that it’s more organized I should scan it all, but that’s a project for another day.

After I made it through the “official” file drawers, I turned to some of the documents I had kept for more personal reasons. It was a reverse chronological tour through what it takes to become a doctor. I started with student loan payoff documents and worked my way back through the application to defer payment during residency and the heart-stopping promissory notes I originally signed as a 22-year-old. I distinctly remember the day I signed the first one – if nothing motivates you to not wash out of medical school, it’s the possibility that you could have upwards of $200K in debt with no way to repay it.

The tour down memory lane also included rejection letters from a handful of medical schools and acceptance letters from others, as well as my original Association of American Medical Colleges application packet. Back in the days of the typewriter, I had filled it out by hand first and then typed it up. Both copies were there and it was funny to think about doing business without the now-familiar fillable PDF or online form. Reading the essay made me smile – it was a good reminder of youthful optimism, untarnished by E&M coding regulations, fear of litigation, or Meaningful Use.

One might ask why I still had all that. Although I do probably tend to be overly sentimental, I think it is more due to the realities of rushing from college to medical school to residency to solo practice without a break. The boxes just moved from one tiny student apartment to another and then to a house. With the crazy hours we work, as long as you have space to keep it, there’s little motivation to spend your free time sorting it all out. It got me thinking about the volume of electronic documents I might have, where space is not a limitation.

For good or bad, my hospital has a fairly liberal retention policy for email. A CMIO buddy of mine works at a hospital where all emails delete after three months and they have limited archive space allotted, so he’s constantly having to either save emails to other file formats or risk deletion. I try not to keep email too long but there’s never time to sit down and clean it out. I realized I hadn’t purged my archive folder in what looked like about two years. I spent a couple of hours deleting tens of thousands of emails. In that history were both the mundane and the heroic. I looked back fondly on standing up the region’s first HIE, but with the bittersweet sense that it is now defunct.

Those electronic missives tell the story of hundreds of thousands of hours of work. Not only by the IT teams, but also by the clinicians and other end users that did the work alongside us, whether enthusiastically or reluctantly. I know the emails needed to go and it was somewhat cathartic to watch those massive chunks of data disappear from my folders. On the other hand, it made me miss the simpler days when our main goal was to do the right thing by our patients rather than checking boxes and counting measures.

I enjoyed being reminded of colleagues who have moved on to bigger and better things as well as some pretty crazy stories. The hail storm that struck during one of our EHR design sessions, totaling cars. The analyst who ran our first EHR upgrade and slept at the office all night in a folding lawn chair while the rest of us went to our vendor’s user group meeting (bad plan, by the way). The vendor rep who got food poisoning during a site visit and still called in to our meetings while lying on the hotel bathroom floor (that’s dedication). Team-building tricycle races, cosmic bowling, and mini golf. And the software developer who put up with my newbie questions and helped me bring a feature live that no one else seemed to care about but that made a huge difference for our users.

Those are not exactly the stories you memorialize in a scrapbook but I’m grateful for the memories and to everyone who has helped me along the way. We may not always have Paris, but we’ll have the EHR.

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March 13, 2015 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 3/9/15

March 9, 2015 Dr. Jayne No Comments

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I mentioned last week that I’ve been gearing up to start a new urgent care position. Unless you have been on the provider side of things, it may be difficult to understand all the moving pieces that go with a physician starting a new job.

It’s not just about adding them to the EHR and making sure they have logins. There are countless steps before you can even consider that. In addition to passing the normal steps in the hiring process (interview, reference checks, background check, drug test, pre-employment physical, etc.) there are applications for medical liability insurance and credentialing applications for all the different insurance payers. We also have to update our licenses and DEA registrations, not to mention state narcotics board certificates, hospital privileges, and more.

Since I’ve done a fair amount of locum tenens work, I was lucky to have all the required documentation already organized and scanned. The practice’s onboarding coordinator was excited about that, as was the medical liability carrier. Rumor has it that my onboarding process was one of the most streamlined they’ve had. I suppose that’s the benefit of having been on the employer side – I’ve seen what happens when a new physician stalls in filling out the paperwork and I didn’t want to be “that doctor.” It can literally take months to get everything ready to go if there’s a lot of back and forth with the documentation.

Based on the initial progress, they were convinced things would come together quickly and scheduled me for some shifts. They use staff management software that not only proactively asks me for my schedule requests, but also makes sure recipients acknowledge their receipt of the final schedules.

I started my EHR training last week while waiting for the above dominoes to fall into place. The online training was engaging, but I didn’t get very far due to the length of the modules and competing priorities on my schedule. Luckily I had completed the EHR overview, so I crossed my fingers and headed to my first day of work.

With as long as EHRs have been around, practices expect new physicians to be able to hit the ground running. Even if physicians haven’t had an EHR in the office, most of us have used electronic records in the hospital to at least some degree. Even if we’re not writing our notes on a computer, we may be doing CPOE or reviewing nursing documentation.

The practice arranged for one of their in-house trainers to stay with me during my shift. I was fortunate that she is not only a trainer, but also one of the most skilled medical assistants in the practice. She was able to teach me about office workflow and how the staff handles various situations in addition to making sure I wasn’t missing key EHR documentation.

I was honest and told her that I hadn’t completed all the training. Apparently getting through any at all was a big plus compared to other physicians she had trained. She said that most physicians don’t bother to do the self-directed learning until they work their first shift and realize they’re unprepared.

I guess that’s one way to figure out whether an EHR is truly intuitive or not, but I’m glad I didn’t take any chances. The EHR wasn’t as smooth as it had looked during the training, which was no surprise because trainers by design are skilled at making things look easy.

Most systems perform differently in the heat of battle than they do in the rarified air of the training room. This wasn’t the first time I’ve been trained on the job in an ER or urgent care – most of the time when you are a fill-in physician, that’s how things happen. Physicians who are paid hourly aren’t willing to donate their time for training and employers aren’t likely to want to pay for training time.

This system wasn’t any different from others I had used in that the first four or five patient notes were acutely painful as I tried to develop muscle memory and a feel for the different variations in the layout for the different patient complaints. Although there was another physician in the office, he was there only to back me up if I got too far behind. The organization prides itself on short wait times and immediate care and he was there to maintain standards while I got my feet wet.

By the end of the shift, I was feeling pretty good, but I’m nowhere close to the productivity I know I’ll have after two or three days in the office. Since I’ve spent the last year documenting most of my work using a paper-based template system, I was happy to be back in the EHR world. I’ll take some extra clicking any day in exchange for allergy and interaction checking, medication refill history, and clinical decision support. The e-prescribing system acted a little quirky, but I’m guessing it’s due to the fact that I’m enrolled on multiple vendor systems. Hopefully a couple of phone calls will sort that out.

At the busiest part of the day, I had 8-10 incomplete charts with a full count of patients in the exam rooms. Things slowly got easier, but I still had a pile of half-finished charts when we accepted our last patient for the night. While she received some IV medication, I was able to complete the rest of my documentation so that I could walk out the door right behind the patient. That’s always a good feeling and I know the staff appreciated the effort so they could get home as well.

Although the practice allows me to complete my charts from home, I’ve never liked that approach. I had to do that during my first EHR implementation and it was too easy to forget patient details and miss documentation. Processing refill requests and reviewing lab results is one thing, but trying to do visit note hours after the fact has never worked for me. I’m taking the immersion approach and working three shifts this week, so hopefully by the weekend I’ll be where I need to be to feel like I’m pulling my weight. It’s a heck of a way to spend a week of vacation, that’s for sure.

How long does it take your new physicians to get up to speed? Email me.

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March 9, 2015 Dr. Jayne No Comments

EPtalk by Dr. Jayne 3/5/15

March 5, 2015 Dr. Jayne 1 Comment

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As a CMIO, I’ve spent most of my time working for hospitals and health systems. The bulk of my experience has been in with face-to-face using a “train the trainer” model. Our in-house trainers learned from the vendor’s trainers; our trainers in turn deliver the training curriculum to end users.

As healthcare has evolved, many organizations have wanted to get away from traditional classroom training, whether due to facility, logistic, or cost issues. Having users participate in at least some kind of online or self-directed learning prior to in-person training is highly desirable.

We created this kind of training at my organization last year and it’s been fairly successful. I haven’t really been able to judge it as objectively as I’d like, however, because I already have a deep knowledge of our system and had been previously trained in the old methodology. I’m glad that my employer allows me to moonlight at other facilities.

I mentioned last month that I was going to start at a new site. Since I’m clearly a health IT geek at heart, I was actually excited to receive the email today with my password to their learning management system.

It’s clearly a vendor-driven system – my new employer didn’t go out and code this on its own. It’s branded with the vendor name and the graphics are fresh and inviting. Maybe I was looking for a reason to procrastinate, but it made me want to put aside the HL-7 specs I was reading and dive right into training. I think I was most excited about experiencing what online training might be like in a situation where I wasn’t involved with designing or maintaining it.

The system was ridiculously easy to navigate, with both a traditional navigation bar and a more graphical representation. That made me smile since I spent a lot of time arguing with some of our developers about the need for “old school” navigation when we configured our system. People have different learning styles – some are abstract thinkers and others concrete – and often seem to do better with one approach over the other. I’m more of a traditional girl, so I dove right in with the top-down navigation.

The introduction was handled with a video presentation. What struck me first was that it had background music. I haven’t seen that much in the training content I’ve used previously, but it was somewhat spa-like and unobtrusive, so I decided I liked it, although it kind of made me want to get up and light some scented candles to match the mood. Once I completed the introduction, it released me to view the courses in which I had been enrolled.

Many organizations assume providers don’t care about the practice management aspects of the system, so I was excited to see that I had been enrolled for training on the billing system as well as the clinical system. Knowing my background, they may want to revoke my enrollment in the EHR Configuration section but I am looking forward to seeing how things work with a new and different vendor.

Once I moved into the provider training, I was glad to see that it had option for both video/spoken content as well as turning off the audio and just reading. Putting myself in a typical physician’s shoes, I found it to be a little heavy on the technical jargon as it discussed virtualization and thin-client delivery. I don’t know that I need to be told that 100 million users have experienced “the promise of proven application compatibility” that is Citrix XenApp, but you can bet I’m going to use that factoid in our next office trivia contest.

I’ve spent most of my career using enterprise-class EHRs that attempt to support every specialty under the sun. This is the first time I’ve used a specialty-specific EHR. I have to admit it’s significantly different than my past experiences.

There were other exciting non-specialty features as well. In contrast to the system in place at our hospital, patients can pre-register and check in online. Instead of jumping right to the physician part, the module then walked me through the basics flow of a visit, including what the front desk staff would see and do. Not at the level where I could perform the tasks, but just to give me an idea of the features. I often think that physicians would be more forgiving of a lengthy check-in process if they understood what really went on in the front office.

This will also be the first time I’ve used an EHR that is optimized to run on an iPad. Although it looks cool, it was kind of jarring to keep looking at a screen in portrait layout rather than the landscape layout we’re all so used to. As I went through the initial training session, I saw a couple of things that raised my EHR developer hackles: inconsistent use of color and blood pressure fields where systolic and diastolic were combined are examples I noted. I know I’m more discerning than the average user, but I had thought vendors were well past those entry-level design flaws.

I have to admit, though, I drooled a bit when I saw how the system handles approximate dates. My primary vendor has struggled with this for quite some time. Maybe the way my new EHR is handling it isn’t glamorous, but it gets the job done much better than I’ve seen other vendors do it. Unfortunately, that was just a teaser during the EHR overview, and I’m going to have to wait to dig into it a little more. Each module shows the length of time allotted and most look like they’re 20-25 minutes. Since my eyelids were already drooping from a long day at the office followed by yet more snow shoveling, I decided to call it a night.

Do you have a passion for online training? When is the last time your CMIO learned a new EHR? Email me.

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March 5, 2015 Dr. Jayne 1 Comment

Curbside Consult with Dr. Jayne 3/2/15

March 2, 2015 Dr. Jayne 1 Comment

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I received an email from ONC on Thursday that they were extending the deadline for nominations to the HIMSS Interoperability Showcase, citing “feedback that organizations needed more time to submit nominations for participation.” From the time the email arrived, that’s a whopping three business days until the deadline. It made me wonder exactly why the deadline was extended and what their current applicant pool looks like. If they were delaying because they didn’t have many applicants, then they hardly gave much of a window for organizations that weren’t already prepared. Was the announcement a way to raise awareness about the Showcase rather than being designed truly to solicit participants?

Perhaps organizations didn’t apply because they didn’t want to spend $8,000 to participate. That’s just for the kiosk at the Showcase, which includes a monitor, keyboard, mouse, power, and Internet connectivity as well as two exhibitor badges. Travel, meals, and lodging will be on top of that. We’re doing some cool things with interoperability at my health system, but they’re not about to spend upwards of $12K for developers to go show it off at HIMSS.

Whatever the reason, I can’t help but think about the ongoing list of government initiatives that have to be delayed, extended, or otherwise modified because they don’t seem to be achieving the desired results. Being a process improvement person, I’m always looking for the root cause when outcomes are not achieved or when projects run off the rails. Recently, we’ve had delays in ICD-10, Meaningful Use, and Healthcare.gov. Some of us, however, remember delays in the implementation of the 5010 claim standard and those of us deep in the weeds know about dozens of lesser-known parts of HIPAA and other omnibus legislation that are virtually unimplementable.

In medicine, we have a doctrine about ordering laboratory and diagnostic tests: don’t order it if it’s not going to change your plan for the patient. I do a lot of work with reporting from our EHR data and we have a similar dictum: don’t run the report if you’re not equipped to act on it. You’d think there would be a similar mantra about not making rules that people can’t actually follow, but that doesn’t seem to be a factor for those happily engaged in rulemaking. Only in healthcare do we come up with creatures like the “Two Midnight” rule and other similar nonsense.

My extended family is always asking about some of the wacky things that go on, such as provider-based billing, which allows hospital-owned practices to charge both a professional fee and a facility fee for outpatient visits. I’ve become as expert at explaining the Medicare Part D “donut hole” as I am at teaching patients to use a home blood glucose monitor. In trying to find some method to the madness, I stumbled on an article that attempts to explain why healthcare regulation is so complex. The first paragraph opens with a perfect summary: “Health care professionals may feel that they spend more time complying with the rules that direct their work than actually doing the work itself.”

The author contends that “regulation arises largely from a set of confrontations between opposing interests that created the system.” I agree that there are clashing agendas and learned that first hand as a young physician when the hospital’s chief of staff wanted to know why he wasn’t getting my referrals. It felt more than a little like a shakedown. He wasn’t aware that I sent nearly all of my referrals in his specialty to one of his partners, so at least his practice was seeing volume if he wasn’t personally. It didn’t matter, though, since it was apparently all about his ego. These conflicting agendas are ongoing, and “Doctored: The Disillusionment of an American Physician” talks about one physician’s struggle.

Although there are certainly turf wars at play, the regulatory soup includes rulemaking at so many levels that it’s nearly impossible to keep track of what needs to be done. I have to follow the rules of multiple hospital medical staff organizations, two state licensing boards, two specialty certification boards, one professional society, dozens of payers, the city, the county, the state, and the federal government. These rules (and non-rules that often have the force of law) sometimes conflict each other and often fail to make sense.

Several times in the last few decades, studies have looked at everything a primary care physician should be doing for his or her patients and how long that would take. An article in the Washington Post summarized the most recent data from the Annals of Family Medicine, which found that for a typical panel of 2,300 patients, the physician would have to spend nearly 22 hours a day to provide all the recommended care. That’s just delivering the care itself – it doesn’t factor in the time needed to comply with everything else a physician does such as arguing with payers, managing staff, dealing with regulations, worrying about compliance with programs, and trying to stay current with medical knowledge.

That’s what we’re dealing with in the ambulatory setting. Hospitals and health systems deal with many more rules and countless regulatory bodies. Similarly their IT departments are trying to keep the systems up and running, prevent breaches, avoid breaking something that’s required for Meaningful Use, and so on. It’s no surprise that people are not coming out of the woodwork to sign up for the Interoperability Showcase.

What regulations keep you hamster wheel spinning? Email me.

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March 2, 2015 Dr. Jayne 1 Comment

EPtalk by Dr. Jayne 2/26/15

February 26, 2015 Dr. Jayne 2 Comments

I literally had almost 100 people forward me news articles about the CMS announcement pushing the Medicare Meaningful Use attestation and PQRS reporting deadlines to March 20. Although no specific reason was announced, possibilities include winter weather emergencies, the fear (or reality) of attestation site glitches, the complexity of preparing reports and audit documentation, and lack of vendor readiness as possibilities. Buried below the fold of several articles was the fact that this does not impact the Medicaid Incentive Program, so I hope those practices realize they’re still on the hook for the original deadline.

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The hideous cold and repeated snows pounding a good chunk of the country have put a cramp in the style of many fitness enthusiasts. Although I once had a serious dislike of treadmills in general, I’m glad that I finally got one at home at least to be able to get some miles in despite the cold. I might have been more fond of treadmills sooner had I known about iFit, which allows compatible fitness equipment to automatically deliver uphills and downhills to match real-world routes while showing pictures from Google street view.

I’ve now run through Ireland, Paris, Norway, and my own neighborhood and definitely like it better than the standard programs on the treadmills at the gym. Once people’s New Year’s resolutions start failing, used equipment will start popping up for sale and I’m glad I have something to talk about with patients who think walking on a treadmill is boring. I also found a National Geographic “Everest” video workout on the site and although it bested me the first time, I’ll be back for more. Having the ability to track and quantify my efforts to stay in shape has been a benefit for me, although I draw the line at sharing every workout to Facebook.

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A reader who has picked up on my running habit shared these high-tech socks from Sensoria that use sensors and conductive fibers to gather information about a runner’s speed, distance, steps, and how their feet strike the ground. They debuted at the recent Consumer Electronics Show and are from the same people who brought us shirts and running bras to sync with heart rate monitors. A magnetic anklet communicates with Android and Apple devices to provide real-time feedback. I’m not sure I want my socks to coach me and they aren’t cheap, so I think I’m going to take a pass this time. I do enjoy reading about wellness-related tech, so keep sending your finds.

I do some volunteering at a local school and they asked me to speak at an upcoming career day. When I get requests like that, I always have to ask whether they want me to talk about my “doctor job” or my “computer job” or both. When I decided to become a family physician, I never imagined myself on the cutting edge so I was happy to come across this piece on physician informaticists to help explain exactly what it is that I do all day. Apparently UCLA is thinking outside the box and is making their informaticists available for consultation with other Epic customers. It looks like a win-win situation to me – in addition to assisting other organizations, their team can also bring back successful approaches from other sites.

NCQA is offering the opportunity for the public to provide feedback on proposed change to 2016 HEDIS measures. There are a handful of proposed new measures and changes to several existing ones, so plan to get your comments in before the March 18 deadline.

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Speaking of deadlines, Friday is the cutoff for HIMSS hotel changes. I’m mixing it up this year and staying somewhere swanky with a couple of my gal pals since I was able to get ridiculously cheap airfare. Although registration for HIStalkapalooza is closed, I know Mr. H is poring over the guest list and I’m looking forward to seeing many of you there (anonymously, of course). The event is one of the most fun parts of being on the HIStalk team, although I am feeling the pressure when it comes to finding a pair of outstanding shoes. Maybe Sensoria should make an insert to gather data on what happens to the feet of fashionable ladies and gents out for a night on the town.

Have you put together your HIMSS wardrobe plan yet? Email me.

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February 26, 2015 Dr. Jayne 2 Comments

Curbside Consult with Dr. Jayne 2/23/15

February 23, 2015 Dr. Jayne No Comments

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I’m leaning heavily towards staying with my current employer as we move to a single platform for all our hospitals and practices, but lots of people keep sending opportunities my way. Today a juicy CMIO position came across my desk. It’s in a great location and with a well-known health system that I’ve had some dealings with previously.

It looked pretty exciting until I got to the part about the heavy inpatient focus and complete disregard for those of us who have come up through the ambulatory ranks. I started to move it to my recycle pile until something caught my eye. They’re looking for someone “politically savvy with a high tolerance for ambiguity… who can put all the pieces together and deliver on time and on budget.”

I’ve got a lot of experience delivering the undeliverable and creating successes despite some of the people I work with. Usually hard work and pixie dust are involved, but we never admit it. My general rule of thumb is that organizations are typically 30-50 percent more dysfunctional than they admit, so I’m wondering what that looks like when they’re already warning candidates about ambiguity and the need to be able to patch things up to get a project out the door. They also mention frequent interruptions and constantly changing priorities. I’m not rushing to submit my CV.

Another prospective position (thanks to the reader who sent me an opportunity in a warm climate) looks like it’s much more up my alley. The nine responsibilities bulleted in the job description are things I’ve been doing for years. I’m less sure, however, about the tenth one – supervising and assigning projects to physician informaticists on the CMIO’s team. Sometimes it feels like I’m lucky to get an administrative assistant to support me, so the idea of multiple physicians helping deliver value from healthcare IT is awfully tempting. They’re also looking for someone either board certified in clinical informatics or with a masters degree in the field, so that tells me they value the education and training that many of us can bring to the table.

In the mean time, I’m still waiting to find out how my health system is going to handle the clinical leadership structure for the EHR consolidation project. I don’t have a lot of time to dwell on it, however, since we’re preparing more than a dozen practices to seek recognition as Patient-Centered Medical Homes.

The first time I went through the process was on paper. Although there are certain aspects of the requirements that are significantly easier with an EHR in place, there are still elements that are much simpler in the paper world. Some of our practice managers have actually laughed out loud when I ask them to use a simple three-ring binder for some of the requirements. Although I’m obviously a fan of technology, sometimes a manual process is quicker, easier, and doesn’t require anyone from IT to give it a blessing.

I’d estimate that three-quarters of our practices are ready, with stable processes and solid physician buy-in. The other few still need some work. We’re likely to urge the others to move forward while we continue to tweak workflows in those that aren’t quite ready. They also need some refinement in staff roles and responsibilities. We’re finally helping our administrators understand that PCMH is not a technology project so much as an operational initiative. I want to try to get as many of our joint operational and technical projects completed before the transition to the new system begins in earnest.

I’m also staying occupied looking for interesting ways to use some of my accumulated vacation time. As of January 1, our health system has gone to a “use it or lose it” philosophy and has capped the vacation hours we can have on the books. I’m dangerously close to the limit and certainly don’t want to leave any hours on the table. I’m planning a wilderness adventure for July, and if I don’t get eaten by a bear, I’m looking for a trip in the fall that will provide not only some R&R but some continuing education hours. I also hope to take some long weekends once the weather gets nice. The new policy should make for some interesting resource challenges as everyone tries to lower their balances.

What’s your plan for R&R in 2015? Email me.

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February 23, 2015 Dr. Jayne No Comments

EPtalk by Dr. Jayne 2/19/15

February 19, 2015 Dr. Jayne No Comments

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We always love hearing about ways that vendors are contributing to the greater good. I was excited to receive a Valentine’s Day card from our sponsor Medicomp Systems, who offered to donate $10 to Doctors Without Borders for each person who views a brief demo of Quippe. It was supposed to end this week, but the executive team generously agreed to extend it a few more days for HIStalk readers. They’re willing to donate up to $5,000, so stop by to do your part for Doctors Without Borders. You’ll also be able to pre-register to compete in their Quipstar game show during HIMSS. I was a celebrity contestant in 2013, so I can attest that it’s a lot of fun.

The Texas Regional HIMSS Conference is taking place this week in Austin. Thursday’s keynote was Ed Marx, speaking on, “Extraordinary Tales From A Rather Ordinary Guy.” Other topics included screening for emerging diseases, interoperability, population health management, health literacy, and of course Meaningful Use. Texas has a reputation for hospitality, but one of my readers was not impressed when another attendee made snarky comments about the fact that she was taking notes during the meeting, asking, “Did you get all your work done?”

Wednesday was National Drink Wine Day, which reminds me of an EHR story a friend shared with me. During a trip to the emergency department, she was asked about her alcohol intake. Do you drink alcohol? Yes. How often – once a day or socially? Yes. She was told she had to pick one or the other. As a clinician, I always wondered what documenting “socially” really tells me about a patient. Does that mean they have drinks once a year at the company Christmas party or twice a week in the stands at their kids’ baseball games? Are they socializing at the bar every night after work? It just goes to illustrate that data collected for the sake of collecting data (and without valid clinical intent) is not only a poor use of scarce time, but meaningless.

There are plenty of phishing scams riding the coattails of the recent Anthem breach, but they’re a drop in the bucket compared to the daily deluge of random emails trying to grab our attention. I am always amused by people trying to get content on HIStalk when they clearly don’t read it. One of yesterday’s offerings tried to convince us that we need guest bloggers to keep up a constant flow of content so that we can relax. There were also a handful of emails that were barely coherent and those are just the ones that made it through the spam filter. I recently read “The 4-Hour Workweek” and the idea of having someone to pre-screen my email is more appealing every day.

Speaking of email, my EHR vendor sent a nice one this week about the recent CMS approval for lung cancer screening using low-dose CT scanning. What would have been even nicer would have been instructions on the best way to identify and track impacted patients since they have to be in a certain age group, have smoked a certain amount, and must be either current smokers or have quit within the last 15 years.

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Even as a member of the HIStalk team, I can’t possibly keep up with all the health IT news out there. HIStalk Practice mentioned a study at Michigan State University. It looks at using children’s fingerprints to track immunization records. Comments on the article immediately seized on it as a way for the government to force individuals to provide their fingerprints. The article reminded me of VeriChip, which was similar to the computer chips many of us use to permanently identify our pets. Reading the article about its FDA approval in 2004 was a blast from the past as it referenced then-President Bush’s EHR initiative. It also mentioned the disparities in animal vs. human medicine, noting that implantation for a pet would have been $50 but for a person it would have been $150 to $200.

Jenn also told me about a review on physician dress done by a team at University of Michigan Health System. The team performed a comprehensive review of studies on physician dress, looking at 30 studies involving more than 11,000 patients in 14 countries. They confirmed what many of us suspected: that older patients prefer their physicians to be more formally dressed, where members of Generation X and Y were more accepting of casual attire. There were some differences in preference depending on physician specialty. The team plans to conduct their own study, “Targeting Attire to Improve Likelihood of Rapport” or TAILOR. Hospitals in three countries have already agreed to participate. My new clinical posting involves monogrammed scrubs, so I might just spring for a new pair of clogs to match.

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With this winter’s seemingly-perpetual cold and abundant snow, I’ve been tending to warm, non-skid footwear. But with the promise of spring around the corner, a reader shared these smart little shoes. “There’s No Data Like Home” by artist Steven Rodrig definitely lifts my spirits, appealing to both my fashion sense and techie tendencies.

What warms your heart with thoughts of spring? Email me.

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February 19, 2015 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 2/16/15

February 16, 2015 Dr. Jayne 1 Comment

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A reader with a keen eye sent me this warning sign, saying it reminded him of the modern workplace. The beach is lovely… except for the sharks, hippos, and crocodiles. It arrived while I was preparing some thoughts on what the workplace has become. The recent Wall Street Journal piece “Everything is Awesome! Why You Can’t Tell Employees They’re Doing a Bad Job” is making the rounds at our hospital. If the pay wall won’t let you read it, I recommend a search using key words from the title – that’s how I got the full text.

I have to admit that I was drawn in by the opening paragraph: “Fearing they’ll crush employees’ confidence and erode performance, employers are asking managers to ease up on harsh feedback.” I’m a firm believer in public praise and private criticism. However, the article seems to advocate swinging the pendulum pretty far to avoid any negative feedback for employees. Suggested employee review phrases include “we haven’t done this” rather than “we can’t do this,” which tells me something about the companies advocating this approach: they are probably not in healthcare. What might work at VMware Inc. or the Boston Consulting Group isn’t going to work in a Joint Commission-accredited, CMS-regulated, state-licensed facility where we’re forced to say “we can’t do this” every single day.

For those of us on the clinical side, as young nurses or physicians in training, we didn’t get to pick our assignments. We did what we were told and we did it as well as we could possibly do it, with the hope that our next assignment would be more educational or at least less odious. At the end of medical school, physicians almost get raffled off (National Residency Matching Program, anyone?) to hospitals for an additional three to seven years of on-the-job training. The vast majority of us work really hard, in part to make sure we continue to be at the top of our games, but also because we realize that people’s lives are on the line every day when we go to work.

In my organization, we’re seeing that as Baby Boomers retire and are replaced by Millennials, we’re being asked more and more to consider employees’ feelings as we assign work to them. I’m not a Baby Boomer, but as someone who has worked in a top-down, mission-critical environment for most of her career, I share a lot of the psychology. For those of us used to doing what needs to be done regardless of how we feel about it, worrying about employees’ feelings is not the first thing one thinks of when something goes terribly wrong. Hospital work places an incredible amount of pressure on everyone to have a zero-error workplace; we need to be able to deliver constructive criticism or even corrective action when it is required. When the Code Blue is over and the patient has either survived or died, we debrief. We talk about the team, how things went, and sometimes the emotional side of it. But that’s well after the fact.

When an employee has a lot of issues or requires more remediation than makes sense for their skills and role, the ability to provide clear feedback is essential. Feedback needs to be ongoing — no one should ever be surprised by what they hear in a performance review. Additionally, we’ve seen employees (and former employees) become more litigious over the last few years. Having appropriate documentation of non-performance and resulting interventions is essential to managing those situations. It’s more difficult for someone to come back at you for wrongful termination when you have a well-organized history of events.

The article cites experts who agree that “tough feedback sometimes motivates people better than praise,” but it was well below the fold. Tough feedback certainly doesn’t mean yelling at staff or belittling them, but it may mean making clear statements of events and their consequences that workers are not ready to hear.

I recently asked a lab analyst to review some normalization work that his co-worker did as a peer review. The reviewer “corrected” the work, adding new values that were clearly incorrect. I marked up the review, provided specific explanations of why each element was incorrect, and met with the analyst to review it. I thought he was going to have a breakdown. Unfortunately, he was less concerned by the fact that his work might have caused a serious patient safety issue and more concerned that I was “going after him.” If he thinks a private meeting where we discuss the facts around why one cannot round lab values or change their units inappropriately is “going after” someone, then he probably doesn’t need to be in healthcare. He also probably doesn’t belong at Netflix, either, which the article cites as “devoted to toughness.”

Reading through the 130+ comments on the piece, I’m not the only one with second thoughts about some of the approaches recommended. One had a great point about the concept of work teams: “Playing on a team is based on performance, perform well = get to play, if I don’t, I remain on bench or I am removed. Regular coaching includes what an employee does well and recommendations on what will allow them to reach the next level of performance.” Another asked, “If we equate a company department or division to an orchestra, how long would the conductor let bad musicians ruin the entire performance?

One comment gave a lot of food for thought: “Under-performers do not hurt their managers nearly as much as they hurt their peers, who daily must compensate for their failures and sometimes watch them reap rewards for inadequate work. Any organization of any real size can compensate for a few under-performers, mostly because their peers pick up their slack, usually with no recognition or reward. However, I have repeatedly observed that when left unchecked, these situations quickly tank morale and end with the departure of those who can afford to leave, usually with no statement of why they are leaving, because they don’t want trouble.”

I’ve seen that situation first hand, when more than half of a manager’s subordinates applied for transfers over a 12-month period. The underlying issue was his inability to deal with two members of the team who were not performing. They were perceived as favorites and the others were afraid to speak out, so they left. I’ve also seen the dark side of ignoring poor performance, when the team members who were tired of picking up the slack went on the offensive. They ultimately took down not only the underperformers, but also the manager.

Every workplace is different. Although some management strategies involve clear expectations and performance goals, others can be quite murky. There may be hidden (or blatantly advertised) agendas and infighting. In other words, the beach may be lovely… but watch out for the wildlife.

How does your organization find the right balance between praise and correction? What did you think about the WSJ article? Email me.

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February 16, 2015 Dr. Jayne 1 Comment

EPtalk by Dr. Jayne 2/12/15

February 12, 2015 Dr. Jayne No Comments

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AMIA announces its Third Annual Student Design Challenge. Teams of graduate students are invited to submit “novel and original ways to facilitate engagement between humans and computing data-analytic systems.” Eight finalists will be invited to present posters at the AMIA Annual Symposium, with the top four teams delivering formal presentations. Proposals are due by June 1.

My wish list of things that would immediately better my own human-computer interaction: high-quality real-time voice recognition that could immediately map to discrete data fields in my EHR to facilitate interoperability and E&M coding support; a reporting platform that would let me do clinical queries based on concept associations rather than painstaking identification of specific data fields; and ways to manage constantly-changing clinical recommendations that don’t require a fleet of IT staffers.

This week has been a whirlwind. We’re delivering the first burst of training for ICD-10. Our corporate decision-makers wanted to maximize physician time out of the office, so they have bundled education on readmissions, length of stay, and preventable harms together as well. Although it may have saved providers from making multiple trips to the hospital for training, I’m pretty sure most of their brains stopped absorbing about 45 minutes into the session. Our team was batting cleanup with the ICD-10 content, so we’ll be planning repeat sessions both online and in-person.

I’ve also been busy preparing a lecture for Grand Rounds. It used to be that Grand Rounds was about presenting interesting clinical cases or new advances in treating diseases, but now we spend a lot of time talking about Meaningful Use and other regulatory concerns. I’ve been tapped to talk about the Security Risk Assessment needed for successful Meaningful Use attestation. It’s probably a reasonable topic since it’s been part of the HIPAA requirements for nearly a decade, yet many physicians act as if they haven’t heard of it.

Not only can providers be asked to pay back incentive money, but they can risk other penalties from the Office for Civil Rights. It’s a complex topic because it’s not once-and-done like “implement a certified EHR” or “turn on drug/allergy checking.” It requires physicians to create the assessment and maintain it as a living document, reassessing risk as they purchase new technology or change their information strategies. Given all the recent breaches, I’d think there would be more interest in security and risk. I’m looking forward to it since I do enjoy helping community providers learn how to navigate some of the thorny issues that employed physicians don’t necessarily have to deal with.

There are a lot of free resources available to providers and they’ll be taking home a tool kit to keep them headed in the right direction, whether they decide to try to perform the risk analysis on their own or hire an outside professional to complete it. I’ll also ask them to suggest topics for the next “administrative” Grand Rounds. Reading the comments and suggestions on their evaluation forms is usually good for a laugh or two.

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The New Year always brings new vendor contracts. In addition to a new benefits manager for our flexible spending accounts, we also have a new purchasing agreement for office supplies. My assistant ran across this informational popup today. I’m going to have to seriously indulge my office supply habit if I’m going to hit that minimum.

Are you hoping your Valentine brings you a fragrant bouquet of Mr. Sketch markers? Email me.

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February 12, 2015 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 2/9/15

February 9, 2015 Dr. Jayne 1 Comment

One of the most fun things about being part of the HIStalk team is the ability to interact with readers. I asked last week if the “Fireside Chat” at the ONC annual meeting (with former Senate Majority Leaders Tom Daschle and Bill Frist) actually had a fire. A reader quickly replied with his summary: “Well attended, interesting, some controversy, but an informative and enjoyable event.” But alas, no fire.

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Another reader sent this sweet little bit of shoe love. It arrived in the middle of a crazy, crazy week and I enjoyed the smile it put on my face. I probably would have enjoyed the smile a little better if I hadn’t been caught multitasking in a meeting, when my grin made it clear I wasn’t paying attention to the ridiculous discussion around patient satisfaction scores that was going on at the time. I bet if we gave patients one of these treats at checkout, we’d get better scores. I’m not being flippant, but it’s at least as good as some of the plans I heard thrown out by the 24-year-old MBAs who seem to be running the place.

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From the practicing physician side, many of us are at a point in our careers where the daily grind of dealing with insurance, regulators, and government entities seems to outweigh the satisfaction we get from actually caring for patients. I was inspired to hear from a young IT consultant who answered my question about, “If you could be anything you wanted, what would you be?”

I asked myself this very question last fall and decided without a doubt that I wanted to be a doctor. I have a liberal arts degree, almost zero science background, and have never taken the MCAT but am in the process of applying to post-baccalaureate pre-medical programs. Seeing firsthand how people approach healthcare convinced me that this was something I needed to do. Thanks for contributing to a great site and being part of the industry driving me towards my dream.

I sent back some words of encouragement and hope he will stay in touch. I don’t think many would argue with the idea that being part of the healing professions is a calling. Given all the pressures associated with healthcare today, I think it may be even more so than it has been in the past. My medical school class had a large number of people without science degrees and I know many medical schools are looking for non-traditional students, so I wish him the best of luck.

Another reader who has worked his way up through the industry over a lengthy career offered some options for what he would do if he had the choice to do something different:

  • Start over. Go back to school and learn something new. Concentrate on helping people help themselves in this messed up world of healthcare.
  • Change. Do something you love and you won’t work a day in your life. So maybe cooking or entertaining. Thoughts of starting a coffee shop or something very new and very social come to mind.
  • Hang in there. Continue to fight the good fight and go down with the ship when the time comes – a comfortable option because I make good money and my schedule is mine (for the most part).
  • Give up. Find some way to make a bunch of money so I don’t have to think about a career. Suing a doctor over something has interest!

I hope he was kidding about the last item, but some of the others do resonate. Right now I’m leaning towards his third bullet – hanging in there. At times my work is crazy, but there’s something to be said about the devil you know vs. the alternative. Option #2 definitely resonates. We used to tease one of our residency colleagues about her hobby of raising goats until the organic movement really took off. Now her income in the niche dairy business allows her to volunteer at a free clinic, which has been greatly satisfying.

In the same vein, one reader would become a professional volunteer. “I do my share of volunteering and giving back, but I always think I could do so much more.” Watching my parents volunteer during their retirement has been great and I’m glad they remain healthy enough to do so. My favorite answer to the “what would you do” question is from a long-time reader. I had to change a few of his answers to protect his anonymity, but I hope you have as much fun reading them as I did:

I would continue to battle the politics and personalities of a non-profit health system. I would work tirelessly for days on end for the same amount of money I could make delivering for FedEx or tending bar. I would get dressed up so that I can sit in a poorly-lit work area in a chair that has celebrated its own retirement working on a computer that can only be classified as “retro” to anyone else familiar with technology.

I would learn the names of the faceless consultants who roam the halls with shined shoes, sharp ties, and opinions on everything. I would let individuals that have no stake in the community or organization play Russian Roulette with our financial and social futures. I would wake up and be the butt of every motivational poster. I would be the buzzword people are looking for. I would wake up and do mock Joint Commission audits every day because it is fun and everyone loves the villain. I would “operationalize” bad ideas more. Since that is the new word, I would need to be great at it, because the consultants said so.

Although he paints a bleak future, it’s a good reminder to some of us about why we went into this in the first place. If I wanted to make more money than the night team at Taco Bell did, I would have quit during residency. (Yes, I did the math, and it wasn’t pretty). If I wanted glamour and a windowed corner office, I would have gone to business school or law school. If I wanted shiny shoes and sharp ties, I could have gone into pharma. 

I chose healthcare, not for the saggy scrubs and rubberized clogs, but because I wanted to make things better. In the immortal words of Dr. Mark Greene, “Helping them is more important than how we feel.” Whether it’s a sick patient or an ailing hospital, I’m here to stay.

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February 9, 2015 Dr. Jayne 1 Comment

EPtalk by Dr. Jayne 2/5/15

February 5, 2015 Dr. Jayne No Comments

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Although our local groundhog said that spring was just around the corner, I’m not sure I believe it. The grey skies seem to match the mood of many of our hospital’s administrators, as they come up with long lists of IT-related projects to keep us busy even though we already have plenty to do.

Regardless of the CMS plans to shorten this year’s reporting period to 90 days, we now have a month’s worth of data and are heading out to our practices to remediate staff and reinforce workflows. It’s a good time to deliver training since business tends to be down in many practices during the first part of the year. With patients having not yet met their ever-increasing deductibles, they tend to be reluctant to come in unless absolutely needed.

I’ve been in touch with some friends in vendor circles, hearing about their plans for HIMSS and specifically what they are planning to help draw people into their booths. I’m not a fan of so-called booth babes (unless they are wearing amazing shoes and can also talk about the product they are representing) and “must be present to win” giveaways don’t do the trick either. One vendor promises a close encounter of the sensory kind, including both aromas and edibles. Knowing the team involved, I can’t way to see what they cook up.

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As I sat having dinner with someone wearing a watch that would have made Dick Tracy do a double take, I remembered that an intrepid reader had sent me an article about jewelry that camouflages  tech rather than showing it off. I’ve been keeping my eye on Ringly but hadn’t realized they raised more than $5 million last month. Although I’ve enjoyed my GPS watch and think it’s motivated me to be more active, I do wish Garmin offered something that didn’t scream “Runner!” and looked a little more businesslike.

One of the email digests I receive had a link to a fluff piece about the November round of ICD-10 testing. The American Academy of Professional Coders polled 2,000 participants, concluding that the results were positive with 90 percent reporting no payment shifts in test claims. I wasn’t able to get my hands on the full results, but some of the numbers cited looked a bit strange without current ICD-9 results for comparison. If anyone participated in testing, we’d love to hear about your experience. Additional testing is planned for April.

Speaking of ICD-10, we are planning to start training (again) at our hospital and outpatient offices within the next month. We had begun orienting providers prior to the delay and I have to admit there no longer seems to be any urgency about it. Some probably think it will be delayed again and others are just tired of the ongoing parade of regulatory changes. Our online sign-up sheets are remarkably empty, so we’ll have to start doing outreach to try to draw people in. Some specialties will face larger challenges than others and I’d rather not have a flurry of “emergency” training in September.

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ONC held its annual meeting this week in Washington DC. I’d be interested to hear impressions from attendees. In particular, was there actually a fire for the Fireside Chat with Former Senate Majority Leaders Tom Daschle and Bill Frist? Email me.

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February 5, 2015 Dr. Jayne No Comments

Curbside Consult with Dr. Jayne 2/2/15

February 2, 2015 Dr. Jayne 1 Comment

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Although I still haven’t answered the "should I stay or should I go" question regarding my day job, I did make a decision to leave the practice where I’m currently providing urgent care services. I haven’t resigned yet since there’s enough strangeness that I want to have my final paycheck in hand before I do.

I didn’t really pay attention to the calendar when I sent my available days for this month, so I’m spending Super Bowl Sunday seeing patients. So far, sinusitis is leading otitis media 13 to 2 going into halftime, where we expect a rousing performance by indie rock band Motor Vehicle Accident.

I’m certainly not a job hopper. Prior to this job, I had been with the same emergency and urgent care staffing company for nearly six years. They had a huge portfolio of customers, which allowed me to experience quite a few different care settings and a variety of different inpatient and outpatient EHR systems, health information exchanges, and more. 

Last year, they lost their contracts with most of the facilities in my area when another staffing company underbid them. I’m not sure the facilities were aware that all the part-time and as-needed physician providers were going to be replaced with non-physicians, but they should have seen it coming based on the pricing model. Along with more than a dozen other part-timers, I was let go.

I didn’t see patients for a couple of months while I evaluated my options. Eventually I received a call from a recruiter which led me to this opportunity — an independently-owned urgent care with two locations. The facilities are recently renovated, the drive was reasonable, and the pay was in my range, so I gave it a shot.

The only downside was their lack of EHR. For some, that might be a bonus — the learning curve for charting is certainly very small. But for someone who is used to the safety features of an EHR (allergy and interaction checking, pediatric dosage calculation, etc.) it was a little rough. I dabbled with a freestanding eRx system for a while, but the dual data entry was a bear.

My employer is certainly nice enough, but he’s suffering from the same things that are impacting most small practices. They don’t run themselves. Without a dedicated physician leader or a hands-on management style, it’s easy to start a death spiral with staff unhappiness, turnover, patient unhappiness, and ultimately physician unhappiness. All of these conditions contribute to a negative impact on the bottom line, as does his obsession with the salt water aquarium in the waiting room.

He tends to manage from afar, yet micromanages at times. Policies and procedures are lacking, but he shows up unpredictably and criticizes how work is being done. Poor performance is not addressed and high performers are not rewarded. The staff is relatively young, and without consistent leadership or supervision, they tend to fall into the behaviors that college-age people do. Smartphone use is rampant, which not only hampers productivity, but leads to some interesting conversations that patients overhear. Staff regularly shows up either at the exact time the office is supposed to open or even after and management doesn’t seem willing to address it for fear of losing people.

Although I can put up with a fair amount of chaos, I recently figured out that there were some significant irregularities in my onboarding. Apparently I’m not fully credentialed with most payers (not even Medicare / Medicaid), which is surprising for the length of time I’ve been here. That’s a red flag right there. The next red flag was when he emailed me to let me know there was an error on my 1099 tax form and I’d have to handle it on my own. Running a practice, or any small business for that matter, is not for the faint of heart or those without education, experience, or solid advisors.

Before making the decision to leave, I put myself in his shoes and considered whether there was anything he could offer to make me stay. He’s not going to run out and implement an EHR tomorrow, so the patient safety issue remains. It’s also an efficiency issue (although a bad EHR would certainly be worse than handwriting on pre-printed paper templates). Then there’s the clinical quality issue. I have no way of sending copies of our notes to primary care physicians unless I personally fax them since there is no system in place unless there is a specific request for release of information. The primary care practices in the area have yet to embrace the patient-centered medical home model. Few of them are open outside the hours of 9 a.m. and 4 p.m. and I can’t name any that have evening or weekend hours, so we’re essentially the safety net. We don’t have access to the local HIE or the state immunization registry, so we’re actively contributing to the fragmentation of care.

I don’t see him hiring a strong office lead or spending more time at the practice himself, so the staff will continue to be relatively undisciplined. The owner isn’t clinical and there’s not a named medical director, so I don’t see any expansion of policies or procedure that could help bring things into line. Strangely enough, he’s opening a third location in a fairly dangerous part of town without commitment by providers or staff that they’re willing to work there. I’m sure that will further dilute his ability to manage the practice effectively and might make staff turnover even more of an issue than it already is.

Although I don’t see him embracing new technology like the HIE or immunization registry web portals, I also don’t see him abandoning some of the problematic technology we already have. The computer-assisted coding system is a concern since it codes the visits after documentation is complete and providers don’t have a chance to confirm or correct the E&M codes before they’re released to the practice management system. Although most of my coding has been consistent with what I would have manually coded, it’s just another red flag.

On one hand I feel bad leaving because the patients are genuinely appreciative and certainly need physicians who understand their needs. But on the other hand, knowing what’s at stake from a regulatory standpoint and that I could wind up personally liable for any creative coding or billing that is occurring, I can’t afford to stay. 

I’ve got a new clinical endeavor lined up, one where they’ll ensure I’m fully credentialed before I see patients and where an EHR is already in place. They’re using a system I’ve never worked with, so I am looking forward to the new challenge. If nothing else, learning a brand new system will surely make for some good stories.

What makes a new employee run shrieking? Email me.

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February 2, 2015 Dr. Jayne 1 Comment

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