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Curbside Consult with Dr. Jayne 10/26/15

October 26, 2015 Dr. Jayne 1 Comment


With the goal of expanding the number of meetings and conferences we report on, Mr. H is sending me to the AMIA Annual Symposium this year. I’ll be reporting on the activities each day. I’m looking forward to it as I haven’t attended previously. I’m also eager to log some hours towards Maintenance of Certification (MOC) for my Clinical Informatics board certification.

I’m not the only one looking forward to getting the continuing education credits. The AMIA listserv for the Clinical Informatics Community of Practice (CICOP) has been hopping with quite a few complaints about the whole MOC process for those of us in this new specialty. With the first cohort passing their exams in the fall of 2013, we’re decently into the first part of our 10-year recertification cycle. Those of us certified through the American Board of Preventive Medicine (the American Board of Pathology also certifies) are required to obtain a certain number of ABPM Lifelong Learning and Self-Assessment (LLSA) hours every three years in addition to regular continuing education hours.

Most of the current LLSA-approved continuing education offerings are within ABPM’s longer-standing subspecialties such as Aerospace Medicine, Occupational Medicine, General Preventive Medicine, and Undersea/Hyperbaric Medicine. The number of courses for clinical informatics are few and far between and typically involve on-site courses. AMIA has completed the process to offer LLSA hours for the fall meeting, and for those of us unable to get hours over the previous two years, it’s a huge help.

When I initially decided to try to become part of the first class of board certified clinical informaticists, I really didn’t think about what it would be like to maintain certification with two different board organizations. The American Board of Family Medicine already requires me to do 150 hours of CME each year, of which a certain percentage has to meet specified criteria. Certification by the AMA or the American Academy of Family Physicians are two of the criteria that count. Finding AMA- or AAFP-approved CME is easy. It’s everywhere, and can be earned not only through face-to-face symposia but also by reading journal articles and taking CME quizzes or doing online coursework.

We’re one of the first specialties that required Maintenance of Certification. Although the policies are a little tedious, they’re well documented and pretty straightforward. With Clinical Informatics being relatively new (coupled with the fact that many of us in the first two certification cohorts are, shall we say, fairly Type-A personalities) there’s a lot of tension around MOC. In addition to the LLSA credit, we’re also supposed to complete a “patient safety module” which is somewhat ill-defined (although ABPM did offer a link to a discounted course from the National Patient Safety Foundation that they’ll accept). A friend of mine got his university course approved as well, but the rest of us may not have that option.

I’m grateful that the Board has agreed to recognize some of the MOC (called Part IV) activities that physicians are already performing for their primary board certification. The current Clinical Informatics subspecialty certification requires physicians to maintain full certification in another American Board of Medical Specialties sanctioned discipline so it seems only fair, especially considering that the Board has yet to come out with a recognized clinical informatics module. I have to admit that the process to have my Family Medicine credits recognized was fairly straightforward, although it did require printing and completing a paper form and emailing it to the Board.

One of the respondents on the AMIA email thread mentioned that as a specialty deeply involved in computer-based projects, we should be at the forefront for virtual and online courses. Unfortunately one of the major challenges is completing the paperwork from the board to have your course recognized, which I hear is not exactly straightforward. I don’t know if there are fees involved with submitting a course offering, but that could be a de-motivator for some providers of continuing education credit.

There aren’t any well-known online providers for the kind of credit we need. Although some of our colleagues in academic settings are going to try to get their local courses certified, that doesn’t help those of us who are in parts of the country where we’re thinly populated. I’m one of two certified informaticists in my metropolitan area of over three million people, and I’m sure there are others even more sparsely arranged than we are.

One of the AMIA representatives mentioned being in contact with the Board and that we’re going to get an extension on some of the initial deadlines, but as a diplomate of the Board, I haven’t received that communication directly from them nor has it been posted on their website or in any other print media that I’m aware of. It’s understandably frustrating then for those of us who don’t want to fall behind but are somewhat stuck about what we need to do to be successful.

We’ll gather at AMIA, though, and see what kind of credits we can rack up and whether they’ll be enough to get us through the first checkpoint at the end of Year Three of our certifications. Hopefully some virtual offerings will be approved soon, or at least some recordings for those of us who aren’t willing or able to spend several thousand dollars (not to mention the time out of practice) to attend a conference in person.

It’s exhilarating to be on the cutting edge of things, but like being in the health information technology industry, it can also be frustrating and at times downright exhausting. I’m hoping that attending AMIA and networking with others in the field will help recharge some of my depleted energy and give me ideas for future projects. If nothing else it’s an excuse to visit San Francisco, which I’ve never done in the fall.

Will I see you at AMIA? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/22/15

October 22, 2015 Dr. Jayne 3 Comments

This week is one of those “you can’t make this stuff up” kind of weeks. It’s been filled with plenty of hard work, a fair amount of organizational dysfunction, and some pretty cliché observations.

Despite the challenges, I’m working with some genuinely nice people who seem to want to be successful and that makes all the difference. I’d rather work with people who know they have issues and want to try to be better than with people that think that everything is just fine when it’s not.

The practice I’m working with provides a fair amount of cash-based services (mostly cosmetic) and we dealt with some complaints about the lack of support for those workflows by their EHR vendor. It’s been interesting trying to explain why vendors have been spending all their time and energy on MU-related features and functions when the providers don’t care about being meaningfully used.

We did get some quick documentation templates done for a couple of their most common procedures, so that was a big win. One of the partners was so happy with the new workflow that he offered to give me some complimentary services. I wasn’t sure whether I should be excited about that or offended that he obviously thinks I need some work.

The physicians also have traditional primary care patient panels, but it feels more like a sideline rather than their focus. They’re trying to get in step with current primary care trends, but it’s a hard sell when you can make more money smoothing wrinkles, lightening dark spots, and making irksome leg veins go away.

Since they’re in a building on the hospital campus, several of the physicians hit the physician lounge for lunch every day even though they don’t admit their own patients. They’ve been taking me with them and it’s been enlightening to see what some of their peers think about the state of healthcare IT since I haven’t done much work in this part of the country.

I almost spit my sweet tea across the table when one physician said that since he was going to switch EHR vendors in the spring, he was going to go ahead and apply for a MU hardship exemption. He’s got connectivity issues with his current “lousy” system and has decided to just stop charting electronically. I’m not sure that qualifies as an extreme and/or uncontrollable circumstance, but he’s welcome to try. The vendor in question has tens of thousands of physicians who have successfully attested, so it’s an interesting position to take.

The practice is one of the first I’ve been in recently that still has pharmaceutical representatives call on the physicians. Most of the reps I’ve encountered over the years are hard-working and spend a lot of time dealing with cranky physicians as they haul samples from their company cars (used to be a lot of Ford Taurus-equivalent sedans, but now I’m seeing a fair number of minivans). The highlight of the week was the sales rep that pulled up in a new Maserati that cost more than my first house. He turned out to be EHR vendor’s regional sales exec. I guess he’s not hurting for business.

While I was fielding agenda changes from the client (who apparently thought of 20 other projects for me to work on during the time I was en route), I got a couple of emails from family members. My grandfather had a bone marrow biopsy last week and was told the results would be available in eight days. He dutifully called the office at the end of the eighth day after hearing nothing, only to be told that the physician would be out of town until October 29 and no one else in the office could give him results.

He sent his primary care doc a message through his patient portal trying to get the results, but was asking me for advice (as were his wife and my aunt). I thought it would be better to try to get in touch with the hematologist’s partners, who would presumably have access to his chart and would know what question the bone marrow biopsy was to answer or what condition was to be confirmed or ruled out. Even if he could see the results in the hospital system, I didn’t think this particular primary care physician would be likely to give them since he wasn’t the ordering physician.

I suggested that they call the hematologist’s office again and ask what the physician’s coverage arrangements are while he is out of town, and if they were told there aren’t any, that they mention the words “patient abandonment” and see what happens. This isn’t a question of a patient misunderstanding how he was to get the results – his discharge instructions clearly said to call for results in eight days. As a physician, I’m horrified at this kind of a process failure and the stress and worry it’s causing the patient and his entire family.

A couple of hours, later the PCP responded, basically saying he doesn’t know much about interpreting bone marrow results but that it “doesn’t look that bad.” That’s not exactly a vote of confidence for a worried patient. I saw the screenshot of the secure message and he definitely could benefit from a little coaching on how he explains things to patients. We’re still waiting to hear back from the hematologist’s office, who said their office manager would be calling to explain the cross coverage arrangements. Like I said, you can’t make this stuff up.

Turning my attention back to the client’s workflow issues, we identified several more commonly-seen conditions where the EHR didn’t fully meet their needs. I headed back to the hotel to get some additional custom templates built before selecting my next dining adventure. Several readers have commented or emailed about their BBQ preferences. The Carolinas are leading Texas two to one and I’ve received some suggestions I can’t wait to try. Tomorrow I’m finishing the day with a tour of the local Bass Pro, which promises to be something to behold.

Where do you get your local color? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/20/15

October 20, 2015 Dr. Jayne 2 Comments


I wrote last week about interoperability, mentioning that attempting to connect through Direct has added confusion for providers like me who have multiple practice situations or multiple locations. A reader commented, “vs. how many fax numbers to create an out-of-paper trail with?”

That’s a very good question. It points to a larger problem with EHRs – one that most if not all providers complain about – which is the shifting of work from staff to providers.

Sometimes this is in the name of efficiency. Why have the patient wait for the referral to be entered when the provider can just do it at the point of care? Why have the provider have to tell a staffer when he or she can do it real time?

In many cases, this is a misguided attempt at efficiency. Although we can reduce the number of steps in a process, that’s not everything we look at when we map workflows. We also need to look at the cost of various people doing various tasks. It often doesn’t make sense for providers to do certain steps that EHR workflows are trying to force them to do.

Other times this is in the name of patient safety. In its purest form, this makes sense. Having providers enter medication and laboratory and diagnostic orders can prevent transcription errors and allow them to acknowledge warnings and alerts. It’s a good use of some of the most expensive employee hours in the office. Unfortunately, that thinking has driven a lot of work upstream that organizations haven’t yet redistributed to where it is most appropriate.

In the paper world, my referral process involved a single page flow sheet where I marked what to send in the referral bundle and who to send it to, along with a diagnosis. My medical assistant knew the short list of common referrals and where to send the packet. They managed that list of fax numbers and locations, not me. They knew whether to send the packet to the West Office for a Thursday appointment or to the South Office for anything else.

Now that the referral workflow has been embedded into the provider workflow in my EHR, I’m supposed to manage those facts while I’m sitting in the room with the patient, because they system wants me to complete it before I move on.

Of course, I could simply send an electronic task to my staff and ask them to do it, but that takes me out of my standard workflow as well. Don’t get me wrong, I’m excited about the ability to exchange secure messages with consultants and colleagues and have a copy added to the chart automatically, preventing phone tag and manual note-writing. But if it’s too complicated to find my key providers, I’m going to struggle.

Two of the three systems I use on a regular basis have no way for the physician user to create their own address book or contacts list outside of the practice. One has a robust partial search where I can search a metropolitan area for a given physician. The other requires me to know the specific postal city associated with my target’s ZIP code. Honestly, I need to just search for Dr. X who is a cardiologist in the Chicago area. I have no idea whether they’re in Oak Park or Oak Brook and neither does my patient.

These are usability issues as well as workflow issues. I can’t help but think that if vendors did more trialing of product with real-world physicians they would be better able to identify these things up front. We know from recent publications that vendors vary widely in how they perform usability testing (if at all) and how valid the results might be.

I’ve been on some usability focus groups as a participant and it’s hard to manage bias and dominant behavior by some members. I’ve also supported usability testing for vendors and know that it’s hard to find knowledgeable participants who are willing to take time out of their busy schedules to participate in a usability study unless you throw ridiculous amounts of money at them. Even then the output varies widely.

There are also physician psychology issues at play when work gets redistributed. Physicians realize how lean their offices run and can be reluctant to shift work to staff members that are struggling to get out of the office on time to pick up their children or tend to other obligations. Employers may be unwilling to pay overtime or to approve the hours needed to actually do the work, so someone has to take care of it and often that is the provider. There is also a perception that it’s quicker to just do the work yourself rather than ask someone else to do it. Couple this with a lack of time and energy to do the actual process improvement work needed to fix the underlying workflow issues and it’s a recipe for dissatisfaction all around.

I’m working with a practice this week that has engaged me to do some workflow re-engineering, so this is in the center of my thoughts. I’ve worked with them before and the issues are complex. They only took about 20 percent of my advice last time, and although they initially made progress, ICD-10 and two software upgrades have caused some chaos.

They’re one of the last independent practices in their community and does a mix of traditional primary care and somewhat fringe (read: cash only) services. The owner doesn’t really have a head for where primary care has been going in the last few years and I’m not sure he’s committed to doing what needs to be done to be successful. Frankly they’d be better off transitioning to a retainer or concierge-type practice, but they don’t want to do that either.

It’s shaping up to be an interesting week and I can guarantee no boredom or downtime as I dig in with these folks. Not to mention they’re in one of the best cities in the US for barbecue, so I have nothing to complain about for dining choices this week.

What’s your favorite BBQ locale? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/15/15

October 15, 2015 Dr. Jayne 2 Comments

Both the American Hospital Association and the American Academy of Family Physicians have publicly weighed in on ONC’s revised Interoperability Roadmap. Both organizations believe it doesn’t go far enough or fast enough.

Although quite a few stakeholders accuse the EHR vendors of being the villains with regards to data blocking, my personal experience has been that health systems and hospital-controlled physician networks are really behind it. Not to mention that ACOs naturally create barriers to interoperability as they encourage physicians to keep patients within a well-defined (often narrowly so) network.

I had the adventure of standing up a private HIE seven or eight years ago. The sponsoring health system’s express purpose was to share data only within our referral network. Providers affiliated with other hospitals were not invited to join.

At least in my metropolitan area, I haven’t seen that philosophy change across the years. While the AAFP calls for “increased accountability on industry and decreased accountability on those who are using their inadequate products,” I think we need to focus the microscope on some of the other interested parties.

Let’s hold health systems accountable. When their vendors provide interoperable products, they need to be using them in an interoperable fashion. They need to force their owned hospitals and employed physicians to accept and integrate electronic health data brought by patients. And they need to release the data electronically when patients request it. Mr. H’s story of his inability to get his records electronically is just one of thousands out there.

Let’s also bring the non-provider technology stakeholders into the business of being regulated in the same way that providers and hospitals are. For example, reference laboratories. The fact that there are still numerous laboratories who cannot (or will not) send LOINC codes with their results is appalling.

Let’s also start regulating the pharmacies, getting their information systems under control. One of my local pharmacies sends scads of duplicate prescription refill requests all the time. This leads our practice to have to spend time determining if they’re really duplicates or not. When we call the pharmacy to complain, we’re told that it happens due to limitations in their computer systems and the inability to match refill responses to the original requests in an accurate manner.

Since all patients and physicians depend on pharmacies and labs, why shouldn’t this be part of the solution? What about standardizing all the other systems we have to interact with, such as home health systems and those used by nursing homes and other extended care facilities? Many patients that we used to hospitalize for care are instead receiving services through home health agencies. It doesn’t do me much good to interoperate with the hospital if the patients aren’t in it.

I started reading the Roadmap essentially to have a break from reading the Meaningful Use final rules. I’ve been jumping around in it rather than reading it through, however. I was pleased that they called out “Authentication and Identity Proofing” early in the paper (page 11 if you’re interested). They admit that lack of standard approaches has hampered information sharing. They mention that Direct was intended to “work much like email and lower the barrier to exchange for providers and hospitals.”

In my market, however, Direct has added all kinds of confusion, especially for providers like me who have multiple practice situations. I have different addresses for the different urgent care groups I work with on different EHR platforms. If a PCP is looking for me to send a follow-up, how do they know where to send it? Other health organizations have created additional complexity. One organization created separate addresses for each location for each provider, so a cardiologist who sees patients at six physical locations has six addresses. Although I understand their original reasoning for doing it, it’s untenable in reality.

Page 36 addresses individual data matching. They point out that although HIPAA required creation of national identifiers for patients in 1996 and Congress blocked appropriations, there is no prohibition against private or non-HHS governmental agencies creating their own. They note that the Department of Veterans Affairs and the Department of Defense assign unique identifiers for service members. Although I understand the arguments against it, I’d volunteer to test drive a national ID myself even if it’s private and voluntary.

I’ve had too many bad experiences with using existing primary data elements (name, DOB, sex, phone number), both personally and professionally. Even existing non-healthcare governmental systems don’t always handle the data in the same manner.

Here’s an example. Due to my southern roots, my actual legal name has a compound first name. My legal middle name is actually a family name, which looks like a last name to most people. Then I have my actual last name. Let’s work with “Peggy Sue Herrington Mitchell” as our example. My original birth certificate was completed on a typewriter, with “Sue” landing squarely on the line between the caption for “first” and “middle” names.

When I was in medical school, I had to get a certified copy of my birth certificate to prove identity for licensure. My birth county had computerized, and the person keying the data had made “Peggy” my first name and “Sue Herrington” as my middle name. It also truncated the “Herrington” by a few letters since there weren’t enough characters in the middle name field. With the layout and truncation issues, the computerized copy didn’t match my college transcript or my medical school transcript or my passport, which had my legal name listed correctly. The authorities refused to accept my identity proofing. I had to petition the county to pull a microfiche copy of the original and certify it.

When I complained about the truncation issue as the reason for needing the original, they said that they were limited by their systems. I pointed out that it was good that George Herbert Walker Bush wasn’t born in my county because his middle names wouldn’t have fit either. The county clerk didn’t find that amusing.

Fast forward a number of years to last year when I applied for TSA PreCheck status. Guess what? TSA in 2014 had surprising character issues. I was told that if I wanted to continue through the application process, I needed to formally shift Sue into my middle name or they couldn’t process my application since “space” was considered a special character and wasn’t allowable in the first name field and they couldn’t run PeggySue all together because it wouldn’t match my passport. This meant changing my name on all my frequent flyer profiles.

Additionally I’ve had hundreds of issues with patient matching during system migrations and data cleanups, not to mention the HIE project. How many people with either longer names or those that are more complex than mine will look like different people depending on how the data was entered? Of course there will be other matching criteria, but it’s going to take a lot of work to meet their stated goals of reducing system duplicate record rates from 2 percent in 2017 to 0.5 percent in 2020 and 0.01 percent in 2024. It should be interesting to see where already strapped (or cheap, as the case may be) organizations find the resources to get it all done.

I still have more to read, but at least it’s more interesting than MU rules. What’s your take on the Interoperability Roadmap? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/12/15

October 12, 2015 Dr. Jayne No Comments


All’s still relatively quiet on the ICD-10 front, so I’m catching up on other projects that have been pushed to the side during the transition. Most of my clients are seeing some sporadic claims issues, but nothing that is going to cause a major cash flow disruption. As long as practices have processes in place to monitor the revenue cycle and take action as soon as they see patterns forming, they should be fine, although it will take a good month to see how things are really working.

Some practices still haven’t sent a large volume of claims. I continue to be surprised when I see practices that don’t bill every night or don’t have requirements for their providers to complete charts in a timely manner. I don’t have a lot of visibility into how ICD-10 is going on the hospital space, so I look forward to hearing from readers.

I’m working on a lab project for a client. It’s the kind of project I enjoy – extremely detail-oriented, beneficial to end users and patients, but something that practices don’t seem to have time to deal with. Essentially it’s an analysis of their lab ordering patterns with an eye towards redoing their primary ordering screen and some order sets. The practice set up their orders when they went live on EHR in 2010 and haven’t touched it since. A lot has changed in the last five years. They’ve added vendors. Vendors have changed test codes. The community standard of care has changed. Professional organization recommendations have changed.

I’ve pulled all their ordering data and can manipulate it by provider, specialty, location, and time. Right now I’m working on the tedious (yet oddly satisfying) task of updating the vendor order codes to make sure they’re all correct. Luckily they’re using two national reference labs that were happy to provide me digital versions of their orders master. Unluckily, they’re also using a hospital lab where all the knowledgeable lab staff seem to be out of the office on an ongoing basis. They won’t give me their order master (citing “intellectual property”), so I’m at a bit of a disadvantage. I’m not sure how having a copy of the orders master is going to cause them harm since they have an online directory for providers to reference.

Their level of cooperation may also explain why the practice sends such a small portion of its business to the hospital lab. If their day-to-day service is anything like what I’ve experienced, I’d steer clear. One would think it was in their best interest to assist customers in cleaning up their orders, because every time they receive an invalid one, they have to call the office for a clarification. But I guess it’s like everything else with being short staffed. Additionally, I’m sure it didn’t occur to them to plan for the eventuality that if all their customers go to EHR, eventually they’re all going to have to update their orders masters. Interoperability seems like a great idea until you realize you don’t have the resources to support it.

Keeping vendor codes in sync can be a full-time job. Some of the national reference labs change codes as often as weekly. Some are better than others at telling you what codes have been retired or replaced. Others leave you guessing somewhat. I’m seeing some challenges, though, with the various vendors coming up with proprietary tests which can make it hard on the end users. Say a user wants to order a serum porcelain level (a common med school/residency joke). In many cases, the physician doesn’t care whether the test is run via liquid chromatography or liquid chromatography and mass spectrometry – they just want the value. For a large number of tests, the methodology doesn’t make that much of a difference.

Of course there are tests where it makes a tremendous difference and I would expect to see the methodology specified in the name of the test to make it clear. Labs, however, seem to be trademarking various methodologies – perhaps one calls it “PorcelainPure” and the other calls it “TruPorcelain.” It’s impossible for the end user to figure out what they’re ordering without going to websites and comparing. This becomes more of an issue when patients are switching insurance or employers (and therefore lab providers) and end up having serial tests done at different facilities. It’s also a problem when the tests really are equivalent but the labs have trademarked them as a marketing strategy. It’s getting to the point where we almost need generic and branded labs like we have for drugs. I’ve seen it become more complex even over the last two to three years, so I can’t imagine what the next decade will bring.

Once I get all the codes up to speed, I’ll provide them with a program to help keep the codes up to date. Usually I suggest monthly, but a lot of organizations aren’t staffed to keep up with that. They may elect to do it quarterly or twice a year. I stress that it should at least be done every six months or more often if the lab provides clear information on the nature of changes to its orders master. After that, I’ll start reviewing the data based on ordering patterns and we’ll really start doing some clinical transformation.

In midsize practices, it’s interesting to see how different providers order even when they share a specialty. I see a lot of variation in ordering of metabolic test panels. Some habitually order more comprehensive panels whether they’re indicated or not. There is also a lot of variation in cholesterol testing and pap testing. These are conditions where the indications are well identified in national recommendations and guidelines, so you can imagine what it looks like when we analyze ordering on less-common conditions and diagnostic workups.

There can be emotional minefields associated with analyzing ordering patterns. What do you do with your senior partner who is ordering tests based on outdated recommendations? Many groups are unwilling to deal with those kinds of issues head-on, so I end up creating educational programs where everyone in the group gets re-educated as to the current standard of care. Although it’s good to make sure everyone is following guidelines, it’s a tremendous waste of resources when everyone else is already in line and you could just deal with an individual directly.

There are a lot of people out there who never want to ruffle anyone’s feathers, which makes it easy to see why they’re having challenges delivering the kind of care they want to deliver and that patients expect. As the old saying goes, sometimes you have to break some eggs to make an omelet.

Once we analyze the ordering patterns, I’ll make suggestions on updates to the main orders screen and the order sets. We want to get the most commonly ordered tests in prime position for ease and speed of selection. There’s an art to it, though, because if you make too dramatic of changes, it can cause issues with muscle memory and the staff getting back up to speed.

We also have to figure out the timing and how we’ll train users, etc. There’s a lot more to it than just updating templates, and often my role is to help an IT team understand that. We need to give the users time to practice so they’re not hunting around when they’re patient-facing.

I’ll be working on this for a while, so I’m interested to hear how readers approach similar projects. Do you like your eggs over easy or sunny side up? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/8/15

October 8, 2015 Dr. Jayne 1 Comment


It’s funny how you look at things differently when you’re a physician or healthcare provider. I’m always noticing automated external defibrillators (AEDs) when I’m in public places, especially now that they’re nearly everywhere. Most places have them prominently displayed with clear signage and the cases are either red or bright yellow so they’re easily seen. When I was recently on Capitol Hill, however, I noticed that the AED of Congress sits in a nondescript pedestal in a subdued black case. No matter where your politics lie, it’s somewhat ironic that Congress operates in a different world than what most of us know.

Since the Meaningful Use rules were published earlier this week, hundreds of health IT people were spending thousands of hours poring over them. Several of my colleagues lamented that it was a huge waste of time since there’s a high likelihood that Congress will create legislation to delay the start of Stage 3 beyond 2018. Without my crystal ball, though, to know if that will be true and when it will happen, I had to dig into all 1,300+ pages of goodness like everyone else. You know you’re an informatics geek when you’re joining your informatics friends in tweeting photos of the cocktails you’re drinking while you’re simultaneously reading federal regulations.

After a while, they became mind-numbing and I just had to quit and go to bed. When I woke up, I unfortunately did not discover that MU had all been a dream. I did discover invites to some CMS webinars, though, which helped provide an excuse to procrastinate the reading until I could listen to the highlight reel.

I tried to register for the webinar, but kept getting a Windows Live Meeting error. It finally registered me after trying multiple times over the next several hours. I started working some issues with my clients and discovered that one of them only sent out 70 claims for the first two days on ICD-10. Although they didn’t experience any unusual rejections, that’s a fraction of the number of claims that should have gone out with the average physician seeing 30 patients per day and this being an organization with more than 100 physicians.

My client is the IT department. They engaged me to figure out what’s going on. After entirely too many phone calls, we determined that apparently the operations team decided to switch to a system where 100 percent of patient visits receive review by a certified coder. Unfortunately, they didn’t let anyone on the IT side know, so IT has been chasing their tails trying to figure out what is going on.

Although 100 percent review certainly reduces your risk of miscoded claims, it’s not realistic in most organizations. I think these folks just gave themselves a self-inflicted cash flow problem. I gave the IT department some advice on how to quickly transition from 100 percent review to representative sampling, but I’m not sure they’re going to be able to get the operations management to listen.

Fast forward to Thursday, when I attended the CMS Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs Final Rule Overview webinar. I’m curious about the inclusion of an additional 60-day public comment period. Although HHS is “committed to working with stakeholders,” what are they really going to do with the information? The comment period is limited to Stage 3, so it sounds like they’re leaving the door open for further changes even if Congress doesn’t act.

Webinar pro tips from a seasoned trainer: when you do introductions, put up a slide that lists the name and credentials of the person speaking. The first speaker was introduced so quickly I barely caught her name. The entire time we were looking at the title slide for Elizabeth Holland, who was the second speaker. Her title, however, was not listed. Although many people know “everyone” in the MU community, not everyone knows exactly who you are and why you’re speaking. She did apologize for the overloaded webinar and that people that were turned away – it should have been something they could have anticipated based on the issues with the registration.

Due to the vastness of the 752-page rule, the webinar largely focused on modifications to Stage 2 and in particular what we need to know for 2015. Attendees were encouraged to read the entire document to find responses to their questions.

The highlight reel for MU Stage 2:

  • No flexibility in using CEHRT certified to previous edition criteria. Providers must use 2014 Edition CEHRT in 2015 and subsequent years until they transition to 2015 Edition CEHRT, which is required for reporting in 2018.
  • Much emphasis on aligning 2015-2017 Modified Stage 2 measures to Stage 3, which will be required for everyone in 2018.
  • Alternate measures and exclusions remain largely unchanged from the proposed rule. These help providers who planned to attest for Stage 1 or Stage 2 to be able to meet Modified Stage 2. These were essential since the rule was released later than anticipated. They’re fairly detailed and were addressed as each measure was covered. I got lost in the details on a couple of them, so I’ll do like the presenter and refer you to the Final Rule for details.
  • CPOE landed at 60 percent for medications, 30 percent for labs, and 30 percent for radiology.
  • Hospitals are at 10 percent of discharge meds meeting the same criteria.
  • Transition of care requires use of the CEHRT to create a summary of care record; more than 10 percent of transitions of care and referrals must be transmitted electronically.
  • Patient education is 10 percent for EP unique patients seen during the reporting period and also 10 percent for EH patients admitted to the inpatient or ED places of service.
  • Medication reconciliation remains at 50 percent of transitions of care to the EP or EH/CAH.
  • Patient electronic access threshold is 50 percent to receive access within four days for unique patients seen during the reporting period. For 2015-15, only one patient seen during the reporting period must view, download, or transmit. This goes up to 5 percent in 2017. Hospitals must provide access within 36 hours of discharge for more than 50 percent of patients. The VDT thresholds are the same.
  • Secure messaging has to be enabled for the reporting period in 2015 on a yes/no basis. For 2016, at least one patient must engage in secure messaging. For 2017, this goes up to 5 percent.
  • Public health reporting has four measures and several nuances, so I’m going to refer you to the rule here as well. Frankly this was covered 45 minutes into the call, so I had glazed over a bit. I zoned back in when they were talking about a FAQ on this issue, so my advice is to read all the FAQs and act accordingly. (And by the way, they change all the time, so you might want to appoint someone to check them daily.)
  • No changes to CQMs and the period is 90 continuous days.

For Stage 3:

  • Removes redundant, duplicative, and topped out measures (no surprises here) and intended to reduce provider burden. Not sure it meets the mark on the latter.
  • The presenter started talking about specific measures and their changes without a supporting slide. I got completely lost. They were not reviewed in detail.
  • The comment period closes December 15.

Tips for 2015:

  • Confirm your stage.
  • Update your registration information through NPPES including email and payment information as well as surrogate users. Ensure your 2014 Edition EHR identification information is documented.
  • Reporting periods are any continuous 90 days in the calendar year except for hospitals, which can go back to the last quarter of 2014.
  • Attestation opens January 4, 2016 and runs through February 29, 2016.
  • If users claim they can’t meet the requirements because the rule was so late, they should apply for a hardship exception. Expect the FAQ to be up shortly.

I didn’t really expect it, but I would have liked to have them at least acknowledge the fact that they put a 90-day reporting period in place for this year, yet announced the requirements after the last possible 90-day period had already started. I know that’s what all the exclusions are about, but it just seems overly complex when it’s supposed to be simplifying and consolidating things for us. Being able to acknowledge a mistake is also a good customer service move. Vendors still have to support multiple sets of reporting and performance criteria.

As a side note, I’ve never heard the CAH abbreviation for Critical Access Hospitals pronounced as “Caaaa,” so that was a bit jarring every time I heard it.

Please excuse any typos or errors in my summary. I’m frantically typing it after a long day of “real job” work so Mr. H can get it to press.

Have you finished the rule? What are your thoughts? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/5/15

October 5, 2015 Dr. Jayne No Comments

Now that we have the official ICD-10 go-live behind us, we can breathe a little easier. But it’s not time to let our guard down. In fact, if one more person tries to tell me it was a “non-event,” I’m likely to scream. The fact that things have gone smoothly so far is largely due to the millions of dollars and hours spent making it go as well as humanly possible.

Although I haven’t seen any major hitches, the majority of practices I work with have had only a small percentage of their claims processed. Many practices haven’t even sent claims out the door yet. They’re waiting for providers to finish their notes, for coders to review them, for managers to harass the providers to finish the notes, for pathology to return so codes can be determined, and more.

Two business days is far too early to judge whether this transition has been successful. I think it’s going to take at least two to three weeks to fully understand whether there are going to be cash flow lags or other downstream impacts. Long story short, it’s too early to let our guard down.

Our colleagues on the revenue cycle side need to be watching carefully and communicating as soon as they suspect there might be issues. Although Medicare has said it will not penalize physicians for coding without the ultimate level of specificity as long as the diagnoses are in the ballpark, I haven’t heard from many payers that they’re willing to look the other way.

Still, for those of us that have been heavily invested on the training side of things — particularly on the provider and coding aspects of the transition — the bulk of our work is behind us. This week I’m doing a handful of remedial training sessions for providers who either didn’t pay attention the first time they were trained or had valid reasons to miss.

One of my customers today has been on family leave with a new baby and warned me that he feels like he’s been “under a rock” as far as keeping up with things. He did well with the training, though, and asked a lot of good questions. Based on his performance with practice scenarios, I think he’ll be fine. He said that compared to the recent upheaval of his life as he knew it coupled with ongoing sleep deprivation, ICD-10 seems like a piece of cake.

A lot of people are asking me what I’m going to work on now that I have some relative free time. I’m going back to helping practices work more efficiently and effectively with their EHRs. I’ve already scheduled several clients both large and small for optimization visits. They know I’m going to go through their processes with a fine-toothed comb and look for ways to make them more efficient or at least less stressed. Some will be micro workflow within the software itself, but I’d estimate that nearly 80 percent of what I do is macro process work.

There are plenty of non-IT processes that need tweaking in many offices. Some may be straightforward, such as reducing the need for patients to call the office for medication refills. In a typical primary care office that hasn’t addressed this yet, I can generally free up a staffer for two to four hours a day by streamlining the process. I work with providers to help them understand the benefits of refilling medications for a year at a time (or at least through the next scheduled visit) or to help them consider a refill protocol where nurses or other staffers can do some triage. We educate patients that they can request refills through patient portals or directly through the pharmacy, which allows us to handle them electronically vs. on the phone. We set up efficient processes for those medications that can’t be handled electronically, such as controlled substances.

This is pretty basic stuff that many organizations addressed during EHR go lives. But there are plenty of people out there whose practices were just fighting their way through EHR training and didn’t spend any time on practice redesign or clinical transformation. Now that they have the technology, they’re having to circle back to figure out the best ways to use it. They’re also realizing the continual squeeze that comes from increasing payer and regulatory burdens. They need to free up time for staffers to start doing new work that’s going to bring revenue to the practice – things like care management, patient outreach, and population health.

I’m also seeing a fair number of practices that want my help with technical projects. Some of them bought tools and technology that they never implemented because their attention has been pulled by Meaningful Use and ICD-10. Now that they have a bit of a comfort level with both of those challenges, they’re circling back to see how they can use their new toys or to see if there are features or functions in their EHRs that they missed the first time around. Maybe they were just too busy or maybe they weren’t philosophically ready for them, but it’s always good to revisit and see if you already have tools that can be of help.

I’m doing two population health implementations for small practices. Both of them have solutions from their primary EHR vendors. One never went through training and the tool has just been sitting on the virtual shelf. The other went through training but never fully implemented it, largely due to perceived lack of staff. They recently added a part-time role for care management and population health, so we’re going to dig in and get a program up and running. I’m familiar with the tool they’ll be using and it’s decent. The biggest challenge they’re going to have is figuring out how to narrow their populations to the most high-risk or high-yield patients.

I think physicians see population health solutions and the ability to find all your patients that have X disease or X need, and reach out to them. It’s an attractive concept for those of us who went into primary care to help prevent disease or help patients maximize outcomes. However, the reality is that many of us have been collecting a lot of data, and if we tried to act on all of it, we’d quickly outstrip our practices resources to handle it. That can lead to some difficult decisions for physicians.

In the absence of real risk profiling data, they have to select whether they want to target the oldest or the sickest patients because they’re at the highest risk of complications. Or perhaps they should target the youngest because they have the longer time-burden of disease in their futures and the greatest opportunity to change. They also have to figure out how much staff capacity they have. Do they have enough open appointments over the next several months or do we need to do a project to burn down the appointment backlog first? Do they have enough phone lines to handle return calls from digital outreach and enough people to answer them? Do they have enough hours in the day?

Physicians are always surprised when I suggest small pilot programs first. Many of them are so used to trying to do everything for everyone that it’s counterintuitive to ask them to do less than that. My goal is to do a smaller project where they can be successful, then build on that to involve more patients or more conditions. This lets change happen organically in the practice rather than it being a complete upheaval. We’ve already had enough of that in medicine. We need to try to stop doing everything at once and just take it one day at a time.

What’s your plan for post-ICD-10? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/1/15

October 1, 2015 Dr. Jayne 2 Comments

ICD-10 Edition


I volunteered to take one for the team today, covering the 11 p.m. to 7 a.m. shift so I could handle any of my practice’s ICD-10 issues personally. It’s usually pretty slow until 6 a.m. and lets me get some sleep in an incredibly comfortable recliner, so I figured I’d be able to get home and have my mini command center up and ready for my consulting clients by the time most of them started adding diagnoses to their charts.

Since we run 24×7, we decided to schedule a mini-downtime from midnight to 1 a.m. to do some testing and make sure everything switched over automatically as our vendor assured us it would. That’s one of the benefits of having hosted software – they do all the upgrades and handle the transition timeline. On the flip side, when things go bad, there’s not much you can do to fix it. We had prepared just about as well as anyone could and have been running dual coding for several months.

This has allowed us to shake out some problems with the ICD-9 to ICD-10 crosswalk and make sure that we were confident our most frequently used diagnoses were converting cleanly. The dual coding in our application is a little odd, though – it takes the ICD-9 code and maps it to SNOMED and then to ICD-10. I guess it’s not using the CMS General Equivalency Mappings, but something else under the hood. That progression would lead to some occasional oddities, but nothing too major had cropped up.

Although I’m not officially in charge of the EHR, I’ve had plenty of opportunity to kick the tires, but as they say, there’s no test like Production. We do a fair amount of workers’ compensation, so ICD-9 isn’t going away any time soon. We’ll still have to do some ongoing conversion to get those claims out the door.

My first surprise of the day occurred before midnight. Apparently some odd mapping was going on, where the ICD-9 code for a symptomatic venomous insect bite was being mapped over to the ICD-10 code specific to venomous snakes. Because the diagnosis code also drives the patient discharge instructions that are printed for them to take home, I had to fix it right away rather than leave it for the billers to take care of.

I also noticed some weirdness with our diagnosis favorites lists. Our discharge instructions for common conditions like sinusitis and bronchitis were no longer linking up correctly. I had someone re-test it about 30 minutes later and they were both working correctly, which led me to suspect that perhaps the vendor was doing some work leading up to the midnight deadline that we weren’t aware of. Alternatively, maybe they were switching everyone over on the Eastern time zone timeline regardless of where they were physically located.

The biggest problem I saw before midnight was one where somehow a diagnosis of “separated shoulder” became mapped over to O32.2xx1, which is “Maternal care for transverse and oblique lie, fetus 1,” which makes no sense whatsoever. We opened a support ticket and flagged the chart for follow up. That was about the time we were scheduled to drop to paper for an hour, so we went ahead and made the switch.

I only had two patients in progress when we went to paper, one for a laceration and the other stopping by to get a flu shot on the way home from work. Neither was a problem as far as documenting on paper, so I let our “official” IT people get on about testing the direct documentation of ICD-10 without dual coding. They quickly ran through our top 50 diagnoses without problems so we decided to go ahead and start documenting in the EHR again before any other patients showed up. I was eager to see how it would function, but the overnight was quiet, so I hit the recliner.

At about 5:30 a.m., we had a couple of patients, one of whom was a workers’ compensation patient coming by for a clearance before returning to work. The patient had already been in and was diagnosed with an ICD-9 code previously, so I just sent that back out on the claim without any conversion. Thank goodness for the “use previous diagnosis” button! The next couple of patients were for easily-documented conditions – cold symptoms and migraine. Both could have been treated at home, but unfortunately both employers required work notes for time missed. Sidebar: In my next life, I’d like to fix all the waste introduced into the healthcare system by employers requiring work notes.

My relief physician showed up early to see how bad it was going to be, but I didn’t have much data to provide an opinion. I signed out the now-empty board and headed home to get ready for my personal clients. The morning has been surprisingly quiet with only a handful of issues, mostly providers who needed help getting their favorite codes added. While researching a couple of issues, I came across some bizarre codes. One was T63.483 “Toxic effect of venom of other arthropod, assault” which I hope I never have to code in practice.

I’ve been monitoring Twitter and it looks like Athenahealth posted their first claim adjudication pretty early this morning. I’ve not heard much from other EHR vendors, but would be interested to hear how things are going both there and at the clearinghouses. We won’t know the true impact until claims make the full circle and payments start coming in.

How’s your ICD-10 going? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/28/15

September 28, 2015 Dr. Jayne 1 Comment

There was a fair amount of buzz around my recent Curbside Consult on Theranos and its CEO, Elizabeth Holmes. Most of the comments and emails agreed with the need to question the company and its approach.

Thanks for putting a little reality into the mix. Like many in the healthcare field, I’ve been shocked at the money and attention being given to them. A couple of facts: the actual blood draw is a fairly involved and still painful procedure involving a “trained pricker” who prepares the finger for a few minutes with warm towels before sticking you to get the blood out. Personally I find finger sticks more painful than traditional blood draws. Sites still need trained people and it still takes 5-15 minutes per patient. Not very efficient. As for timing, the results don’t come back immediately and I believe it takes 15, 30, or more minutes. Most patients will be long gone anyway, so how is that much different from sending to a lab and getting them back the next day? I’m not sure “point of care” labs are hugely valuable for the typical primary care physician as the results are not immediate, and even if they were, they would only make sense if the patient got labs before the visit.

The reader goes on to agree that the industry is ripe for disruption, but that we need a couple of evolutions first. We need non-invasive testing that can be done almost instantly, as well as tests that are so cheap every patient will be able to come to the office to have them done immediately before seeing the physician. Maybe they’ll be able to do them at home or on a regular basis. He thinks maybe Theranos will evolve to that or maybe some quicker, cheaper company will come along. Another possibility is computerized algorithms that clarify what needs to be ordered and how to understand the results and explain them to patients.

There were also anecdotal stories about the risk of ordering labs without a clear indication.

I am a medical technologist, moving over to IT after having spent over a decade in the reference lab industry. I agree with your statements regarding interpretation of test results. My pregnancies were after age 35 and I chose to have an amniocentesis. A physician inadvertently ordered an AFP test during my second pregnancy. I didn’t know it was ordered, but found out it was elevated after a negative amnio. If I had received the results without the context of the amnio, it would have led to a great amount of stress. I fully support technology to lower costs in our healthcare system and consumer-friendly strategies to expand access and experience for patients as purchasers, but frankly don’t get the buzz around Theranos. Coordination around the right test for the patient at the right time with the right engagement of the patient makes sense. If the patient can get the order fulfilled easily and at a low cost with communication to their care team, than I am interested.

I have also been on the receiving end of tests ordered without my knowledge. Even as a physician, the results were stressful because there wasn’t a clear indication and I was confused as to what the ordering physician suspected. We’ve come a long way from the paternalistic “doctor knows best” days and I fully agree tests should be ordered with patient understanding and consent.

Additionally, physicians should explain why they’re ordering a test and what they hope to do with the results. In addition to justifying the medical necessity, this can get the patient thinking about the potential outcomes and what we might do with the information we get back. Several wise medical school professors beat the fact into my head that you should never order a test unless you’re ready to do something with the result. Unfortunately, I see a lot of tests ordered for no good reason. Some of these orders are influenced by our reimbursement system, which makes it easier and cheaper to order a bundle of tests than the individual tests that one actually needs. Medicare is guilty of supporting, this but I don’t think it’s ever going to change.

Some readers took issue with my assessment: 

Traditionally, physicians have purposely kept patients in the dark in regards to what their lab tests mean. Even today, physicians routinely send “normal cards” to their patients without any explanation as to what the real values are or how to interpret. As healthcare requires increased patient engagement and increased participation in their care, it is imperative that all providers either teach or provide educational materials to start the educational process on what lab tests mean. That would be to understand normal variants, normal abnormal for the patient, etc.

I wholeheartedly agree. Most of the major health organizations in my area did away with “normal cards” for patients more than a decade ago, along with the antiquated notion of “no news is good news.” Our patients have been getting copies of their labs since 2008 or 2009 and most of the time they have physician annotations, unless the labs result on a weekend when the office is closed, in which case they should receive a communication on Monday. At my former employer, physician bonuses helped drive this behavior.

It sounds like this reader is also advocating that we all have a role in promoting health literacy. Dr. Wu commented on this topic, saying,

Health literacy is, as you may agree, embedded in the archaic public health concept of health promotion, which is still rooted in a pre-Internet, paternalistic medical model approach… Perhaps Ms. Holmes’s analogy is ironically correct — a weapon can be used for good (crime prevention) or bad, and how it is used, intent, and training are variables. Giving patients unfettered access to their medical data without context, training in a usable format, accompanied by an actionable plan is like handing a loaded weapon to a random person on the street. Oh yeah, we allow that.

I disagree that the concept of health promotion is archaic or paternalistic. Although it may not apply to all specialties, most family physicians who have trained in the last three decades have been schooled in health promotion as a shared interest between the patient and their care team. Health literacy is an essential part of health promotion and should be all of our responsibilities, whether we’re part of the public health infrastructure or not. As I mentioned above, physicians that order tests without explaining the risks and benefits to a patient are part of the problem.

Reader Long Time, First Time also disagrees:

Is this what passes for critical thinking in the doctor’s lounge? I doubt Theranos or Ms. Holmes has any more obligation to educate patients than your profession does. After centuries of privilege, your profession seems to take little accountability for the ignorance of your “real world patients,” as you like to call us sheep. You seem to think like the clerical elites that one resisted translating the Bible from Latin into the vernacular. In fact, I bet some of these same arguments are used in Saudi Arabia to keep women from driving cars. First they must understand fuel injection before they can drive… So in order to be acceptable, Elizabeth Holmes must first succeed where your professional has failed. I will posit that your professional elite never tried to educate us. This is a false and unattainable standard you are applying to Theranos. The Pot has once again called the Kettle black. I do not know if Elizabeth Holmes is the next PT Barnum of the next Steve Jobs. I do doubt she has any obligation to educate me, either in a moral or legal sense.

I didn’t say she had an obligation to educate patients, rather my hope that she would champion health literacy so that the average person could truly be empowered to take charge of his or her own health. Theranos and Elizabeth Holmes are receiving a tremendous amount of attention these days and could use that to the further advantage of patients across the country. I also hoped she’d find greater connection with the people she’s trying to serve, as I agree with many that her isolation isn’t good for her (or the company) in the long term.

I take issue with your point about making people understand fuel injection before they can drive. Keep in mind we don’t just let anyone drive in this country either – one has to be of a certain age and has to have passed both a written and skills test to do so legally. They may not need to understand fuel injection, but they do need to know the difference between the gas and the brake so that no one gets hurt.

Although I know that many physicians don’t have the time or the skills to truly engage with their patients, there are tens of thousands of us that do so on a regular basis. We do take it personally when our patients have difficulty understanding their health issues, and if we can’t get the job done, we’re not afraid to leverage other members of the care team. I certainly don’t have “centuries of privilege” behind me and was trained in several programs that kept the patient at the center of the care team.

There’s no litmus test that requires Theranos to atone for the sins of other professions, but one would hope they could use the spotlight currently shining on them to do more to help people understand exactly what it is they’re offering and how it could be of benefit. I do, however, think there should be a litmus test for companies that sell products that could be potentially harmful. If we have to put a disclaimer on a set of lawn darts, then we should probably have some protections around patients ordering tests whose results could lead to harm. Most physicians who have had to work up something like a false positive CEA (cancer antigen) test would probably have stories to share about the harm something like that can do and the unneeded fear, pain, and costs associated.

A couple of other readers made similar points that I agree with. From Not From Monterey:

Honestly, and this isn’t a cop-out, I believe that both you and the Theranos lady are correct. It is right to have people (or put differently, consumers) be allowed to buy tests on their own and it is also correct that many, many people in our fair nation would have no idea how to interpret the results of those tests. I think Elizabeth Holmes’s target customers are not the 50+ percent of our nation that are working poor or lower middle class. She’s targeting the young and well-educated who are doing pretty well but would love to get more information about their health. I know plenty of people who are not smart enough to understand the basics of lab test results, and that number of people might at times even include myself. But I also know lots of very smart people who can use Google, compare information across authoritative sites, and ask for advice. The second group is the bunch that Holmes will be targeting. I can’t pretend that this direct model, taking physicians out of the loop, won’t create confusion or misinformation. But it might also help some people. Some people.

I think you’re spot on. As a physician, though, I am morally obligated to serve all types of patients, not just those with the resources or education to manage tests on their own (and I’ve seen plenty of really smart people, including physicians, get in trouble managing things beyond their expertise). I’m happy to support greater engagement to those patients with the desire to be engaged whether they have the financial or educational resources to do so.

I’ll close with one reader’s personal Theranos story from Engaged Patient:

Just read your article on Theranos. I use to be in awe of this upstart who went up against Quest and Labcorp. But that impression changed when I got my own test done there. I have a severe family history of diabetes and had a wake-up call with a hemoglobin A1c of 6.0. I became an avid runner and ate well for three years. August 2015 was my next turn to see what improvements I brought to my health. Theranos did a complete venous draw (traditional test tube) on me, not the much-advertised finger prick. The result came back 6.0 and my PCP advised getting it done with a local reference lab. Their result was 5.4. If three years of sincere lifestyle changes had not moved my A1c lower, I was contemplating medication in the near future.

My issue with Theranos is that they don’t make it explicit to patients that not all their tests are FDA certified. They get undue press attention for the one-drop capillary draw – lots of marketing done for that. But the truth is that they, too require venous blood in huge amounts. How the heck does FDA/CLIA let unverified tests be out there for public consumption? I find Theranos to be dishonest and deceptive. I think we (health IT enthusiasts) are sometimes so deep in our MU/HIE/EHR world that these small, dangerous twists in the mass market go unnoticed. I shudder to think what would happen if a non-health-IT person would use Theranos to make health decisions.

I’m not the expert on laboratory regulation except where it is involved in how results are ordered and rendered in EHRs, so I’ll have to rely on readers to comment on the latter points. But the example brings up another wrinkle, which is that sometimes it’s important to make sure serial tests are being done by reference labs using the same or at least comparable methodologies. Different reference ranges can also cloud results even for tests that are supposedly “standardized.” I once counseled a patient who was in tears about his lab results, which were essentially identical. However, one facility reported them in nanograms (10) and the other in picograms (10,000) making it appear to be a dramatic change.

I don’t claim to have all the answers. If the comments are any reflection, none of us really do. The only constant is change and it will be interesting to look back at Theranos in three, five, or 10 years and see what they accomplished.

What do you want to accomplish in 10 years? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/24/15

September 24, 2015 Dr. Jayne 1 Comment


We’re just under a week until ICD-10 hits and I’m starting to hear about some potential issues. One of my colleagues received an email from his vendor informing him that although he had taken all required patches and performed all necessary steps, he needs to take another small patch. Needless to say he’s not amused and I don’t blame him. As one of the few independent small practices left in the community, it’s not like he has a full IT staff that he can just hand it off.


I’ll be glad to stop receiving daily emails about ICD-10, especially the ones from CMS including these questionable graphics. Although the cardiology and orthopedics ones make sense, I’m puzzled why family practice is represented by the Star of Life, which traditionally represents ambulance and emergency medical services. If you look carefully, there are two snakes on the staff, making it the staff of the god Hermes rather than the Rod of Asclepius. Wikipedia has a great summary of the “one snake or two” controversy, including some ironic points, if you’re looking for a diversion. At least we’re not represented by an unfortunately stylized uterus or a sad-appearing bear, so I shouldn’t complain.

It will be interesting to see if we have a government shutdown competing with ICD-10 for attention. Regardless, the work of ONC rolls on. Public comments are being accepted on a draft of the 2016 Interoperability Standards Advisory. The comment period is open through November 6. The Advisory includes not only recommendations from the HIT Standards Committee, but also feedback from public comments on the 2015 Advisory.

Primary care physicians are nowhere near the top of the physician salary list, so they’re often concerned about the cost of delivering new models of care. Although they will receive higher payments if they can demonstrate greater quality, it often requires hiring more staff to implement programs to move the quality needle well before the first payment increase arrives. One of my former partners forwarded a Medscape article that lists the cost of maintaining a Patient Centered Medical Home practice at over $100K per physician per year. This represents the extra staffing needed for increased quality reporting, patient outreach, and care management.

The data comes from a University of Utah study that looked at 20 primary care practices across Utah and Colorado. The data assumed a patient panel of 2,000 patients with an incremental cost per member per month of about $4. Physician leaders are using the information to help spur payment reform, including requests for upfront payments to transform practices and train staff. The study looked at practices that were already high functioning with EHRs in place. For less-advanced practices, the cost of PCMH will be even higher.

I’m extremely happy to report that I have delivered my last scheduled ICD-10 training session. I left a few days open for last-minute stragglers, but it doesn’t look like I’m going to have any takers. I’m glad for a couple of days without client engagements so that I can recover from the last six weeks. I can only describe them as a slog. I plan to catch up on Netflix (“Call the Midwife,” Season 4 is beckoning) and rest as much as possible. I’m sure next week will bring some emergency consultations and I want to be ahead on my beauty rest.

It won’t be all fun and games, though. I’ll be attending Monday’s FDA/CDC/NLM Workshop on “Promoting Semantic Interoperability of Laboratory Data.” I’m looking forward to the scheduled panel discussion on LOINC adoption. Although all the EHR vendors I work with support LOINC result codes, I’ve struggled with several reference lab vendors who fail to deliver the codes with results. Even the large national reference labs seem to struggle with this and I’ve had to push some regional lab representatives to deliver what my clients need. It shouldn’t be this hard. There’s also an open public comment section, but comments had to be submitted in advance, so I don’t expect much drama.


I wanted to be a physician since I was small. Thinking back on a career in medicine that morphed into one in informatics, sometimes I’m still surprised by some of the things I end up discussing in casual conversations. LOINC codes are one of those things. I stumbled into a lab normalization project at my health system that led to a clinical repository project that morphed into a standardized order project. After beating my head against the wall with disparate lab systems as they gradually came together, I really became a fan of LOINC and it’s something I enjoy working with.

I have a client who insists on pronouncing it “Low-Ink.” The first couple of times they said it, I had trouble connecting the dots to figure out what they were talking about. While I was cruising the LOINC website the other day, I came across this page confirming it really does rhyme with “oink” and also that the pig is the “unofficial official mascot” of LOINC.

Have you worked with a vendor or a technology that has a mascot? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/21/15

September 21, 2015 Dr. Jayne 6 Comments


A quote in this week’s Monday Morning Update caught my eye. Billionaire CEO Elizabeth Holmes of Theranos addressed concerns that average patients aren’t capable of understanding their test results:

The idea that I as a human should not be free to access my own health information, especially using my own money – even though I can buy weapons and anything else I want – and rather should be legally prohibited from doing so, summarizes the root of the fundamental flaw we’re working to change in our healthcare system.

While Holmes may be a prodigy and a billionaire, I wonder how much real-world experience she has interacting with real world patients. It’s likely to be minimal, since she readily admits to barely having a life outside of Theranos. She’s quoted as saying she “doesn’t really hang out with anyone any more” and also doesn’t date, saying she “literally designed my whole life for this.” She even chooses her wardrobe based on efficiency and elimination of the need to make decisions.

Certainly she has advisors — some of them might want to clue her in on what the average patient’s situation looks like. Most of my patients don’t have the means to buy anything they want. Many haven’t had the opportunity to attend college and would find it hard to understand why someone would drop out. Some of them barely graduated from high school. General literacy is an issue, pushing health literacy farther down the list. Most of our patient education materials are written at the fifth grade level and even then it’s still not understandable.

I’m puzzled by her reference to buying weapons as well as her premise that we aren’t already free to access our own health information. Although it might be sometimes challenging (as Mr. H has illustrated in his quest to get a copy of his hospital chart), records are generally more open than they’ve ever been. I’m confronted on a regular basis by patients who have received laboratory results directly through a patient portal and are worried about what they see since it’s often delivered without context. I have had several patients bring in printouts from an EHR patient portal and ask for me to explain high or low lab values when they see them on the weekend and can’t get in touch with the ordering physician.

Unfortunately, they’re often out of context even for me. If I don’t have access to the ordering physician’s thought process or other benchmark values, I can’t really advise the patient one way or the other. Maybe it’s a low value and it’s trending up or maybe it’s getting worse, but it’s often impossible to tell. Knowing that many patients don’t understand the idea of reference ranges (defined by statistics – so that you can be “out of range” but still healthy) it’s likely they won’t understand more complex concepts such as the positive predictive value of a test or its ability to rule in or rule out a disease.

In the interview Mr. H referenced, the examples of breast and prostate cancer are mentioned. Screening tests can lead to false positives and unnecessary procedures. Over the last several years, we’ve seen PSA testing fall out of favor, but patients still request it. Once I discuss the evidence, a good percentage of patients decide to opt out. Given the availability and accessibility of cheap testing, patients might opt in to testing that could be dangerous to their health. Theranos has been instrumental in creation of Arizona laws that allow patients to order their own tests. Based on the fact that tests aren’t without risk, I’m not sure I agree with that approach.

I also disagree with their premise that 40 percent of people don’t get blood tests ordered by their physicians because of the fear of a traditional blood draw. Holmes is admittedly “terrified” of traditional needles. I agree with her assertion that cost is an issue that prevents patients from receiving recommended tests, but I’ve only seen one patient in my career with an actual fear of needles.

I do agree our healthcare system is broken. If Theranos can compete with the large reference labs, everyone will benefit from reduced costs, improved access, and less-invasive testing. If they inspire patients to take charge of their health, even better. But I’d challenge them make sure they’re putting their proverbial money where their mouth is by also providing education, not only to patients, but to the greater community.

Holmes is experimenting with life in the outside world and has been speaking to young women to promote academic achievement. I’d love to see her champion health literacy so that the average person can truly become empowered to take charge of his or her own health. Theranos has multiple job postings for creative, sales, and marketing positions – what better way to leverage them? Even though she’s dedicated her life to solving a narrow problem, she may find other ways to think about it as well as experiencing a greater connection with the people she’s trying to serve.

What do you think about Theranos? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/17/15

September 17, 2015 Dr. Jayne No Comments


Even though I’m no longer on staff, I’m glad that my former employer still hasn’t taken me off its mailing list. The quarterly Medical Staff Newsletter is a nice way to keep up with my former colleagues. I was excited to see that the hospital recently launched a new community outreach program. In an attempt to prevent readmissions, it uses paramedics with advanced training to perform scheduled home visits. Patients can be assessed for signs that their chronic health conditions are progressing are becoming unstable. The paramedics also provide disease management counseling.

For an initial panel of pilot patients, emergency department usage was reduced by 67 percent. Since I work in a couple of different practices, I wondered how they are contacting the providers of record and whether we’d be seeing any communications in our EHR. Unfortunately they are using a standalone system that was designed for home health and it isn’t connected to anything but the hospital’s clinical data repository. The mode of communication to attending physicians: fax.


I also chuckled at its promotion of staff physicians who appeared in the “Best Doctors” edition of a local magazine. The methodology used by some publications to create those lists is sometimes questionable and reminds me of a high school homecoming court election. People often vote for the names they’ve heard most often, regardless of personal experience or knowledge. Two of the providers on the list have been gone from our community for more than 18 months, so they’d be hard to refer to. Another one is retired. My favorite entry is a physician who has been disciplined multiple times and who sexually harassed me in the operating room. It’s bad enough that they were included on the magazine’s list, but I’m embarrassed at the hospital using them for marketing purposes.

The newsletter also included the first communication I’ve seen about the new EHR conversion project. The vendor was officially selected in December, but planning has been kept fairly quiet. They’re still not saying which facilities will go first, but they’re at least warning clinicians that it’s going to take more than three years to complete the migration across all business entities. Although I wish them the best, I’m glad to not be fighting in that particular skirmish.


A reader sent me this awesome ICD-10 countdown clock, which I’ve added to my personal website. As I continue my practice road show, I’m seeing people who are seriously worried about the crash of the revenue cycle as we know it.

I’m thinking about making one of those construction paper chains that we used to do in elementary school as we counted down to holiday break. Tearing off a link each day as we march towards what some are describing as “billpocalpyse” might be therapeutic. One physician I trained today actually talked about provisioning a safe room in his house in case staff comes with pitchforks and torches when he can’t pay the bills. Although I think it was a joke, at some level I think he was actually consider it.

Several readers wrote in about their ICD-10 training experiences. One works is tasked with helping clients navigate the transition. At a recent client forum, he describes comments that, “Most of the training that is out there is useless. The only content that had any agreement on whether it was not it was useful was CMS’s Road to 10 specialty content – specifically the coding scenarios for each specialty.” As a physician (and purveyor of training myself), I agree that scenario-based practice is essential. In addition to making sure they know how to code items that are on specialty-society or CMS lists, providers should also ask their IT staff to run a list of their top 10 or 20 diagnoses and practice coding those. If your docs haven’t done it, please make the suggestion. You’ll be glad you did.

Another reader commented on my recent mention of electronic prescribing of controlled substances. Apparently Imprivata has a hands-free authentication solution, capturing the token code from a cell phone without requiring manual entry. I’m pretty sure we could get away with having phones as long as they stayed in our pockets. I’m definitely going to check it out and appreciate the tip because as much as I try to stay on top of new products and offerings, it’s impossible.

As part of one of my ICD-10 engagements this week, I also presented to a group of physicians about Meaningful Use. Although we know a final rule for Stage 3 is imminent, many of my colleagues think it has become a big joke. I’m hearing from more and more that they’re willing to take the penalties just to regain control of their practices. Of course I’m not hearing that from physicians who sold out to large health systems or to hospitals – they’re stuck with whatever is handed down. Many organizations have already budgeted the incentives and planned not to incur penalties and don’t seem open to altering the future balance sheet.

Have you opted out of Meaningful Use? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/14/15

September 14, 2015 Dr. Jayne No Comments


We hear a lot of chatter about big data and the ability to conduct analysis and draw conclusions from enormous volumes of information. I know I’ve written previously about attempts to determine whether Agatha Christie was developing dementia through analysis of her writings. I’d love to do analysis right now on some of the physicians I’m connected with through social media. Based on some of their posts, one might extrapolate a far-reaching conspiracy, mass paranoia, psychosis, or all three.

What has them so excited? It’s ICD-10, of course. Apparently quite a few hospitals are just beginning their ICD-10 preparations. For physicians who are on staff at multiple facilities, the training requirements are converging to form a perfect storm of regulatory madness. One of my friends from medical school reports being required to complete training programs at all three hospitals where he has medical staff privileges.

Despite having completed two previous programs, the third hospital is requiring him to complete more than 20 online training modules. Even though he’s a particularly specialized surgeon that deals with a part of the human body smaller than an elementary school milk carton, he had to sit through courses on coding for OB/GYN, neonatal diseases, and specialties he’s never going to use.

Since this was his third go-round, he timed the modules. They took more than 15 hours. He also reports that the narration was done by someone “with no idea how to pronounce medical terms.” I hope he was multitasking during the non-relevant portions or at least enjoying a cocktail because I know I would have gone crazy if faced with the same scenario.

It’s been entertaining to watch the back-and-forth as other physicians respond to posts complaining about ICD-10. One friend asked, “Is it just me or is ICD-10 going to make the practice of medicine more inefficient? Does it seem like it was created by bureaucrats who are trying to assert a rationale for their existence?” Another responded that the second question provides the answer to the first.

A third friend answered that without required ICD-10 courses, new regulations, and more hassles, “the woman who doesn’t know how to pronounce medical terms and lots of other people like her wouldn’t have a job, so they come up with new rules to keep themselves busy to justify their jobs.”

Indeed, that sounds a lot like some of the bodies that have been making an increasing number of healthcare regulations over the last several decades. There was a comment that ICD-10 is a conspiracy “to force physicians into the arms of hospital networks.” Certainly one might be inclined to only be on staff at one or two facilities rather than three or four if one has to take redundant training. I sympathize with what he’s going through – I once went live on the same EHR at two different hospitals and had to complete the entire training curriculum for both, even the parts of the system that are not client-configurable.

Another friend suggested just blowing through the slides and taking the end of module test since “doctors are some of the best test-takers in the country.” One physician chimed in that she has so many emails in her inbox about ICD-10 that it would take days to go through them. She plans to take a course at a local medical school and hopes it will be “helpful rather than soul-sucking.” Unfortunately, many of the ICD-10 courses I’ve heard about represent the latter.

One of the best follow-up comments I read was from a friend of a friend of a friend (funny how social media works that way) who said his hospital offered an animated course with a cowboy and a talking horse/donkey character. I certainly haven’t heard of that one, but would love to see it if anyone can point me in the right direction. Just thinking it reminds me of my own hospital’s HIPAA videos, which had a questionably-executed gangster/flapper theme.

It’s all too easy to get sucked into social media and I didn’t want to waste much more time than I had already spent. Before I closed my browser, though, I did come across this video  of a woman surfing in stilettos. I thought it was pretty impressive, but one of my shoe diva friends commented it was a way to ruin a good pair of shoes for sure.

What’s the best ICD-10 training you’ve seen? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/10/15

September 10, 2015 Dr. Jayne No Comments


I was pleased to see that Vermont finally legalized electronic prescribing of controlled substances, making the process now legal in all 50 states. According to Surescripts, only 2 percent of physicians are electronically prescribing controlled substances. Early on, even if it was legal in your state, it was still a challenge due to lack of pharmacy participation. Now nearly 80 percent of pharmacies can accept controlled substance prescriptions and I’m guessing that the cumbersome workflows involved are contributing to the low numbers.

The two-factor authentication options offered by my primary vendor include a key fob token or a soft token installed on a cell phone. We have a strict “no cell phones” policy (even for physicians) so that option is out and my partners weren’t too wild about having to carry a token. We dispense most of our controlled substances in-house, so our practice hasn’t adopted yet. Since we dispense, we’re not afraid of being able to meet the controlled substances requirements, but I have several friends who are nervous about the auditing and reporting requirements.


This week, CMS is urging practice to contact their software vendors, clearinghouses, and billing services to “ask about testing and training opportunities.” We’re three weeks out and I think it’s a little late in the game if practices are just starting this process. I continue to be amazed by the number of practices that are way behind on their preparations. A solo physician contacted me today, finally realizing that we’re not going to get a reprieve. He forwarded a 26-page “checklist” of to-do items from his software vendor. It was more like a novella than a checklist and had cross-references to more than a dozen other documents, each with other check lists.

Although the document was overwhelming, I can’t fault the vendor too much because their checklist outlined a timeline that was to have begun six months ago. Had the work been done on the vendor’s suggested timeline, the steps would have been relatively small and manageable by any practice. Trying to tackle it at the last minute though is like standing at the bottom of a cliff and hoping a flying elephant can help you get to the top. I’m going to do some ICD-10 coding training for him, but had to refer him out for the technical pieces. I haven’t adjusted my fee schedule for the last-minute rush, but I bet clients will be paying a premium for technical services as we get closer to the deadline.

CMS also released webcasts for Dental, Lab, Pharmacy, and Radiology clinical concepts. In addition to new documentation requirements, the presentations cover physician perspective. I’m sure the physician perspectives they present are pretty far from what many of my colleagues are thinking, which ranges from, “Why did I go into medicine again?” to, “I should have gone to a cash-only practice when I could.”


Last week, Mr. H mentioned a study that looked at episodes of “Grey’s Anatomy” and “House” and how on-screen patients fared with CPR. They survived at twice the rate of real patients. Thanks to Netflix and some quality time on the treadmill, I’m finally caught up on “Grey’s” and was happy to see Dr. Miranda Bailey discuss her end-of-life preferences with her husband even if he didn’t agree.

HIMSS recently sent me a “Connected Health” survey that asked about my organization’s plans to expand technologies in the next year. Most of the organizations I’m working with are delaying any strategic planning sessions until after the Meaningful Use final rule is released. Between the uncertainty of the requirements and the strain of ICD-10 and related upgrades, everyone just seems to be running out of gas.

A reader made my day with this piece in The Onion: “Health Experts Recommend Standing Up at Desk, Leaving Office, Never Coming Back.” I’ve definitely had days when I feel like taking their advice to use my lunch break “to walk until nothing looks familiar any more.” I sent back an email of thanks and was rewarded with this gem from Gomer Blog detailing an EHR upgrade gone wrong.

Have you ever had a week when you feel like you’re going to have to send your IT team to a safe house? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/3/15

September 3, 2015 Dr. Jayne 2 Comments


CMS is pushing their “ABCs of ICD-10.” Although this week’s focus is on “B,” I hadn’t seen the campaign before. As a physician, I couldn’t help but think of the fact that when we hear “ABCs” we immediately tend to think “Airway, Breathing, and Circulation” as we’re trying to resuscitate patients. Based on some of what I’m seeing in the community, I think we’re going to be resuscitating more than a few providers and billing supervisors as their practices are decidedly not ready for the transition.

I was on the phone with a client today who has decided not to take its vendor’s mandatory ICD-10 patch and instead will try to customize the system on their own. They plan some brute force workarounds if that doesn’t work. At this point in the game, I just don’t have the stomach for working with people in that mindset. I told them that if they agree to take their vendor’s patch I’ll be happy to assist, but if not, they’re on their own. It’s just too risky when there are fewer than 30 days on the clock and there are tested solutions available.

Interestingly, the “B” campaign stands for “Be sure your systems are ready.” They recommend practices test to make sure they can generate and submit claims, schedule appointments and procedures, verify eligibility and benefits, submit quality data, update patient histories and encounters, and code encounters. If you’re just thinking about testing these items now, you have a lot of work in front of you.

Speaking of the October 1 date, I’ve seen an uptick in requests for last-minute locum tenens placements spanning the go-live date. I am not sure if people are thinking the system will grind to a halt and want to staff up or if small practice providers are deciding to take vacation during the transition and return to practice when things are stable. I see more specific EHR information in the listings than I have seen in the past.

I had to laugh though at one of them, which was not only trying to recruit a “Physican,” but also said the small-town practice includes “tell a med.” I can only infer that telemedicine is involved, but there were enough problems with the listing to make me worry about what one might be walking into (including spelling the name of the EHR wrong and failing to capitalize “September.”) The one site only sees 6-10 patients a day and that’s certainly tempting, but I doubt the locum agency’s ability to handle professional liability coverage and credentialing when they can’t spell.

My former hospital made me chuckle today by announcing (at 11:30 a.m.) that they would be taking the hospital system down from noon to five for a scheduled upgrade. Seriously, who performs upgrades in the middle of the work day? They’re offering a special support line from 5-7 p.m. then going back to regular support hours. I suppose they assume all bugs will present themselves in the first two hours after the upgrade. There was no mention of what the upgrades would bring or how users should anticipate their workflows might change. Needless to say, I’m feeling pretty good about having jumped ship when I did. I just hope they keep me on the distribution list because it’s been amusing.


I’m always happy to feature companies that are giving back to the community. While the Epic User Group Meeting is in full swing, Nordic Consulting is partnering with local organizations to make the world a better place. Monday night at their open house, Nordic served a custom-brewed Nordic EHR IPA. For every pint poured, they donated $1 to The Road Home program at Rush University Medical Center, which helps veterans return to civilian life.

For beer connoisseurs, the EHR IPA contains Equinox, Hallertau, and Rakau hops. It’s also on tap at more than a dozen bars and restaurants in Madison, so grab a glass if you can. Their open house also featured cookies from The River Bakery, which provides job training and placement in the baking industry. Everyone knows how much I love pastry, so this made me smile.

From Eager Reader: “Re: keeping up. I’m working on an informatics project and wanted your take on something. How do physicians with extremely busy schedules keep up with new scientific data? Do you rely on certain sources now, or do you have to grunt through the medical journals on your own?”

That’s a great question. The short answer is that it’s hard to keep up, especially if you’re really in the trenches. I have a few key journals that I read. Unfortunately, I don’t read them regularly, but rather stack them up (I’m still a paper girl at heart), and when the pile gets so tall, then I curl up and read the articles that are pertinent to my practice and my clients. In addition to new articles and reviews, several also have “tips from other journals” sections that may lead me to read parts of other journals.

I’m also a big fan of the Wolters Kluwer Health UpToDate product as far as researching the most current thinking on a given condition, especially when you have someone in front of you with a condition you may not have seen in years. In my clinical setting, I’m often working alone and don’t have a colleague I can grab between patients and bounce ideas off of them. I do have clinical decision support in my EHR that links to the literature, but I rarely use the links. With my current vendor, I trust that the physician informaticists on staff did the right thing when it was built, but I’ve seen some crazy bugs in previous systems.

How do other physician readers keep up? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/31/15

August 31, 2015 Dr. Jayne 2 Comments


A reader recently contacted me about strategies for dealing with providers that are struggling with chart completion:

My outpatient physician group is struggling with chart completion after conversion to an EHR. Some physicians have no issues, but others are having considerable problems. Not surprisingly, the ones struggling are the same physicians who had trouble on paper and had stacks of charts in their offices before EHR. Our policy is that charts need to be completed within two days. However, we have physicians who have hundreds of charts open and are months old and therefore not billed.

We are considering a policy that states charts over two weeks old will result in fines, which is similar to one of our competitors. We are estimating over $100,000 of accounts receivable that we will not be able to collect due to the age of the charts. There is another $25,000 in incomplete charts being added on a weekly basis. I wonder if any of your readers can share their approach.

The reader wanted to remain anonymous, which shouldn’t be hard because there are probably hundreds of organizations in this same position. I’ve personally worked with dozens of them.

Ideally, this problem is best addressed while the organization is still on paper. This allows leadership to get a handle on undesirable behaviors without physicians blaming the EHR. I can count on one hand the number of physicians I’ve seen who were delinquent on paper charts but got faster with the addition of an EHR, so confronting it head on is the best way to handle it.

Unfortunately, many organizations don’t have the resources to optimize their workflows before implementing an EHR. This leads to one of two things: either the EHR implementation team is forced to deal with problems and behaviors that are potentially outside their area of expertise or the behaviors simply don’t get addressed and the EHR takes the blame.

Like the reader, many organizations are motivated to action when the delays start to impact the revenue cycle and some let it get significantly out of control. The last client I helped with this problem had almost $6M in unbilled encounters before they realized they had a problem. Needless to say, they also had other revenue cycle issues which led to it getting that bad.

Meaningful Use throws another wrench into this process, particularly with the need for eligible providers to send out clinical summaries with pertinent information within a set number of days. Although some organizations go ahead and send out the incomplete summaries (a reader shared his or her own story with Mr. H) others hold the summaries which will cause the provider to fail attestation if they can’t meet the threshold.

Generally most approaches to this problem fall into either the carrot or stick categories. In the incentive space, physicians may receive cash bonuses for timely documentation or receive advantages in the creation of on-call schedules or vacation requests. Although some physicians (particularly ones earlier in their careers or with young families) respond well to this, not everyone cares about extra money or call schedules. Some physicians also aren’t motivated by the desire to get information to patients in a timely manner (via MU-required clinical summaries) either, so that may be off the table.

When organizations decide to employ a stick, usually it is a financial one. My residency program did this to the faculty and it was successful. (The residents had their grades withheld if charts were delinquent, so they weren’t a problem.) Charts older than five business days resulted in a fine, which came directly out of the faculty member’s paycheck. It took months to get it set up with the accounting and payroll departments and the physicians had to sign a contract addendum agreeing to it. The faculty did it grudgingly and most of them waited until the last hour, but at least the charts stayed current.

Another group I worked with also made it contractual. Physicians had to meet chart-completion standards in order to be eligible to receive a bonus. They also had to use the EHR in a prescribed way (entering data discretely rather than free texting) in order to reach the bonus round. Bonuses were then calculated based on clinical quality measures, patient satisfaction scores, and a couple of other factors. It was successful because it could completely block the physicians from getting any bonus at all, but again took a contract amendment to give it teeth.

I’ve seen two clients hire scribes for physicians that had documentation issues. Whether or not they charged the cost of the scribes back to the physician depended on the physician’s impact on the bottom line. For example, a high-volume surgeon who was bringing in millions of dollars in revenue was not charged for the scribe because the money recouped from non-delinquent charts more than paid for the extra overhead. At another group, a primary care physician who swore up and down that the EHR was at fault was charged for the cost of the scribe because all of his partners were getting their charts done on time and were unwilling to subsidize or reward his lack of compliance.

This does come up in my consulting practice all the time, so I’m also interested in hearing other approaches. If someone has a great way to do it that doesn’t require a major overhaul of dozens (if not hundreds) of employment agreements I’d love to hear it.

How do you deal with delinquent charts? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/27/15

August 27, 2015 Dr. Jayne 2 Comments


For the last several months, people have been asking me what I think is going to happen on October 1. Will vendors be completely ready? Will customers have time to take upgrades and patches? Will users have enough time to test and practice new workflows as well as learning new documentation standards? Will things come to a screeching halt? Or will it be like Y2K and turn out to largely be a non-event?

I’ve been telling them that I think the majority of systems are going to be ready, but I think that there will be some glitches. Although I don’t anticipate complete chaos and the breakdown of civilized medicine, I have been recommending to my small practice clients that they should prepare for delays in cash flow and consider having access to a line of credit to cover expenses if there are lags in payments. I’ve helped most of my clients develop business continuity plans so they’ve already thought through various scenarios and it’s just a question of applying ICD-10 problems to existing plans.

Larger practices, especially those owned by or affiliated with hospitals and health systems, appear to be pretty well prepared. Several that I’ve worked with have fleets of staffers dedicated to ICD-10 preparedness, from coders and compliance officers to EHR trainers. Nevertheless, most of them have increased the amount of cash they have on hand. They have also prepared to bring on extra staff to help them power through the glitches through a combination of manual data entry and brute force if it is needed.

All of the groups I’m working with have come to accept that the odds of a delay or reprieve are miniscule. I’m encouraging them to be cautiously optimistic but to continue preparing and drilling. There are so many moving pieces in the medical billing process and so many different systems and vendors involved. Although a practice might be prepared, what if their billing clearinghouse drops the ball? Or what about failures on the payer side? There are bound to be glitches.

Unfortunately, there will also be catastrophic failures. I came across one of those situations today when I received a frantic phone call from a prospective client. They’re using a specialty-specific EHR that started behaving erratically this week after turning on the ICD-10 dual-coding functionality. Apparently the system didn’t have the level of code mapping they anticipated, but it wasn’t discovered before it went live because they didn’t thoroughly test it.

They are unable to revert the feature and were told by the vendor that they need to very quickly do a code mapping and setup project. Due to the number of providers, the complexity of the build, and the skills of the IT support team, there is no way the practice can fix it in time for ICD-10, let alone fix the issues they’re currently facing.

Several of the problems are patient safety issues. On a pediatric chart, selecting a simple diagnosis of sore throat in ICD-9 is recording an ICD-10 diagnosis for Ludwig’s Angina, which is not only uncommon in children but also life-threatening. Needless to say, the physicians are struggling and the practice is in full freak-out mode. Although I’ve not worked with this specific system, I told them I was willing to take a look under the hood and see if I could help.

I had to wake up my database guy early on a Sunday morning, but luckily he’s always up for a challenge. After a couple of hours of massaging the data in their test system, we put together a plan and the client agreed to our proposal. We extracted the data from the relevant tables and I’ve spent most of the day comparing it to the CMS General Equivalency Mapping data. Our goal is to very quickly identify the data that is correct and stage it against their historical diagnosis patterns. We’ll validate their most frequently used diagnoses first and load it back into the system in batches every night. Then we’ll work our way through the rest of the data in order of frequency of use.

Although we can’t turn the dual coding feature off, we’ve completely wiped out the ICD-9 to ICD-10 crosswalk so that they can at least code without fear of adding incorrect data to their charts. Once we start adding data back in, if there isn’t a clean ICD-9 to ICD-10 map, they just won’t get an ICD-10 code. I was able to juggle some of my other commitments and hope to be ready to test the first batch of data later tonight. In the mean time, we’ll have a contract coder going through the charts where ICD-10 codes have already been applied, suggesting corrections as needed.

Due to the volume of codes that we need to examine and the premium they’re paying me to do it quickly, I’ve been chained to my laptop most of the day. I see code tables when I close my eyes and I’ve started to feel like an ICD-10 apocalypse might be on the horizon. I found some tips from AHIMA on how to survive such an event.

Do you have your medieval mace and leather armor ready? Email me.

Email Dr. Jayne.

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