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Curbside Consult with Dr. Jayne 2/8/16

February 8, 2016 Dr. Jayne 3 Comments

Last week I talked about physician understanding of the economics involved with a transition to value-based care. This week I’d like to entertain the idea of opportunity cost, which is the loss of potential benefit from alternatives not selected when a choice is made. In explaining it to my niece, it’s missing out on buying a cool pair of boots in three months because you’re buying too many lattes and not saving anything from your part-time job.

I’ve had a series of events lately that make me think that healthcare leaders don’t understand the concept of opportunity cost. I know I have a penchant for working with organizations that tend to be fairly troubled, but this is a pretty basic concept. Let’s take a look at a few of those scenarios:

Hospital A had a very strong IT analyst who had been working in a physician liaison role, meeting with new hires and personally setting them up with various credentials, their VPN tokens, etc. She would meet them either at their offices or in the physician lounge and do whatever it took to get them activated and make sure they felt supported for the first few months of employment. She was dearly loved by everyone. 

When her husband developed an ongoing medical issue and she asked to reduce her hours, it seemed like a done deal. Instead, the IT department informed her that they had no part-time positions available. She was forced to take early retirement in order to care for her family.

Subsequently, they contracted out the position to a third-party desktop support group, who immediately hired the staffer part time. She earned close to her previous full-time salary as a part-time contractor while the hospital ended up paying more than her full-time salary.

It’s bad enough to not do the right thing for an employee who has been with you for 30 years, which is unheard of in the working world today. To make such a poor business decision on top of it, though, is just mind-boggling. They’re now essentially paying twice as much for her services. Making it even more bittersweet, her husband’s condition turned out to be not as dire as predicted. She’s now back in a full-time position, performing project management services in addition to the desktop support.

Hospital B had been trying to hire a CMIO for some time. They engaged me to help put together the job description and evaluate candidates since they had never had a CMIO and wanted someone to help sort the wheat from the chaff.

We first ran into trouble when they created the job posting and its accompanying salary range, which was less than what most physicians make fresh out of training. Yet they expected to hire a board-certified clinical informaticist who had been working in the field at least five years with their specific platform.

They were surprised that no one was interested in the job. Only a handful of folks who had lost their licenses or had other suspicious gaps in their employment history had applied in several months. None of them were board certified. They changed the salary range, but by then the organization had lost momentum. After engaging an external recruiter, they were able to finally get some good candidates. 

The human resources department processes of running the background checks and making the offer sent the first-choice candidate running for the hills. Why would someone want to work for an organization who can’t even get the hiring process right? I’m not sure, and neither was he, apparently.

As time elapsed, their second-choice candidate had already accepted another position. Their third choice turned them down with inadequate compensation as the reason. They were unwilling to respond to a counter-offer. 

The newly-created position has now been vacant for six months. Had they been able to get themselves in order, how much could a new CMIO have accomplished over the last several months? How many opportunities for improvement were missed? How much money have they lost in recruiting after trying to “save” it on salary?

They’re now back at square one, cobbling the role together with a host of physician champions who are trying to fill in on top of their regular jobs and hiring me to do tasks that are beyond their capacity or skills.

Hospital C had an employed physician group that was preparing to change EHRs. They hired me to shepherd their data migration. After looking at the quality and quantity of the data (which was really pretty appalling), I recommended against trying to extract the data to to seed their new system.

As an example, most of their blood pressure values were unusable since their previous vendor didn’t have adequate control of data fields. Nonsense characters and inappropriate abbreviations filled tables where only numbers should have been.

In looking at the overall poor quality of the data, the specialty mix, the volume of truly “repeat” patients vs. those that were episodic, I recommended they use a third party to abstract and load the data so they could have a clean start. It looked costly on paper, but I thought I made an adequate argument for the return on investment given the risk to patient safety of poor data quality.

The IT team felt my concerns were “ridiculous” despite my experience and decided to go it on their own. They now have spent nearly a quarter of a million dollars trying to get the data to a point where the incoming vendor will accept it. They’re paying their own physicians (who aren’t informatics trained) to work on the data. They have done so much manipulation that now they’re questioning the data integrity themselves.

I was asked if I am willing to come back and help. Of course there is no way I’m touching it at this point. I referred them to the abstraction firm and hope they can take a rush job. Their go-live is in a few weeks and the physicians are at risk of starting on the new system with nothing.

Figuring out the money wasted is easy. But how do you put a value on all the stress that has been generated and the growing negative feelings about the transition?

I have friends that work in all kinds of industries and we always swap war stories. It seems like mine are always the most outrageous as well as being most plentiful. It’s like no one is watching the store. Healthcare organizations hire someone to give them advice, then ignore it, then act surprised when things turn out badly. I’m very much concerned that the move to value-based care will only make a broken system more dysfunctional.

Where do we go from here? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/4/16

February 4, 2016 Dr. Jayne No Comments


This week we celebrated the creation of National Women Physicians Day on the birthday of Dr. Elizabeth Blackwell. As the first woman to receive a medical degree in the United States, she helped pave the way for many of our careers.

There has been some backlash about adding another recognition “day” and jokes about whether we’re going to also have National Men Physicians Day. For those of us who trained and continue to work in environments that can range from covertly sexist to outright discriminatory, it’s nice to be recognized. In some areas, girls are still discouraged from pursuing science and technical careers.

I vividly remember my oh-so-Southern college roommate being told by her parents to just “paint your nails and do your hair and find a good husband and let daddy and me worry about the rest.” She was shocked to have been paired with a roommate who actually planned to be “pre-med” and not just use biology 101 to be “pre-wed.”

My medical school class at Prestigious University was the first to be more than half women. We crammed more than 60 women into a locker room designed for 20 as we changed for gross anatomy. The school refused to provide any other accommodation. Some of my gutsier classmates protested by changing in the hallway. You’d have thought they’d seen the admissions trends and made some preparations, but apparently it didn’t occur to the administration.

Despite having trained in the last two decades (when we should have known better), I’ve been sexually harassed more times than I can remember and have had to watch male residents harass a female faculty surgeon without repercussions. The joke was on them, however, because in their refusal to staff her cases they left the door open for the rest of us to actually perform procedures while they were three-deep holding retractors for a male surgeon.

Although we’ve come a long way, subtle sexism still exists. I look forward to the day where our children and grandchildren can choose whatever career suits them without sex- or gender-based comments. I’ve never heard anyone ask a male executive how he balances his family and career, but I hear it asked of women all the time.

It goes both ways, though, and I sympathize with men who have chosen careers that have been historically “female.” No one should ever have to justify their vocation based on chromosomes. If people take issue with that, I have a Marine Corps pastry chef I’d be delighted to introduce.

In other news, this week has been chock-full of things that are almost too ridiculous to put into words. Unfortunately, most of them involved fairly specific situations with vendors and hospital executives that I can’t write about without risking my anonymity.

That’s one of the hardest things about being on the HIStalk team – not being able to share the best stories because they would out us. Often I go ahead and write things up but let them sit for a couple of months until memories fade, but several of these were so over the top I don’t think I’ll ever be able to use them. A couple of them though were general enough to have occurred anywhere, so I’ll offer some pro tips.

If you are creating recorded training materials that are going to be viewed by not only your internal staff but also by your strategic partners, you might want to have some “webinar hygiene” requirements for the staff conducting the sessions. First, address the barking dogs before they bark or figure out how to pause the recording while you do it. I now know the names of your dogs and the fact that they don’t listen to you at all. BTW, the kissing noises were cute.

Second (and I thought this went without saying), use a headset and not your speakerphone. Make sure your microphone gain is adjusted properly. Otherwise, you end up yelling at your audience or being nearly inaudible.

Third, close your Outlook or hide your alerts.

Finally, for the love of all things, please turn off your instant messenger. I saw some things pop up during one session that were completely NSFW. Since it was a recording, they’re preserved for posterity.

Whether you’re recording content or just presenting, it might be a good idea to ask someone to peer-review your slide deck. Typos are embarrassing in front of hundreds of people. Also, when introducing a guest speaker or secondary presenter, make sure you’ve vetted the introduction with them first. I was completely embarrassed when I was recently introduced as “the CMIO of Big Medical Center” when in fact I haven’t been there for months.

I’m not ashamed of being without a title other than “independent consultant” and provided a bio prior to the session that was essentially a three-line introduction suitable for the call and edited for the audience. Apparently the moderator missed it, however.


Adding to the ridiculousness of the week was the arrival of some malware on my laptop. Thank goodness it was my older one that I’m only using for music, movies, and browsing. Its arrival was suspiciously timed with a visit from my nephew who spent quite a bit of time on it, showing off his skills with Scratch and Python. I fought with it for several hours and finally gave up, having tried most of my own tricks and several from friends. I’m taking it tomorrow to my favorite “will trade Jameson for IT support” guy and hopefully we’ll get it back on its feet.

Regardless of his contribution to my stress level, my nephew is a great kid and I’m impressed by his technology skills. In his school district, they offer a program where students can sign up to spend a day at work with alumni in various fields. He was disappointed that they don’t have anyone who writes code for a living, but his eyes lit up when I suggested that I might just know some people who build EHRs every day. Looks like we’ll be cashing in some frequent flyer points for a spring break adventure of the health IT kind.


I spent some time away from the craziness working on my HIMSS schedule. I already have lunch scheduled with one of my favorite start-ups and am eager to hear about what they’ve been doing. We spend some time catching up at Midway after HIMSS last year and have checked in once since then, but I’m sure their product has grown in leaps and bounds. I also tracked down the truth behind the rumor that Medicomp was planning something different for their Quipstar game show this year. Indeed they are!

This year will feature teams (!) competing using their new Quippe Clinical Lens product. I’m pleased to announce that I’ll be captaining “Team HIStalk” on March 1 (Tuesday) at 11 a.m. We need four readers to join me in kicking off the week’s game show play at booth 1354. If you’re interested, email me with your credentials, witty comments, outright bribery, or a photo of your favorite shoes and tell me why you want to play on Team HIStalk. I can’t promise much more than the opportunity to meet me and have some fun, but you never know what you’ll see at their booth.

Last year’s appearance by Jonathan Bush was one for the highlight reel. I’m looking forward to having some team backup to make up for my appearance a few years ago when I blanked on David Brailer’s name even though I could see his picture in my head.

I don’t know who we will be competing against, but I hope it’s someone fun. Could it be Karen DeSalvo? Perennial contestant Jacob Reider? John Halamka? My not-so-secret crush Farzad Mostashari? Or the dashingly hilarious Matthew Holt?

Are you ready to get your game show on? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/1/16

February 1, 2016 Dr. Jayne 6 Comments

A wise man once told me to take as many business and finance classes as I could, even though I planned to go to medical school. That advice has served me well over the years, particularly as medicine has become more of a business and less of a calling.

Although my residency program provided solid education in practice management, it still didn’t fully prepare me to run my own solo practice. I was lucky to have some good advisors who could point me in the right direction and were willing to mentor me in learning more about healthcare economics.

As we move into the realm of value-based care, the ability to understand economics and finance will be critical for physicians and other care providers if they want to remain solvent. There has to be a return on investment — not only on technology and infrastructure expenditures, but also on staff.

The latter seems to be the hardest for some organizations to understand. I have worked with quite a few employers over the last several years that don’t have a working knowledge of productivity benchmarks. I’m not saying that everyone needs to go out to national sites and compare their staff right off the bat, but at a minimum, organizations should understand productivity within their own site, practice, or location. If they’re serious about operating in the value space, they’re going to have to get very cozy with benchmarking and determining the total cost of various episodes of care.

It’s hard to reconcile complaints about the EHR being too clicky or too cumbersome when you have physicians seeing dramatically different numbers of patients. I was recently at a site where providers were seeing 16 patients a day in the primary care setting. Personally, I haven’t seen that few patients since I was a first-year resident and still had to review every patient visit with a supervising physician. After getting them past their initial arguments about how their patients were sicker or more complex than anyone else’s, the physicians in question were eager to blame everything on the technology, when a careful review of their office process revealed otherwise.

I spent several days in the office observing workflows and what I saw was shocking. Staff were blatantly surfing the Internet on their phones and ignoring patient-related tasks that were waiting for their attention. The amount of gossip and chatter reminded me of a middle school lunch room.

The Hawthorne Effect poses that when people are observed, they change their behavior simply because they are being studied. I couldn’t help but think that if this is what they were doing in front of someone observing them, the amount of waste when they weren’t being observed might be staggering. And yet the physicians felt that they couldn’t give the staff any more work because they were “too busy” and therefore were taking on more non-value-added work for themselves, such as filling out forms and looking for missing lab results.

After documenting the current state thoroughly with not only summary statements but actual time studies, I presented my case to the physicians and practice managers. Generally, I expect a little push back, including concerns about being able to hire better staff or that staff will leave if they are confronted with a lack of productivity or with rising expectations.

This organization, however, had worked its way into a seriously co-dependent state, with the physicians mounting a strong defense of the status quo even though it was adding to their misery. They continued to blame the EHR and government mandates even when presented with data from high-functioning practices using the same EHR under the same government mandates. The practice’s leadership was unwilling to accept the possibility that the staff (and lack of management thereof) was a significant part of their problem even though it was directly impacting physician satisfaction and the bottom line.

After presentation of a proposed set of future state workflows, we had several hours of discussion. I used all my Jedi mind tricks, but was unable to get them to consensus around what needed to be done to take their practice to the next level. They have it in their minds that they want to achieve Level 3 Patient-Centered Medical Home recognition. How are they going to create a highly functional team care structure when they are unwilling to take the time to even discipline a staff that is obviously goofing off?

They also want to join an Accountable Care Organization because they’ve heard it’s the way of the future. Don’t get me started on changing your model of care just because you read somewhere that you should. Furthermore, if they’re not willing to address both staff and provider performance issues, how do they think they are going to use data to address patient compliance issues and drive outcomes?

Knowing that I was getting nowhere fast with the idea of practice accountability, I tried to appeal to their understanding of economics. We discussed the money they are losing by not making the most of their existing resources as well as the potential cost of hiring incremental resources to accomplish their goals. Again, they tried to throw the technology out as a cause, citing what they perceive as a high cost of ownership of their current client-server EHR.

One of the doctors mentioned that they were considering chucking the system in favor of the free online EHR that he saw an ad for in one of his journals. I asked how much they thought it would cost to migrate 10 years of data from their existing system to a new one and how much they might lose in the transition. It was clear that those thoughts had never crossed their mind.

I know they have at least a minimum desire to move to a better place. Otherwise, they would not have hired me to come in and do an assessment. I have to say, though, that I was grateful that my engagement with them only included the assessment and the creation of a report with basic findings, and not the actual optimization effort. Without committed leadership that “gets it,” they are doomed to stay right where they are.

Frankly, I don’t think I can handle another train wreck client right now. I know they’re going to push me to provide a proposal for the next phase, but I think I’m going to have to respectfully decline for my own sanity.

There is at least one health system in the area that is in acquisition mode. I wonder if this practice will become a potential target. Despite the mess they’re in, they have a fairly large patient base and a decent location. Stronger leadership with a better understanding of the big picture and a willingness to ruffle some feathers (if not getting rid of the chickens all together) could turn this into a much more successful situation.

Although some of the practice’s leadership thought I would be able to force change from the outside, I had told them that it rarely works that way and played out exactly as I had predicted. Unless they’re willing to give an outsider control of their staffing or are willing to take charge themselves, they’ll likely just keep running in circles. Worst case, they’ll run themselves into the ground if they attempt to do an EHR replacement no matter how “free” they think it is. I’ve never seen that turn out well despite the claims of the vendors.

What do you think about free EHRs? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/28/16

January 28, 2016 Dr. Jayne No Comments

One of my clients reached out to me today to discuss a potential safety issue with one of the network-enabled devices they use for patient care. Although there hasn’t been an official recall by the manufacturer, there have been enough concerns for my client to want to remove the devices from use while they perform an evaluation.

The new devices had only been in service for a couple of months. Luckily they still have the previous devices in storage and can redeploy them for patient care. They were looking for guidance on how to communicate the issue without alarming physicians who had come to rely on the data points from the machines. They haven’t had to do anything like this before and didn’t have a policy or procedure in place.

I recommended that they use the procedure they follow for pharmaceutical recalls as a potential template. It hadn’t occurred to them to think about it that way – I think they were mostly still getting over the idea that they had to deal with a situation with a number of unknowns. I was able to talk them through a step-wise plan for addressing it, and by the end of the call, I could tell their stress level was substantially lower.

It reminded me of some of the disasters I encountered during my first couple of years in the CMIO trenches, when it felt like every day brought a giant pile of unknowns that I had to deal with. It was a good reminder of the ways in which being a consultant can be rewarding as well as the fact that the role of CMIO is a relatively new one and there are plenty of us still learning as we go.

Many of us are homegrown clinical informatics professionals who got into it either because we enjoyed technology or we were “voluntold” by our employers that we would be wearing a new hat. I like to think that makes us very skilled at thinking on our feet and being creative with problem solving. Still, I sometimes envy people who completed formal informatics studies and had easy access to mentors at critical points in their careers.

One of my former colleagues who accepted an informatics role much in the same way that I did (come on, it’s only four hours a week!) is planning to take the Clinical Informatics board exam this year before the “grandfather” period expires. When you’re already in the trenches, the idea of trying to find the time and money to enroll in a formal program can be daunting.


On January 26, the US Preventive Services Task Force issued a final recommendation that all adult patients be screened for depression. Changes in recommendations usually lead to a flurry of IT activity as preventive services tracking and reminder software requires updating to accommodate the changes. The most nimble vendors will have the new guidelines embedded within a few weeks, but others may take significantly longer.


The HIMSS16 invitation cycle is finally upon us. I always get a kick out of the different event invitations. Some of the best parties I’ve been to are at HIMSS and putting together the social schedule is always a bit of a challenge. I’m hoping the Monday start will shake things up a little and allow me to attend parties I’ve previously missed due to conflicts. If you have an event (whether after hours or on the show floor) and you’re interested in coverage from the HIStalk team, let me know. We try to make as many events as possible as long as schedules (and our tired feet) allow.

ONC shared a list of its activities at HIMSS. The Tuesday session with Karen DeSalvo and Andy Slavitt might be a “must see,” especially if Mr. Slavitt goes off script again and starts lauding the demise of federal programs. If nothing else, the session should be Tweet-worthy. I’ll also be keeping my out for my favorite former ONC staffers, including Jacob Reider and of course Farzad Mostashari.


I heard a rumor that Medicomp Systems has something new in store for its Quipstar game show booth. I always enjoy seeing the game and catching up with the team, as well as taking advantage of their seating when I’m running out of energy. I had the opportunity to hang out with CEO Dave Lareau at HIStalkapalooza last year – I wonder if he’s eager to pinch hit for pie-throwing duties again?

A reader shared this piece on physician burnout. My initial read of the data focused on the specialty distribution, but that approach masks a larger problem. Burnout rates increased across all specialties from 2011 to 2014. Even more significant, only one specialty reported a burnout rate of less than 40 percent. The comments section is worth a read for those looking to understand why physicians are angry, stressed, and looking to do something else.

What are your strategies for dealing with burned-out physicians? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/25/16

January 25, 2016 Dr. Jayne No Comments


Although I’m still thinking pretty seriously about hanging up my consulting shoes, I decided to accept an EHR vendor’s offer to become a potential subcontractor. Apparently they’ve heard about my work with some of their clients and would like to able to book my services on their paper.

I thought about it for quite some time before accepting. Although financially it’s a wash for me, it has the potential to increase my pool of potential clients. It might also lead to a bit of accounting efficiency, as I will bill the vendor for my time and expenses rather than having to deal with the accounts payable departments of multiple practices, hospitals, and health systems. That can be a blessing and a curse, though, if their accounting department turns out to be chaotic or they’re a slow payer.

Any of their clients that I’m already working with will remain my direct customers. The agreement is year-to-year and I have a 90-day out clause if it doesn’t work out, so I thought I would give it a shot.

One of the benefits of being an official subcontractor is gaining expanded access to their client support site and their online training and education materials, so that’s a plus. I can also attend formal training at the corporate office if I choose. Prior to this, I’ve had to rely on the kindness of my clients in obtaining access to the vendor’s support system and documentation.

Although I had taken a bit of a break from travel at the end of 2015, I’m now back in the air and watching some of their client-facing training sessions from 38,000 feet. What did we ever do before in-flight Internet?

I’m pleased to see that the vendor has made some significant improvements to the application from a user workflow standpoint. They’ve added quite a few “nice to have” items that I’m guessing have been in their development backlog from some time. For many of the products I work with, vendors were forced to push pure usability enhancements to the side while they pressed forward with a seemingly endless list of Meaningful Use and regulatory enhancements. Although MU3 continues to lurk, it feels like there may be some breathing room and ability to go back and give users things they actually want and need.

I’m grateful that my travel this week takes me away from the Blizzard of 2016. I’m going to meet with a potential new client who heard about my work after I met one of their physicians at the AMIA meeting. Apparently they’ve been through multiple physician and operational leadership changes in the last few years and the organization has finally hit rock bottom, or at least that’s what it feels like to the physician I met who is stuck trying to get value out of the EHR with little support.

From the information I have so far, it looks like they may have been a victim of trying to follow the “flavor of the month” in healthcare without any semblance of strategic planning. The group dabbled in Patient-Centered Medical Home, followed by an Accountable Care initiative, then acquired several independent physician groups and tried to do some work with procedural subspecialties including an Ambulatory Surgery Center. They applied for numerous grants and agreed to participate in multiple incentive programs without a clear plan or strategy.

Based on those goals, they went on to build custom reminders into the EHR for all of them, which has largely driven the end users to their wits’ end. They also mysteriously spun up a practice that operates on the concierge model, yet has to document using the same templates and content used by everyone else even though some of them are not relevant. The physicians feel bombarded by an alphabet soup of initiatives that lack coordination or staff support.

They’re also suffering from staffing issues, including high turnover, lack of coverage in certain skill sets, and perceived budget constraints that have led to the departure of seasoned clinical managers. They allowed several payers to embed care management staff in the practices, but didn’t have a plan for how they would document in EHR or how they would truly coordinate care. In many instances, care has actually become more fragmented as some of the care managers are documenting in systems hosted by their employers rather than in the practice’s EHR.

It’s not just their clinical house that’s in chaos. Their revenue cycle management has also taken some hits. He’s had patients complain that they’re receiving bills for visits that were never sent out to insurance. After investigation, it appears that timely filing deadlines were missed, so the billing office just moved those balances to patient responsibility.

Needless to say, the patients are irate. Co-pays aren’t being collected at the time of service, so even for those visits that did get sent to insurance, they’re spending an inordinate amount of money sending statements to chase the co-pays. Physicians aren’t seeing regular performance metrics and have been told that there are problems with the EHR that prevent accurate reporting.

Sometimes when I meet with groups like this, they want to dwell on the aspects of what went wrong and how they got to this place rather than putting their resources into moving forward. Although some root cause analysis and probing of organizational psychology is a good thing, pointing fingers or trying to pin the blame on people who have left is not.

Even if the organization is ready to move in a new direction, change leadership is difficult. If they don’t have the collective will to devote long-term support to new processes, they might find themselves back where they started or potentially in a worse position. The outgoing CIO had tried to bring in some assistance previously, but was stymied by budget issues.

The physician who recruited me for this adventure isn’t sure whether they’re truly ready to accept outside help, but I am certainly willing to pitch to them. In reality, he didn’t have to do much arm-twisting since the client is located in one of my favorite cities.

As a bonus, I get to visit with one of my health IT mentors while I’m in town. He recently retired to the area and I’m hoping he has some sage wisdom to offer. I won’t just be pitching to a potential client on this trip, but also to him, in hopes that if I’m successful, he’ll agree to help with the onsite work. There’s just something about the lure of putting the band back together that I don’t think he’ll be able to resist.

Are you a sucker for hopeless causes? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/21/16

January 21, 2016 Dr. Jayne 1 Comment

I’m not always able to practice what I preach. Last week was one of those weeks. Our practice is experiencing a wild growth spurt and my last patient care day was one for the record books. Not only did we see more patients than we’ve ever seen in a single day, but we had several ambulance transfers and other critical situations. 

I admit that my charts got out of hand, even with a scribe joining me partway through the day. At least 90 percent of the notes were done before the end of the day and all of them were done within 24 hours, but I had to spend some evening time going through and doing a final review and locking them.

Normally our “default” settings are great, but as I was reviewing, I discovered that partway through the day that my “award-winning, cloud-based EHR” began documenting a negative male genitourinary Review of Systems on all patients, even if they were female. Of course they’re not having any problems in their male organs, because they don’t have any.

I’m not sure what went haywire, but I had to stop my review process and call in the experts. Our practice’s staff tinkered with it for a while and then contacted the vendor. We still don’t have an answer. Although I can manually correct them, I’d rather not have to go through scores of charts if there’s a quick fix. In my consulting practice, I see a lot of physicians that quickly click through their documents without reviewing them, so this is a great cautionary tale for me to use in the future.

In the meantime, I’ve had plenty of diversion with dozens of people emailing me the CMS blog backpedaling on comments about the end of Meaningful Use. At least they made it crystal clear that they’re not eliminating MU and that we’re still stuck with it for the near term.

Although it was about as nice of an “oops, we take that back” post as I’ve seen, I take issue with their comments on offices being “wired.” As we all know and as I’ve said time and again, just because technology is present doesn’t mean anyone is using it or that it is useful at all. Most of us in the clinical trenches have used EHRs that have been decent and those that have been soul-suckingly bad. The fact that they’re “wired” has nothing to do with our outcomes.

I have several close friends that ran Level 3 Patient-Centered Medical Home practices using only pen, paper, and Excel – and with a level of efficiency and improved outcomes that would put many EHR-based practices to shame. Of course, that level of performance requires not only skilled staff, but individuals who are dedicated, compassionate, and believe in the practices and their missions.

It becomes harder to retain that level of staff when they become demoralized by a poor product or a good product with a poor implementation. I’d like to see people who should know better stop using computers as a proxy indicator of whether a practice is moving in the right direction or not.


I didn’t make the list for the HIMSS16 Social Media Ambassadors. I shouldn’t be surprised because my use of Twitter and Facebook has been at low tide for months. But I found coverage of the announcement rather funny, in that it says that they are “credentialed by HIMSS to cover the conference.” I didn’t know you could be credentialed for social media – perhaps a license to Tweet?

Regardless, I’ll be covering the conference in my usual style, with scheduled strolls through the exhibit hall accompanied by real, live providers and in-the-trenches users of healthcare IT. The reasons I’m not all over social media became clear in another piece, this one featuring tips from the Ambassadors. Medicity’s Brian Ahier @ahier talked about only following “five or six hundred folks” but that he tries to read “every tweet of the people I follow.” There aren’t enough hours in the day for me to be that active in the Twitterverse, even when I multitask while hitting the treadmill.

Lately on the treadmill I’ve been working on some required Continuing Medical Education content for my primary specialty certification. I’m six years into a 10-year Maintenance of Certification cycle. Although at least one Board has somewhat put MOC on hold, mine hasn’t. I like to try to get the arduous (and wholly irrelevant) required module out of the way early in the year so I don’t have to sweat it later. In response to my comments last week about there being Clinical Informatics “LLSA” CME hours offered at HIMSS16 (my that was a lot of acronyms in one sentence!) I heard from a couple of readers.

One lamented the fact that there are virtually no approved LLSA hours relevant to clinical informatics unless you can attend one of the AMIA conference or HIMSS. It costs thousands of dollars to attend these conferences (most of the registrations are pushing $1,000 on their own) and they’re not always ideal venues for learning. Although I learned a great deal at the AMIA symposium, many of the non-LLSA sessions were more valuable to me as an informaticist than the approved courses. I also learn better when I can focus at home rather than being in a hotel meeting room with hundreds of other people some of whom are having sidebar conversations or moving around and being distractions.

Another reader complained about the costs of HIMSS in general and shared his hope that perhaps in the future the conference will become the irrelevant part of the week since there are so many events outside of the actual proceedings (did someone say HIStalkapalooza?)

Another reader shared some of his correspondence with the American Board of Preventive Medicine, who certifies a good chunk of the Clinical Informatics diplomates. The Board staffer commented that they had planned for AMIA to provide more LLSA-approved CME by this point. My response to that is that it’s irresponsible for a certifying board to rely on a third party to provide credits unless there is a contractual obligation to do so. At least my primary certifying board has its act together and provides adequate content (volume wise – some of it may be irrelevant depending on your practice) on its own.

HIMSS also responded to my difficulty in being able to find information on the LLSA sessions. Unfortunately, three staffers sent me a link that didn’t take me anywhere helpful. One did send a PDF with the schedule and instructions which was very helpful. Although many of them overlap, they also mentioned that after the meeting they will be posting the sessions online so that we can access them as “enduring materials.” That will help for those of us who wanted to attend multiple sessions at the same time.

There are now over 1,000 of us who are certified in clinical informatics, so for those of you in the latest class of Diplomates, welcome to the CME/LLSA party.


A reader who knows my fondness for shoes shared a link to this church recently completed in Taiwan. It’s supposed to draw more women to attend, but I’d also be on the lookout for fetishists.

Do you have your shoes picked out for HIStalkapalooza? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/18/16

January 18, 2016 Dr. Jayne 3 Comments

My inbox lit up last week after Andy Slavitt’s comments about the end of Meaningful Use. My clients were asking for immediate analysis of “the new rules,” but among friends, the emails were more along the lines of, “Did I miss a memo somewhere?”

I think Slavitt is overly optimistic in stating that MU will be replaced by “something better,” because ONC and CMS haven’t done such a great job of making things better in the modifications and revisions we’ve seen already. Frankly, I’m not sure they even understand the definition of “better” as it might be applied by a practicing physician.

Some of the emails had links to articles which either took the comments out of context or overly simplified the situation. That’s not surprising given the fact that we live in a society driven by sound bites, tweets, and Snapchat. Even if CMS wants to make the program go away, it may not be able to do it without a little bit of legislative assistance. MU is tied into the MACRA law, with MU being one of the elements contributing to the physician performance score that will drive payment adjustments.

I also take issue with his comments that, “We effectively have technology in virtually every place where care is provided.” That’s not really true – I know of quite a few primary care practices that still haven’t made the leap, largely because they’re in rural areas and are too busy actually caring for patients to deal with what they consider government nonsense.

One of my best friends from residency is one of those physicians, who has been in solo practice for many years and just splurged on the “luxury” of hiring a physician assistant to help support the practice since she’s been on 24×7 call for nearly a decade. We’re still lacking EHR in many care settings (home health, and nursing homes, anyone?) Not to mention that even though we may have computers in offices, that doesn’t mean that they’re used effectively or that they’re doing anything actually improve patient outcomes.

In my consulting practice, I see dozens of clients who may be meeting the letter of the law through workarounds and administrative processes, but who aren’t using their expensive EHRs to do anything truly meaningful. The ways in which vendors exploit vagaries in the requirements are often shocking. The CMS Frequently Asked Questions are sometimes confusing and occasionally contradictory, so I imagine it’s tempting to use what loopholes you can find.

I spend a lot of time counseling clients that, although they may be able to check the box for attestation, they’re cheating themselves and their patients out of the improvements that systems were intended to drive.

Some of my correspondents had conflicting thoughts on what the end of MU as we know it might do to the EHR industry. One was adamant that it would cause market consolidation since there are too many products out there that are certified but not terribly useful. Another felt that it would cause the return of diversity to the market, as vendors could focus less on certification and more on functionality and the ability to deliver improved patient care outcomes.

I tend to think that we’re headed for more consolidation due to economic and other factors. It won’t be easy to tell whether the proposed demise of MU really played a part.

It’s unclear how this will impact vendors who aren’t at risk for consolidation. Will this allow them to shift some of their development dollars back to usability and needed enhancements that were placed on the back burner due to certification requirements? Or will they still be dealing with regulations and calculations, but just in different forms? My physician friends that work in the vendor space share horror stories about the number of people vendors have dedicated just to keep up with ever-changing regulations. It’s not only federal, but state and payer regulations, too. The burden is endless, just as it is for providers in the trenches.

Personally, I’d like to see the regulators go after other parts of the health delivery system and spend some time regulating them in a way that will help all of us. Want to mandate that physicians include lab data with LOINC codes in their EHR? Then maybe you should require the lab vendors to transmit LOINC codes with their results. I spend a lot of time helping clients manually code around this issue because the lab vendors refuse to send codes.

That to me seems unconscionable — to force providers to clean up after other vendors who are in a better position to do something to make things better for patients. Want interoperability and portability? Force nationwide or multi-state lab vendors to standardize their various business units onto a single lab compendium rather than forcing EHR vendors and customers to code around it.

Let’s mandate that home health agencies, therapy providers, and other ancillaries also adopt electronic records and start communicating with us in a way that fits our new workflow. I still receive handwritten, barely legible reports from home health and PT providers, yet I’m held to the standard of doing everything in discrete and codified data.

While we’re at it, let’s also look at extended care facilities, nursing home providers, and everyone else that touches patients. Let’s back off on the providers and invite everyone else to the party, whatever ONC and CMS decide it should be.

What do you think of expanding Meaningful Use to other entities? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/14/16

January 14, 2016 Dr. Jayne No Comments


In the early days of Pay for Performance, many physicians and patient advocates worried about the practice of cherry-picking patients. They feared physicians would refuse to take more complicated patients who might negatively impact their quality metrics. We didn’t see a significant spike in situations where patients were terminated from the practice, but in those days, the stakes were significantly less high than they are today.

Today we not only fail to realize an incentive if our quality doesn’t measure up, but we are at risk of actually being penalized. This grates on those of us who strive to do right by our patients but simply can’t control their behavior no matter how much motivational interviewing we conduct, what support systems we provide, or how well we try to partner with our patients.

I’m wondering if we’re about to start seeing the feared spike in patients who are asked to leave physician panels. My suspicions started when I saw a recent article in one of the throw-away practice journals that talked about the “right” way to terminate a physician-patient relationship. Some of the overtones involved patient non-compliance.

I’m not against the idea of terminating a patient for failure to follow the care plan, but have only done it when the patient’s failure to follow the plan was directly putting their life at risk and I felt that we had reached an impasse where they no longer trusted my judgment and I could no longer be effective as their physician.

Since that first article, however, I’ve seen at least three more. The most recent one specifically addressed the idea of terminating patients when their failure to comply impacts quality measures. Some of the concepts discussed were well past the “slippery slope” stage, so I hope this isn’t where we’re headed.

I had a recent experience where a patient who was branded as a controlled substance drug seeker turned out to have a much more complicated situation. Although she indeed had become dependent on narcotic pain medications while appearing to have no physical findings to support the need, she was eventually found to have an extremely rare condition that was only identified after visits to multiple specialists across several disciplines. Her pain was legitimate, but vague enough to make her potentially appear as if she was a liability concern.

I personally had only seen her once before and she expressed concern about making sure that her records reflected her recent surgery. The only problem was the fact that she was again at the urgent care with pain, stating her regular physician was unreachable and that the medications she had at home were not working.

Thinking about it from the other direction, though, putting on my value-based-care hat, it would certainly be cheaper to keep her in an ambulatory practice and just keep her supplied with pain pills than to get her into a pain management treatment program or have her turn up in the emergency department (at least in the short term). That’s where the equations measuring quality, cost, and access become less reliable than they might otherwise be.


A reader asked about my recent purchase of a Surface Pro 4 just prior to the holidays and what I thought about it after several weeks of use. Other than some self-inflicted casualties (like deleting my Outlook data file on accident and purging my trash before I realized it) it’s been a generally good experience. I love the fact that it’s more powerful than my previous laptop yet much lighter, although the keyboard is such that I can’t use it on my lap without a lap desk. I haven’t used it much in non-keyboard mode but the ability to use the touch screen while typing (just reach up, swipe, tap, whatever) feels like it’s more efficient than mousing or using the keyboard’s touch pad, especially when working with PowerPoint.

I had some initial bad experiences with the charging cable. Although it’s cool and magnetic, it’s at an odd place on the tablet and the cord seems pretty short. Because of the length and position position, it’s always bent at a 90-degree angle, which I’m guessing will wear it out. It would be “plugged in, not charging” for no good reason. That seems to have settled down quite a bit, but I haven’t figured out the battery life.

On my trusty Dell laptop, when it hibernates, it uses no power at all. The Surface seems to consume power even when it’s in sleep mode, sometimes akin to the way that college students consume tequila on spring break. It’s intermittent, though, and I can’t find a pattern.

The only other negative is because I’m a creature of habit, and that’s the problem that I can’t run Microsoft Money on Windows 10 without hacking the registry. (Yes, I’m using software that was sunset in 2009, because it’s free, works well, and provides continuity for my data.) I’m looking for new financial software, though, and would appreciate any recommendations. I use QuickBooks for my consulting business, but it’s more trouble than I need for home finances.

Bottom line though, I’d still buy it again. Two of the vendors I work with have gone to Surfaces for all their executives, which is what finally convinced me to take the leap.


I finally had some quality time to sit down today with the HIMSS agenda. I was hoping to plot out a strategy for trying to obtain the American Board of Preventive Medicine LLSA credits required for those of us who are board certified in clinical informatics. Those of us who certified in the first year have to finish 30 hours by the end of 2016 and unfortunately my recent trip to the AMIA Symposium didn’t net me as many as I had hoped.

Although the conference says it’s approved for up to 19 hours of LLSA credit, I couldn’t figure out how to determine which of the 300 sessions were approved. ABPM is fairly picky about how they give credit and attendees generally have to complete questions for each activity, so I want to make sure I do it right. I found a couple of links but unfortunately became trapped in a circle of “page not found” errors.

Have you cracked the code for LLSA credit? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/11/16

January 11, 2016 Dr. Jayne No Comments

Even though I haven’t been their CMIO in some time, my former employer continues to include me on many of the communications as they move forward with their migration to a single EHR platform. They just sent out a “year in review” listing some project highlights.

Although we were always strapped for staff, they’ve mysteriously found the budget to bring on more than 300 positions, the majority of which are incremental additions. I shudder to think of what we could have done with the “old” platform if we had even five more staffers. It always felt like we were holding things together with bubblegum, baling wire, and duct tape. The software was often blamed for problems that were, more often than not, due to our implementation or processes.

They also listed how many hundred hours of training, design, and decision sessions have occurred. Again, I know that had we been able to pull people away from their daily work, we could have made a tremendous difference in their user experience as well as in patient care.

Leadership appears to be on board, but I wonder if it’s because they really believe in the project or whether it’s because they know it’s a substantial financial commitment and they have to be on board. Maybe it’s also the “me too” effect since we’re the last health system in the region to move to a single product platform.

I was amused by their back-slapping about being on a single “seamless” record because they seem to be overlooking the fact that they carved out the lab systems and the revenue cycle systems. Of course they’ll be interfaced, but that’s not always what it’s cracked up to be.

I was surprised though to read that they’re going to allow the platform to be hosted outside of their corporate data centers. The mere idea of hosting anything externally was enough to make them cringe when we brought up our HIE the better part of a decade ago. I still remember making the rounds trying to twist people’s arms since I knew that independent hosting was the only way to get the community-based physicians on board.

Although they’re consolidating clinical applications, they’re bringing several new vendors into the fold. I’m not surprised since they tend to come along with some of the big-name systems these days. They provided a detailed list of what they’re keeping and will integrate with the new system and it was significantly larger than I expected.

There are whole hospital departments that will keep their same software, although it will interface to the central EHR. In some areas, the physicians will keep documentation in an external system but the nursing staff will document in the new system, which although likely intended to keep the physicians happy, feels a bit like a recipe for disaster.

Not two emails later, I received notice of the monthly fixes to the inpatient application that was written in a new format (probably in honor of the new year) that was extremely difficult to read. If you have to use multicolored highlighter on every single item, you’re probably not writing clearly enough for your audience. The amount of color on the document was enough to make my head spin. For a few moments I contemplated sending them back a user interface document on effective and appropriate use of color, but figured that I’d much rather them not know I’m reading so I can continue to play along with the home game and not risk being removed from the distribution list.

Although the EHR consolidation project is at the top of the scale for visibility, promotion, and funding, I’ve heard there are rough waters ahead. There may be an impending shakeup in the clinical leadership and possibly in the IT leadership as well.

It wouldn’t be the first CIO that we’ve seen sign up for a major initiative like this and then step out the door, although usually there are cost overruns or delays first. Maybe the CIO in question was planning to use this endeavor as his swan song all along – it’s hard to tell sometimes. I’m putting money on the fact that he won’t until go-live, though.

Reading all the updates reminded me of how much I miss the CMIO role. Being a consultant definitely isn’t easy and the travel isn’t glamorous, fun, or sometimes even tolerable. However, it’s been a great way to see under the covers of dozens of hospitals and health systems and to learn in a way that I would not have been able to had I stayed in my previous role.

Unlike Mr. H (who just got his Global Entry), I may be ready to put my rolling luggage in the closet permanently. I’ve decided to hold on accepting new clients while I consider going back on the market as a CMIO. Spring is just around the corner and I’m ready for some new growth.

Who else is planning to job hunt at HIMSS? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/7/16

January 7, 2016 Dr. Jayne 2 Comments

Lots of buzz this week about practices getting ready for Meaningful Use attestation. One of my independent colleagues reached out to me about an offer to provide batch attestation for all physicians in the practice for less than $1,000. Looking at the amount of time that practices can spend doing an attestation, it certainly sounds tempting. Given the risks of a badly-done attestation, I’d make sure that I read the fine print and included some kind of language on performance or lack thereof. If anyone has used one of these services, I’d be interested to hear about it.


AMIA as requesting submissions for the iHealth Clinical Informatics Conference to be held in May. The submission deadline is January 22. I’ve been to Minneapolis and enjoyed it. I’ll likely attend if I don’t have a conflict with a client engagement. I’m still working to get all my Maintenance of Certification hours for Clinical Informatics. I know there are some available at HIMSS, but I’m not sure if the courses are going to work with my social schedule. I did finally complete the required “patient safety module” for the certification and am grateful for ABPM for giving a six-month grace period to those of us who were in the first certification class.

I’ve received quite a few LinkedIn announcements lately that are congratulating people on new positions that they’ve actually held for some time. This usually makes me think that they’re buffing up their profile in preparation for job hunting, especially if they couple it with a “please endorse me” message. The one I received today was particularly amusing as it was from a former colleague who has habit of overstating his qualifications. I’m not likely to put my reputation on the line for that. In other cases, people might just have been delinquent in updating their profiles, but it’s more likely to be the former.

Speaking of job hunts, a reader responded to my recent comments on Glassdoor suggesting several more companies whose reviews are downright entertaining. I almost spit wine all over my new computer, so he’s lucky he’s not buying me new hardware. Feel free to send me your funniest examples and I’ll put together a top 10 list.


Now that we’re in the new year, I’m starting to get excited about HIMSS and have secured my date for HIStalkapalooza. This year it’s someone clinical, so it will be interesting to hear feedback from that perspective. I’m starting to work on wardrobe and of course accessories. Last year I had a wardrobe malfunction involving my handbag becoming tangled up with my dress on the dance floor, so I’m not eager to repeat that episode. If you have any great wardrobe finds, let me know.

The new year is also a time of stress for many patients. I was at my own doctor appointment the other day and watched multiple patients being turned away because of issues related to a change with their insurance coverage. Some didn’t have referrals and others didn’t realize the physicians they were trying to see were out of network on their plans.

One of the patients had an interesting situation where she has a PCP on her HMO insurance but actually sees a “direct primary care” physician for her primary care needs. Although she had a consultation request from her actual PCP, she didn’t have one from the PCP on her card who she had never seen, so the practice wouldn’t see her unless she agreed to pay in full. Most of the patients were extremely frustrated, which is not surprising. The way we deliver care in the US is just crazy.

My visit was frustrating for other reasons. I was having stitches taken out from a skin biopsy and had received the results by phone the other day. The medical assistant offered me a copy of my results and I said yes, since I hadn’t received them through the practice’s patient portal and wasn’t sure they did pathology that way. She then said, “Oh, I need to go talk to the doctor and see if you need a re-excision” and walked out of the room leaving me with a giant “!?!” hanging in the air. Certainly people shouldn’t be calling with results if they don’t know the whole care plan or if it’s not documented anywhere.

She returned a few minutes later saying, “You’re good to go,” but didn’t have the result in hand. I was pushing being late for a client call and will just request my own copy of the results so I didn’t argue the point, but it was not the care I expected from a major university health system.

Once I made it home and finished my client call, I was glad to see this blurb from another reader with a fondness for unusual news. Possibly some competition for Weird News Andy? A suburban Chicago funeral home recently received approval for a liquor license. They’re hoping to partner with a nearby Italian restaurant to offer the refreshments and build the idea of funerals as a “life celebration.” I think EHR vendors could offer similar refreshments at their training centers – it certainly would make the experience more pleasant.

What do you think could be done to enhance EHR training? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/4/16

January 4, 2016 Dr. Jayne No Comments


This year started with a bang as I received my first request to bid on a new consulting engagement over the weekend. I need to do quite a bit of discovery before I decide whether or not I’m going to take it, but I admit I’m seriously intrigued.

It’s from a group of physicians that consults at various extended care facilities and nursing homes where documentation is still done on paper. They’re looking at ways to better manage the use of potentially harmful medications in the elderly. Their needs initially sounded like more of a traditional “assistance with system selection” effort, which I’ve done quite a bit of. That’s how they heard about me. But the more we talked, I understood that they’ve already narrowed it down to three vendors and are looking for some very pointed critiques of the approaches.

In hearing overviews of the proposals, they range from moderately serious to what sounds downright comical. They seem like they would be a good bunch of people to work with, although I’m halfway tempted to tell them they need to choose Door #4 and go back to the drawing board. I can tell from several states away that the one proposal was cooked up by some sales team who really doesn’t understand the business or the needs of the providers and I’m tempted to take the job just to skewer them. I’m not sure I’m going to be able to dedicate enough time to this job as it would likely need, so I may have to take a pass depending on their timing and some other factors.

I worked New Year’s Eve in the trenches, which is always a good time. My experience over the years is that staff members working the holidays tend to be motivated to help move things along as quickly as possible, since you never know when your next rush of patients is going to arrive and you don’t want to be caught behind if you can help it. My shift ended before midnight, though, so I didn’t get to see a lot of the more story-worthy patient visits.

I can say honestly, though, that influenza season is here in full force. If you haven’t received a vaccination yet, there’s still time and I would encourage everyone to do so. If this weekend is any indication, there’s a high potential for this season being quite challenging.

I spent the rest of the weekend getting caught up on email and around the house. My goal this year is to not have an inbox that is perpetually full.

I took particular delight in clicking “delete” on a couple of emails from CMS. One was regarding batch upload for 2015 EHR incentive program attestations. Although I’m still peripherally involved in assisting my clients through this process, I am glad to not be personally accountable for managing the process for my own physician group. The attestation period for Medicare programs starts today and runs through February 29 for those of you playing the home game.

I also enjoyed deleting a CMS “year in review” email celebrating a look back at ICD-10. There were several emails from CMS and ONC covering their joint effort to address quality measure reporting under the various inpatient and ambulatory reporting systems as well as the EHR incentive program. They’re trying (again) to streamline the reporting process and reduce the burden to users, organizations, and vendors, but I’ve not been impressed by their previous work in this regard.

I also found an email from CMS about the new Medicare Drug Spending Dashboard and spent a few minutes checking it out. Drugs were selected for inclusion on the main dashboard due to high total program spending, high annual spending per user, or a large increase in average cost per user. Some of the drugs having the highest jumps were generics – why is digoxin up 298 percent? It’s been generic as long as I’ve been practicing. It’s still relatively cheap in the grand scheme of things, but I was surprised by the numbers.

Not surprising was the inclusion of several medications that are extremely expensive and often-prescribed despite being only marginally more effective or tolerated than the traditional / generic / cheap competitors. There were more than 20 drugs on the list which have more than $1 billion in total spending (2014 data) with some in the $3B range. The original email about the dashboard mentioned that HHS convened a group of consumers, providers, employers, vendors, payers, government agencies, and others to discuss how to balance “the dual imperatives of encouraging drug development and innovation while ensuring access and affordability.” I’d personally like to see Medicare beneficiaries take this list to their doctors and if they are on some of these high-dollar drugs, discuss whether there are alternatives and how much benefit they’re really getting from the Cadillac vs. the Buick vs. the Chevy and how that meets their life goals.

I shudder when I see patients in their 80s and 90s who are on medications that are adding little to their health besides higher costs and an increasing risk of complications due to polypharmacy. I remember when a patient in her early 90s came to “interview” me as she was shopping for a new doctor. She and her daughter (who was 70) came to talk about my philosophy of geriatric care. She was reasonably healthy and shared a home with her daughter and had only been hospitalized once in the previous five years. I honestly told her that I didn’t have a lot of patients in her age bracket, but if she were to join my practice, my main goal would be to prevent as much as possible and to give her medications only if absolutely required. I must have made an impression because she transferred her records the following week.

Some of the reporting around the CMS drug dashboard data shows the shift in disease burden as different populations join the Medicare rolls. Hepatitis C treatment has a significant cost impact along with cancer, diabetes, and pulmonary disease. It also mentions that this is only part of the relevant data – it doesn’t include spending data for commercial payers, Medicaid, the VA, or the military and doesn’t show whether there are rebates or other cost-shifting arrangements.

I expect Medicare to be insolvent by the time I’m 65 and out-of-pocket costs to be absolutely insane, so I’m doing what I can to keep chronic disease off my doorstep. Although I’m not the most disciplined when it comes to food choices (the pastry therapy doesn’t really help either), I’ve got a pretty solid relationship with my treadmill since I upgraded it early last year. Committing to be on it as many days as possible is as close to a resolution as I’m getting.

What’s your New Year’s resolution? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/28/15

December 28, 2015 Dr. Jayne No Comments


I must have been very good because Santa brought me a new Microsoft Surface Pro 4 to play with. As much as Windows 8 gave me fits last year, the transition to Windows 10 has been just about seamless. I’m enjoying its small size and the touch screen even though it has run through a couple of upgrade cycles in the few days I’ve had it.

The only downside has been that I haven’t been able to get my Outlook .pst file to import into Office 2016. I’m not sure if it’s because I’m making a large jump in versions or because I’m going from regular Office to 365, but it’s going to be a non-starter if I can’t get it done before my next client engagement.

I can’t believe 2015 is coming to a close. It’s certainly been an interesting one, with lots of ups and downs for everyone. Many of us have bonded through the trials and tribulations of ICD-10, although more than a few people have expressed their happiness that they’ll likely be retired before another version of ICD goes into use.

Depending on how fast that becomes a reality, I can probably arrange to be in that category if I keep picking up extra shifts at the urgent care and invest well. I’ve spent so much time on the road this year that my living expenses have been lower than usual, so once I finish my taxes, I might be able to make a pretty good contribution to my nest egg.

I knew I had been on the road a lot since going the consultant route, but it really hit me when I started receiving the year-end summaries from my frequent traveler programs. I gained status on one airline and lost it on another – too bad we can’t use accumulated miles to buy our way up because I’d be able to keep status for a long time. I rarely use my free miles since I’m usually out with clients.

Since I was in quite a few smaller towns, I ended up splitting my hotel nights among three major chains, so I didn’t have enough nights at any of them to keep the highest reward tier. Two are merging, though, so we’ll have to see what happens with that. My favorite summary was from National Car Rental, which not only listed the number of rentals for the year, but also the total miles driven. I’m very glad I wasn’t putting that mileage on my own car!

Also in my mailbox were some year-end messages from vendors. Although most were of the folksy greeting variety (pine trees, snow, fireplaces) one was extremely salesy and seemed to have the undertone of a company desperate to meet quarter-end numbers. It probably would have been OK a month or two ago, but in the flurry of holiday niceties, it stuck out like a sore thumb. It wasn’t surprising, though, because this particular company has been in a relative tailspin for some time and constantly misses the mark on knowing its audience and managing social media and other communications channels. If you think this might be your company, I know some tremendously savvy PR people who could help if you’re interested in making a change.

Just for entertainment, I did a random sampling of the 100-odd pieces I wrote for HIStalk this year. There were definitely some consistent themes across the year, including data breaches far and wide and the push for interoperability. Hackers have also been big news, although it feels like they’ve been busier with other industries besides healthcare. Our harm is more likely to be self-inflicted although no less alarming. If hackers decide to consciously target healthcare rather than banking or other industries, it’s certainly going to be a wild ride.

There was also a consistent theme of market consolidation through vendor mergers, acquisitions, and closures. That can often be bad news for physicians and hospitals, although I suppose it could be a good thing if you have a bad vendor and are the kind of group that has to be pushed in order to jump.

Even among customers that aren’t struggling, there have been quite a few de-installations and it’s obvious that Epic will continue to dominate in the large health system space. My former employer is knee deep in migrating to a single vendor system and I enjoyed catching up with some of my old colleagues last week. The project is already behind and over budget in the first year after contract signing with the first go-live being almost a year in the future. It should be interesting.

Other big news included the repeal of the SGR payment system through the so-called “Doc Fix” bill. In addressing other new payment models, it’s going to add complexity for many customers and vendors who will have to add code to address new requirements and the need for additional robust reporting around shared risk arrangements. Less-prominent government-driven news included reporting from the Open Payments law, which is still less accurate than needed, but a good start.

The end of 2015 also saw the final state approving e-prescribing of controlled substances. Although it’s legal in all 50 states, that doesn’t mean it’s well-adopted. Most of my clients don’t have it live due to lack of pharmacy participation, but maybe we’ll do some projects around that in 2016.

In consumer news, the topic of whether wearables have peaked was fairly big news, as was the rise and fall of Theranos. The latter should continue to be an interesting topic in 2016 and I expect we’ll hear more tales from the inside as some of the investigations continue.

Interoperability was a huge buzzword and there has been a lot of push around it, but I’m not sure it’s making a huge difference in the lives of the average physician unless you’re just referring to being able to see data across your entire health system or hospital platform. I’m certainly not seeing competing hospitals doing any data sharing at all and it looks like RHIOs and HIEs are on their deathbeds in some parts of the country.

This year gave me several things to celebrate, including being able to practice my way from multiple part-time and locum tenens gigs to a steady one working for people I not only respect, but have a lot of fun with. Their decision to opt out of the Meaningful Use program (and the subsequent removal of many time-consuming and sometimes useless clicks from the EHR workflow) was one of the highlights of my year. I also made it to AMIA and caught up with old friends, made some new ones, and learned a few things along the way.

This is the close of my fifth year writing for HIStalk, which has been a tremendous experience. It seems like just yesterday I was sending Mr. H my humorous “Top 10” list of reasons he should hire me. It’s been exciting to watch us grow beyond the blogs to hosting webinars and supporting the next generation through the DonorsChoose projects. I’m looking forward to another year of healthcare IT news and opinion.

What are you looking forward to the most for 2016? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/21/15

December 21, 2015 Dr. Jayne 3 Comments


The year is rapidly coming to a close. Typically this is the time when things are relatively slow in the industry trenches, at least until the first of the year when the frenzied run-up to HIMSS begins.

I’ve got my countdown page ready, not because I’m dying to go to HIMSS, but because I’m excited to see many of the friends I’ve made in the IT world that I only get to see once a year. Although we stay in touch through email, it’s just not the same as being able to get together in person, share a drink, and swap stories. Of course I’m also excited about HIStalkapalooza, although I haven’t given a single thought to my shoe wardrobe yet.

Several of my colleagues are still waiting to see if they will be able to make it to HIMSS. Those who are vendor employees have seen cuts in the number of attendees sent by their companies the last several years. Others from the provider side sometimes find HIMSS to be not only overwhelming, but given the current economics of medical practice, not worth the cost. There are also those who work at faith-based organizations that will not pay for conferences held in Las Vegas, but at least those folks know outright that they’re not going to attend unless it’s in Orlando since everywhere else seems to be out of the running.

I’m wondering what the big buzz will be about this year. Meaningful Use is old hat, although there will still be some picking over the bones of Stage 3. Value-based reimbursement has been on the rise, although for many, it’s more of a buzzword than an actual strategy.

The reality of putting together some of the IT infrastructure required to maximize the promise of value-based reimbursement is daunting. Although the large health systems and academic medical centers can be demanding about their networks and try to control their physicians, it’s put a terrible strain on independent practices and also on patients who want to see physicians across multiple systems but are being steered to stay within the vertical. It was bad enough when insurance networks were restricting choice, but to have your physicians negatively incented to refer you to the consultant of your choice is another thing entirely.

Many people think that interoperability should solve this problem, but the reality for many physicians is that interoperability is a joke. Not only are there incentives biased against sharing from the hospital side, but as an independent physician, I can’t even get access to the hospital web portals in my area because I’m not on staff.

Being a member of the medical staff has not only a financial cost but a professional one, with many hospitals requiring physicians to provide call coverage for patients in the hospital. Although that requirement can often be shifted to a hospitalist physician, they also require physicians to be available for outpatient follow-up, which is nearly impossible when you are a part-time physician at a practice that doesn’t have scheduled appointments and doesn’t provide primary care.

I would love to be able to log into a hospital portal and get follow up on the patients I have to transfer to the hospital. We’re seeing more and more of them as cost-shifting drives them to urgent cares when they really should have been in the emergency department in the first place. Although we’re pretty advanced at my facility, the last few shifts I’ve worked have included multiple ambulance transfers for people who were actively having heart attacks. There was one just the other night with a life-threatening stomach bleed, which let me tell you looks pretty much exactly like it does when they show it on TV medical programs.

All of the patients I’ve had to transfer have cited cost and access as the primary reasons they chose us instead of another facility. Since my roots are in primary care, I always wonder how they are doing, but I never see a discharge note or any kind of communication from the hospital despite my multiple Direct addresses that should make it easy. Maybe I should head to the mall and ask Santa to bring me some discharge summaries for Christmas. I’m not sure if the elves have signed a BAA, however.

I’m winding up the year with a last-minute lab interface project that is keeping me pretty busy. The client is super nice and had an issue with their lab vendor canceling their contract with minimal notice, so they’re in a hurry to get a new one live before their interface is shut down. The work is somewhat tedious, but that will be good to keep me busy.

Today is the shortest day of the year and I’m glad it’s here. I’ve missed having light in the evenings and have had to spend more time on the treadmill than I like. I’m looking forward to longer days and being able to get back on the streets without fear of a broken ankle from tripping over something in the dark. We certainly can’t have that in the run-up to HIMSS. Once this project is done, I’m laying low until the New Year.

What are your plans to wind up 2015? Email me.

Email Dr. Jayne.

EPtalk by Dr.Jayne 12/17/15

December 17, 2015 Dr. Jayne 4 Comments


Time is flying and it’s hard to believe that HIMSS16 is barely two months ahead. My annual preparations have started, including the creation of the social schedule. It can be difficult to juggle meeting up with colleagues I only see once a year, sessions, sponsor events, and of course stalking the exhibit hall with some of my BFFs.

I booked my flights really early this year and didn’t realize that HIMSS had shifted to the Monday start, but it was easy to fill Sunday with some spa time. I have a penchant for something called Watsu, which is water-based Shiatsu massage, and there aren’t many practitioners in my part of the country. The Bellagio has a wonderful therapeutic pool, so I’m definitely going to get my Watsu on so I’m plenty relaxed for the week.

Flu season is upon us and we’re already being inundated with patients, many of whom opted out of vaccination. It’s not too late to get yours if you’re interested. Although it takes several weeks for them to reach maximum effect, flu season runs through April, so it can still be useful.

I was surprised to learn that payers are playing games with vaccination payments. Vaccines are one of the most cost-effective interventions we have in our arsenal and the flu vaccine is pretty inexpensive in the grand scheme of things. We have one payer who refuses to cover any vaccines when administered at our practice, simply because we’re an urgent care. Even if a patient comes in with a laceration that merits a tetanus shot, we can’t give it unless the patient pays out of pocket.

Patients are already paying big dollars for their healthcare premiums and don’t want to have to pay cash on top of it, so some of them decline and plan to follow up with their primary care physician. That can lead to gaps in care, and frankly PCPs have better things to do than give vaccines sometimes, like managing chronic illnesses and diagnosing new problems. Plus, the hardship of patients having to go two places to be treated for a single problem when we should be able to do it all at once is just a waste of resources. Just another aspect to our broken healthcare system. Although coverage is mandated, payers are finding a way around it.

I’ve been spending a lot of time in the practice and have picked up some kind of a respiratory virus. If we weren’t so focused on patient experience I’d love to hang out a sign that says, “If you’re not sicker than the doctor, you need to go home and try some cold remedies.” That’s not how we roll, though, so I apologize to the patients who are subjected to my sniffles. I like to think that I’m providing some level of patient education, since if I’m still sniffling it’s clear there’s no magic bullet to resolve all the symptoms.

I’ve been sad ever since the decongestant phenylpropanolamine was pulled from the market, because it actually worked. One of the most-used products around, phenylephrine, has been re-examined and found to be ineffective. But it’s easier to obtain than pseudoephedrine, so a lot of people try it anyway. Still, I’ll keep up with my humidifier and hot tea and hope for the best.

I’ve been playing around this week with my new technology purchase, a Microsoft Surface Pro 4. I am enjoying it, although I can’t get Outlook 2016 allow me to set up my inbox like I had it on my old computer. The change is just enough that it’s making a mess of my muscle memory, but I’ve tried everything I can think of. The settings screen looks just like it does in Outlook 2013, but it doesn’t behave the same way. Maybe it’s a bug or maybe I should just get used to it.

Speaking of bugs, the American Medical Association emailed yesterday to offer me tips and resources on how to pass the USMLE Step 3 licensing exam. Since I’ve been licensed for more than 15 years, they’re a little late. They did send a follow-up email asking me to disregard it and to enjoy my complimentary 2016 resident membership, which is even funnier.


Speaking of funny, I spent some time surfing Glassdoor looking at reviews for a couple of employers that are clearly in a downward spiral. A friend had sent me a few links and the email arrived at a time when I really needed a laugh. For the one employer, it’s clear that they have someone occasionally posting anonymously that the company is great, but 95 percent of the other reviews are negative and the themes go back several years.

I’m sure disgruntled employees make up a good chunk of the postings, but everyone has disgruntled employees and when you look at similar companies, you don’t see that kind of skew towards the negative. If you’re in HR and you haven’t looked at your own employer’s reviews, it might be worth a few minutes of your time. Reviews with titles like “Rome is Burning” should definitely catch your attention.


I’ve also been catching up on my holiday baking, and in the spirit of the holidays, I’ll share one of my favorite recipes. Double Chocolate Peanut Butter Chubbies are one of my favorites the last few years. They’re insanely chocolatey and you can modify the recipe by using different kinds of chocolate (or non-chocolate if you prefer) chips or different kinds of nuts. Personally, I like mine with Hershey’s Special Dark chips and chunky peanut butter.

What’s your favorite holiday cookie? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/14/15

December 14, 2015 Dr. Jayne 2 Comments


In my experience, this time of year is always a mixed bag in health IT. Sometimes it can be extremely busy, with groups trying to frantically spend any remaining budget before the end of the year if their fiscal year follows the calendar. Those are always interesting clients to work with because some of them just want to book the work and not really do anything until after the holidays, while others want to try to cram the work in as well as getting it on the books. I try to avoid the latter since I typically plan for a lull at the end of the year so I can enjoy some downtime.

Then there are other kinds of clients who have either run out of money (often long before the end of the year) or are short on staff and are trying to figure out a way to complete projects before the end of the year. I also try to avoid these clients if possible since it’s often someone’s bonus requirements that are driving the work. There is typically a lack of planning (hence the end-of-year approach) and the team is often not resourced correctly to get the work done even with support. The handful of times I’ve done consulting engagements around projects like this, I’ve always made sure that I have enough backup resources to just do the work for the client rather than with them.

I was approached by a client last week who was clearly desperate and fell into multiple categories. It’s a small practice that has been working on Meaningful Use. They attested to Stage 1 in 2013 and planned to attest to Stage 2 in 2015, but their project went way off the tracks. They have four providers and about 10 staff members, but have not been able to figure out how to dedicate anyone on the staff to shepherding a Meaningful Use project.

They spent the first half of the year knowing that they needed to upgrade their EHR to a version that would support MU2, but doing everything possible to avoid it. Much blame was placed on the vendor despite the practice not having adequate servers to support an upgrade. They had worked with another consultant to get through the upgrade, which luckily included a migration to a hosted platform so that servers won’t be an issue moving forward.

Despite having upgraded over the summer, the practice hasn’t done much to further their MU efforts. They haven’t been running reports to see how they are doing on their quality metrics and haven’t really checked their workflows against the best practices recommended for MU documentation. They also haven’t yet purchased (yet alone installed) a patient portal. They were under the impression that all they had to do was to get the portal installed, which is why they called me. It never crossed their mind that they would actually have to have patients live on the portal or actually using it. They just thought they could hire me to run interference with the vendor, get a proposal, get the contract signed, and then “turn it on.”

I know the vendor is more than happy to send them a contract immediately, but scheduling an installation during the holidays never goes well. Not only do many vendors have people taking time off, but usually people who work in a medical practice also hope to take time off to spend with family and friends. Not to mention that hurrying this through isn’t going to help their cause with Meaningful Use since there are many other requirements that they are not meeting.

I’m not typically one to turn down work, but in this case I elected to take a pass. Not only would it add a lot of stress to my planned downtime, but I just don’t think it’s the right thing to do for the client.

What the client really needs is a solid sit-down with the owner to actually create a strategic plan for the practice. He needs to figure out whether he really wants to participate in the Meaningful Use program and if so whether he is willing to dedicate resources (either a single staffer who can own the project or money to hire someone outside to do the job) to create a comprehensive plan. If he is agreeable to that, then he needs to commit to dedicating time for staff members to receive training and adapt their workflows for success.

In addition, he will need to get the employed providers in line with the expectations. He needs to agree to a plan that not only covers the installation of a patient portal, but also a campaign to engage patients and get them to sign up and to incorporate the use of the patient portal into the daily workflow of his office.

I tried to schedule a meeting with him to discuss all of this, only to find out that he has taken the rest of the year off. The fact that a practice owner would just hand off a task to staff such as, “Hey, let’s do a patient portal” and leave town is just shocking.

As a consultant, it’s also a key indicator of marked unhealthiness in the practice. It’s unlikely that I’ll be doing any work with them even as much as I like a good challenge. The longer I’m in this business, the less interest I have in total train wrecks regardless of how well they pay.

I’m going to maintain my planned downtime and continue contemplating my career plan. Although my clinical employer’s offer was somewhat open-ended, I don’t want to keep them waiting if that’s the way I’m going to go. During the lull, I have some craft projects planned and of course some pastry therapy.

What are your end-of-year plans? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/10/15

December 10, 2015 Dr. Jayne 2 Comments

A couple of reader comments on my piece about employer wellness programs caught my attention. I have to thank Al Lewis, who provided my laugh of the day when he asserted that, “There is no adult supervision in this field, so vendors can do things that doctors would get sued for doing.” He goes on to call out a vendor who provides carotid artery disease screening even though the US Preventive Services Task Force (USPSTF) specifically recommends against screening the general adult population. I didn’t know this was creeping its way into employee wellness programs, so thanks for the warning.

I have, however, seen mass carotid artery disease screening in a promotional offering for senior citizens that I can only describe as predatory. For an upfront cash fee, it touts the benefits of multiple “screening” tests that aren’t recommended. In addition to the carotid artery test, it also offers abdominal ultrasound screening (only recommended for men aged 65 to 75 who have ever smoked, and selectively recommended for men in this age group who have never been smokers). It also offers screening for peripheral arterial disease via an ankle brachial index (insufficient evidence to assess) as well as multiple blood tests that aren’t necessarily recommended for average-risk individuals.

When looking at the flyer and the number of tests offered, it may be easy for some to come to the conclusion that it’s a good deal based on the sheer volume of diseases they talk about. However, no test is without risk and just getting them because they’re cheap and available is a bad idea. Although we did tend to “shotgun” batteries of tests on our hospitalized patients when I was in medical school, by the time I reached residency training, the focus had shifted to doing fewer tests and only those that were evidence-based. That was good, because I can’t even count how many wild goose chases we went on due to abnormal labs that should never have been ordered in the first place.

The worst wild goose chase of my career still haunts me and I wonder if a different attitude (and better interoperability) would have prevented it. The patient was a delightful lady with significant and complex medical problems who had been my patient for three years during my residency. When I decided to stay in town and open a practice, she asked if she could follow me. Although I said yes, I cautioned her that there would be a two-week period between when I graduated from the training program and when I hung out my shingle when I would have no malpractice insurance and could not be her doctor. I advised her to remain with the residency clinic for continuity until my doors were open.

Unfortunately, one week into the gap (while I was cramming for my board exam) I received a call from the emergency department of my “new” hospital where the patient’s caretaker had taken her, not realizing I could not yet care for her. She was admitted and placed in the care of a hospitalist and three specialists who were working up her problems, unaware that they had been worked up thoroughly in the past. Because the patient was non-verbal, her ability to consent to the evaluation was limited. She had abdominal pain and her exam was challenging due to her other conditions, so someone ordered a cancer antigen test, which was positive. They didn’t realize it had been positive for some time with a completely negative workup and a previous informed consent decision to stop pursuing it.

I attempted to reason with one of the house doctors, begging them to request the chart from the residency program so they could provide good care. Unfortunately the goose chase persisted and the patient remained hospitalized, developing a life-threatening problem with her platelet function. This was in part due to the blood thinner injections she was given in the hospital to prevent blood clots due to her immobility. Oddly enough, the patient has been immobile for the better part of 50 years and survived without blood thinners, but the doctors were just following the hospital protocol for giving heparin to immobile patients.

The cancer workup was completely repeated, including several invasive procedures. By the time I assumed care of her barely a week later, she had suffered multiple complications, including a heart attack, and was being considered for bypass surgery.

Thank goodness I was able to corral things before that happened because the patient and I had previously discussed her surgical prospects and she had clearly indicated that she didn’t want anything like that done. I realized that for most of the hospitalization, she had been without the computer she uses to communicate with people (she has mobility of one hand and creates computer-generated speech using it) and probably hadn’t consented to most of what she had been through.

At that point, my goal was just to get her out of the ICU, and then out of the step-down, and then to the regular floors, and then home – one day at a time. Eventually we accomplished all of those and she did well despite the “care” she received. Even years later, just thinking about this scenario wants to make me track down whoever ordered that initial (inappropriate) blood test and give them a good talking-to. Whenever one of my students or supervisees orders an unnecessary test, they hear this story. I hope it sinks in.

Another comment was from John Lynn, who asks that if a patient showed up in my office and said they were healthy and wanted to stay healthy, what would I do? I agree with him that some doctors would offer a physical and try to find something wrong. However, many physicians (especially those trained in family medicine and other primary care specialties in the last two decades) would know exactly what to do. We’re well trained in health promotion and disease prevention, but many of us don’t get to use those skills often enough. My personal recipe includes the following:

  • Find out if the patient has any concerns about their health, even if they think they’re generally healthy. Those concerns should be addressed through additional history and a targeted exam and a specific workup if warranted.
  • Take a detailed family history to review the patient’s risk factors and discuss ways to mitigate those risks or avoid developing additional risk factors.
  • Discuss general health behaviors (diet, exercise, tobacco, alcohol, caffeine, sexual behaviors, seat belt use, etc.) and advise accordingly in line with current evidence. Refer to appropriate resources as needed (nutritionist, smoking cessation, psychology, social work, etc.)
  • Assess psychosocial and other determinants of health as needed (social supports, financial ability to get care if needed, etc.)
  • Targeted physical exam as recommended for evidence-based screenings and to establish a baseline rather than “looking for” something.
  • Recommendation for additional screening tests and preventive services as appropriate based on evidence-based recommendations. This may include in-office services such as vaccines or external testing such as mammograms, colonoscopies, etc.

There are more things involved, but you get the idea. It’s about the doctor and the patient sitting down and talking about things. Which in our system doesn’t get you paid very well, and because of that, we don’t have anywhere near the time we need to do it right.

Add in the fact that patients often have to change doctors every year or two due to insurance changes and it’s hard to develop the rapport needed to work together on some of the more challenging situations that come up when you actually talk to people and get to know them. I’d love to be able to have a solid hour with patients to do a wellness visit and to leverage proven techniques such as motivational interviewing, but that’s just not how it works.

In my ideal world, I’d not only have the time to do it right, but the resources – access to other clinical professionals as needed (psychologist, social work, nutritionist, health coach, etc.) at times that work for the patient so they don’t have to take off work. I’d also like to see these preventive services fully covered by insurance. Although the Affordable Care Act mandates coverage for preventive services recommended by the USPSTF, patients on so-called “grandfathered” plans may still not have coverage. Until recently, I was on one of these plans so know exactly what is involved.

I’d love to see all preventive services fully covered. Not only because it’s the right thing to do, but also because they have been proven to be cost effective. I remember the first time I realized that Medicare wouldn’t pay for blood sugar monitoring supplies for certain diabetic patients but they would pay for amputations. I was appalled.

If that ideal world existed, I’d likely still be a primary care physician rather than a mercenary CMIO and part-time emergency doc and blogger. It’s something for the politicians and pundits to think about when they talk about the shortage of primary care physicians and wanting to bend the cost curve. But unfortunately, I don’t think it’s anything I’m going to see in my lifetime.

What’s your ideal care paradigm? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/7/15

December 7, 2015 Dr. Jayne No Comments


A Tale of Two Articles

I subscribe to quite a few news digests, including some from the AMA and other professional organizations. The headlines are always attention-grabbing, so “Framework evaluates 20 top EHRs – and they don’t quite measure up” definitely caught my attention. It links to a usability analysis done by the AMA and MedStar Health’s National Center for Human Factors.

Using an EHR User-Centered Evaluation Framework, they looked at data that 20 vendors (15 ambulatory and five inpatient) provided to meet ONC certification requirements. The Framework goes “beyond the ONC’s criteria… to encourage the ONC to raise the bar for usability certification.”

Being a good clinical informaticists means being a critical reader and making sure that one understands the information being presented before coming to conclusions. That approach has served me well when providers would storm into my office with “conclusive evidence” that our EHR was bad, waving copies of articles in my face such as a reader survey that had a grand total of 13 respondents using our product from a nationwide sampling.

In reading the introductory information carefully, one can see that they’re somewhat comparing apples to oranges. They looked at what vendors submitted for certification, not the totality of what a given vendor did or did not do with regards to user-centered design.

I have several friends who work for vendors and have heard that providing more than what is required for certification is the equivalent of being on the witness stand and offering more than a single-word answer to a yes or no question. The “just the facts, ma’am” approach seems to be preferred.

You can’t blame them. Vendors don’t want to get tangled up in showing something not required that might lead to questions. The certification process is already onerous enough.

The AMA blurb goes on to conclude that, “Out of those 20 products evaluated, only three met each of the basic capabilities measured.” I’m not surprised by this since they were measuring information from a data set that was designed for a different purpose than that for which they decided to use it.

I fully understand that they’re trying to make the point that they think the ONC certification process for usability best practices isn’t robust enough. Unfortunately, it seems to tar and feather some of the vendors despite the process they’re actually doing (but didn’t include in the ONC documentation because it wasn’t required).

The AMA blurb also didn’t include clear language that was included in the actual MedStar Health documentation on the User-Centered Design Evaluation Framework. It clearly says it is not designed to look at actual usability by clinicians, but to look at vendor practices as reported to ONC on the eight required patient safety capabilities.

I’ve personally used many of their top-scoring systems and found them to have major usability issues. Casual readers aren’t going to dig into the details. This piece is likely to be misleading.

I found the whole thing even more interesting when I opened this month’s JAMIA to find an article by the same lead author, Raj Ratwani. This time the researchers actually visited 11 EHR vendors to look at their user-centered design processes. I found this data much more interesting (not to mention peer-reviewed).

Six of the vendors visited have more than $100 million in revenue, with the top three being over $1 billion, so you can guess who they are. Interestingly enough, four of the six were found to have “well-developed UCD” processes and another was found to have “misconceptions of UCD.” I actually laughed when I read this, likening it to delusions of grandeur somewhere in the back of my mind.

The specifics of what the researchers define as misconceptions include that, “vendors do not have any UCD processes in place although they believe they do.” This also includes vendors who cite being responsive to user complaints and feature requests as evidence of UCD.

The overall distribution of the vendors was four with well-developed UCD, four with basic UCD, and three with misconceptions of UCD. The authors go on to cite the fact that even the “misconception” group is certified by ONC, illustrating why certification requirements may need an adjustment. They do at least mention the challenge of creating requirements that lead to improvement for the poor performers but don’t hamper those that are already doing well.

My favorite quote of the article is one vendor who stated, “Our product is used by thousands of people every day. So if it was that bad, it would already be out of the market.”

I certainly prefer the scholarly approach of the latter article, although I’m sure it didn’t get anywhere near as much press as the first one. I was trying to figure out what category my EHR vendor fell into. It turns out they weren’t one of the participants.

How does your vendor perform on UCD and what do you think about it? Email me.

Email Dr. Jayne.

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