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Curbside Consult with Dr. Jayne 10/9/17

October 9, 2017 Dr. Jayne No Comments

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I spent another weekend seeing patients, the by-product of a practice that is expanding physically faster than it can expand its staffing. In an environment where various organizations are grappling for market share, there’s good business justification to grow quickly, but it can create pressure on the people, processes, and technology needed to support the growth.

I mentioned last week that we had a mini-release from our EHR vendor that added some clunks to the documentation workflow. The clunks are still there, with no end in sight as far as streamlining around them. They were added to facilitate document upload to a health information exchange, but we’re not connected to one. Based on some of the patients who arrived at my location, I could really have used the HIE.

The day started pretty slow, allowing me to catch up on some journal reading and continuing education. I read an interesting article on physician burnout from the state medical society in one of the states where I’m licensed but don’t practice. In addition to physician burnout, it talked about how physicians receive healthcare in general, which is to say poorly at times. There are many physicians who feel like seeking care is a burden, either to their schedules (having to cancel office days or move patients for a sick visit) or to their colleagues, who have enough on their plates.

This leads to physicians often treating themselves, which is generally a bad idea. It’s hard to be objective about your own symptoms and examining yourself isn’t the most productive diagnostic activity. Nevertheless, it happens, with studies estimating the prevalence of self-treatment from 52 to 90 percent. Physical illness can impact how we render care, as can psychological problems like burnout. The article mentions that in the particular state, licensure applications require physicians to self-report any conditions that limit or impair judgment or affects the ability to practice medicine in a safe and competent manner.

I’d argue that burnout can affect the ability to practice medicine in a competent manner – loss of empathy, loss of patience, tunnel-vision, and more – but physicians aren’t likely to self-report because that triggers the need for a sheaf of documentation and an investigation from the licensing board. The article goes on to mention a 2009 study that found that 69 percent of state medical licensing applications ask questions that would be considered “likely impermissible” or “impermissible” based on the Americans with Disability Act and relevant case law. Other countries have fewer barriers to physician care, with Norway leading the pack with a group of physicians trained by the Norwegian Medical Association to specifically care for other physicians.

It was in the context of having read this article and been thinking about physician stress and burnout that I cared for a couple of challenging patients. The first had some drug-seeking behavior that was validated by a query to my state’s Prescription Drug Monitoring Program. It’s not integrated with my EHR, but rather is a separate website, but I was happy to do those extra clicks to confirm what I suspected. Score one for technology assisting the physician, although the technology doesn’t make the conversation with the patient any easier, especially when you’re denying them the care they’re seeking. Fortunately, this was a patient who accepted her situation rather than one who became angry when I refused to prescribe oxycodone, because as an urgent care, we’re not well equipped to handle angry or potentially violent patients.

That happy technology-enabled bubble burst a few patients later, however, when I was confronted with a medically complex patient with difficult social circumstances. She had issues following a transplant for over a year, largely related to changes in her insurance and inability to get new coverage. Transplant patients need coordinated care that has many inputs, including the surgical team, organ-specific team, pharmacists, social workers, and more. Being disconnected from your team and having to rely on episodic care can result in organ rejection and serious complications. She had bounced around due to the insurance issues and then was further impacted by a recent hurricane, which displaced her to another state.

At least in her previous city, urgent care or walk-in clinic providers might be willing and able to call the transplant team for advice, regardless of the insurance coverage situation. However, providers in another state aren’t going to necessarily have that willingness to try to make that connection, especially if they’re in a stressed healthcare system. The patient realized that and had been trying to connect with a transplant group in her new state, but began to have signs of organ failure before establishing that connection.

Due to some family issues, she traveled to yet another part of the country, and several weeks and a 30-pound weight loss later, she wound up in my urgent care an hour after we closed, halfway across the country from either of her previous residences, feeling terrible and looking very ill. As soon as I heard the basics of the story from my triage nurse, I was wishing that clicky HIE popup was actually connected to something. I can log in separately to a regional HIE, but it’s a fairly immature repository that rarely contains anything useful for my local patients, so I wasn’t hopeful about finding anything on this interstate traveler. Regional HIEs often have web access for people like me, but I doubt they’d be too keen on a request from out of state, and even if they were, it’s not like that request is going to get validated and turned around at 11:00 on a Sunday evening.

After seeing the patient and dividing her concerns into short-term and longer-term categories, I started to work on a plan. One concern for transplant patients is the sensitivity of their medication regimens and their relatively immune-compromised status. In general, you can’t rely on the “bread and butter” medications we use every day because they can have serious consequences. I maximized my use of drug interaction checking but was still unsure about my plan, and had to turn to a quick literature search to see if I could get the answer. The search was fairly silent about what I was considering in my plan of care, and without documentation of safety, I couldn’t use it.

As a community physician, I don’t have any transplant colleagues I can just call up and ask questions. The hospital I’m most closely affiliated with doesn’t have transplant services, so that was a dead end as well. Since this was after closing time, we were paying overtime to our staff, and as an hourly employed non-partner physician, I couldn’t authorize more overtime to have them start to call around to the local academic centers and hope we could track down a transplant fellow on call as it approached midnight.

I was left with providing simple and supportive advice to the patient for her short-term problem, with the hopes that she could reach her original transplant team in the morning and that they would be able to offer definitive advice despite the lapse since her last visit with them. I can’t begin to describe the feelings of helplessness that these situations evoke for caregivers. We are wired to help people and our training supports that. But when we’re placed in situations like this, it’s hard to not internalize that sense of failure or the feeling that you should have been able to do more. Especially when there are multiple and ongoing situations like this, they contribute to physician burnout and further stress our healthcare system.

In thinking back through it with my CMIO hat, would a true national HIE have helped? Maybe a little. If I could have looked through past records and seen how her previous physicians handled similar symptoms, that might have given me a clue. If I could have accessed past medication lists (older than the year I could get from our Pharmacy Benefit Manager link) that might have helped. Direct messaging to providers wouldn’t have helped given the time of day or the acuteness of the situation, but at least I would have felt more like I was doing something. Direct messaging might have been tricky though, because she didn’t know the individual names of her physicians, but rather listed the transplant program as her primary care provider.

Health information technology has so much promise, but most of us are working with only bits and pieces of it and it’s not in an integrated fashion. The care we’re giving isn’t worse than it was in the paper world, but how we feel about it has changed. We feel like we should be able to do more with the technology or that we could have done better if we were fully connected along with the rest of a patient’s caregivers. There’s a certain psychic load to knowing what could be and comparing it to where we are.

I don’t know what the answers are, but hope that the people who are making healthcare policy and deciding how and if we are going to fund different healthcare initiatives think about situations like this. It’s not only how it impacts the patient, but also how it impacts the caregivers and their ability to stay resilient. In my area, losing a physician from active practice can result in between $200K and $300K in replacement and ramp-up costs, not to mention the lost patient accessibility during the transition time.

We’ve got to find a better way to ensure the available technology makes it to caregivers across the country, not just those in academic medical centers or large cities. We have to figure out how to help those who are in backwards states that don’t adequately fund PDMP or HIE efforts. We have to figure out how to get past hospitals and health systems that are actively engaging in information blocking and refuse to share patient information with the greater clinical community.

Do you see a solution in your crystal ball? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/5/17

October 5, 2017 Dr. Jayne 1 Comment

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This week is National Health IT week, with events being held across the country. The “points of engagement” for this year’s events include: supporting healthcare transformation; expanding access to high-quality care; increasing economic opportunity; and making communities healthier. I’m particularly fond of the point regarding healthcare transformation, as so much of my work revolves around helping healthcare organizations make sense of the changing delivery environment and payment models. Many organizations are transforming for the right reasons, such as patient and community health, and those efforts make me feel energized and that I’m doing valuable work.

However, I still see far too many organizations that are on the “stick” end of transformation, only changing because they feel they are being forced to. Many of these groups are fighting themselves as they move through the change, with the C-suite saying change is here while allowing some of their more vocal (and often more profitable) physicians and subspecialties to basically opt out. I watched one group mandate that primary care physicians enter all data through discrete template fields, while allowing their orthopedic surgeons to dictate because they were afraid the surgeons would leave the group. This kind of behavior doesn’t do much to engender collegiality or build professional rapport. The most successful groups I work with are transforming because they believe in their ability to deliver care more efficiently and effectively, but trying to spread that enthusiasm continues to be a challenge.

It feels like there is considerably less buzz around Health IT Week than there was even just a few years ago, let alone what it was like in the heyday of excitement around Meaningful Use. Even Google seemed a bit lackadaisical, with my “national health IT week 2017” search bringing up an article about the 2016 events as the fourth item in the search. Let’s face it, healthcare IT isn’t as sexy as it once was and there aren’t as many so-called rock stars out there doing the moving and shaking, but it’s something in which every single one of us is a stakeholder. Having gone through yet another round of medical adventures this week, I’m grateful to have care with physicians that continue to use technology to its fullest and who enable me to be a more educated and engaged patient.

Despite the relative lack of buzz, healthcare IT continues to be of interest to young physicians and those still in training who have decided that clinical medicine may not be right for them. Maybe it’s the rigors of the schedule, the stress of feeling responsible for so many outcomes, or lack of resilience to deal with the chaos that can be modern medical practice that are raising interest. I’ve been mentoring a young resident who is considering whether he should pursue a clinical informatics fellowship or give practice a try. It’s hard to watch a once-idealistic trainee talk about his level of burnout before he’s even made it out of training. Primary care salaries continue to lag behind other subspecialties and doing something other than going straight into the trenches has a certain appeal. He’d like to stay in our metropolitan area for family reasons, so I’m encouraging him to try some moonlighting shifts in the urgent care setting to see if that’s a better fit.

One of the reasons he’s so burned out is that his residency program hasn’t truly embraced the model of team-based care. The faculty physicians are still in the mold of doing things how they were trained, which means a lot of work rolls downhill to the trainees. They have to do all their own patient callbacks and aren’t allowed to leverage staff to manage routine patient requests or to do care management activities – everything must be done by the resident physicians. I don’t dispute that this gives them a lot of knowledge about managing patients, but it doesn’t teach them how to work effectively with other members of the care team or how to lead the care team. The residents don’t get assistance with chart prep or morning huddles, leaving them to try to address gaps in care as part of the routine office visit. Worst of all, when patient-facing work is delayed by other clinical rotation activities, the patients aren’t getting good care. I’m trying to help him arrange some elective work in a setting where he can see clinical transformation in play, along with a rotation with a clinical informaticist in the academic setting. He needs to see first-hand that healthcare IT isn’t all that glamorous either, and depending on where you wind up, you may not escape patient care.

I’m still waiting to see if all this talk about the shift to value-based care will increase primary care salaries, but I’m not holding my breath. I do have a number in mind for which I would hang up my frequent flyer card and go back to primary care, but it would also require some addressing of the details of physician autonomy and practice structure. The wait for a new patient appointment with a primary care physician in my community is upwards of two months if you have commercial insurance, three months for Medicare, and four to six months for Medicaid. When people complain about the potential for rationing in healthcare, they don’t understand that in all practicality, it’s already here. These issues are daunting to new physicians (and old alike) and aren’t doing much to increase enthusiasm among physicians in crisis.

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I’m always on the lookout for new vendors and found one this week in the form of CampDoc. The product is positioned as an electronic health record system for camps and they’ve been doing some epidemiologic research looking at the camp population. In addition to injuries, heat-related illness, insect bites, and allergic reactions, camp physicians also have to contend with head lice, infectious diseases, and disaster preparedness. They’ve partnered with the University of Michigan to broaden their research, which has been presented at the American Academy of Pediatrics, the Society of Academic Emergency Medicine, and other groups. Upcoming studies will focus on head injuries and concussions during summer camp activities. Interested parties can visit their website or reach out to CampDoc for more information.

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For all you IT road warriors out there, join me in saluting Southwest on their retirement of the Boeing 737-300 series planes. The last of the fleet without Wi-Fi or exit windows that open like a DeLorean vs. having to be thrown out, they officially ended service September 30. I was pleased to see that several will be turned into firefighting tankers and others are in the process of being brokered. I’ve spent many hours in its confines, usually on time. I’m looking forward to its replacement, the 737 MAX 8 ,which has enough range for destinations in South America and the South Pacific. If SWA ever heads to OGG or HNL, I’ll be cashing in my points faster than you can say humuhumunukunukuapua’a.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/2/17

October 2, 2017 Dr. Jayne No Comments

I saw patients this weekend and was dismayed to find a mini-release from my EHR vendor that disrupted my muscle memory. Apparently they’ve decided to create a workflow to allow documents to be uploaded to a health information exchange. However, instead of putting that feature in place to automatically send when I sign my charts, they’ve broken the signing process.

Previously, upon hitting the “signature” icon, I received a nice little pop-up where the cursor defaulted into the field where I could enter my PIN, then the pop-up closed after PIN entry. Now I get the pop-up, to which has been added a pre-populated “send to HIE” field with the cursor defaulting nowhere. Since we are not connected with a health information exchange, I have to unclick the HIE field, put my cursor in the PIN field, then key my number to sign the chart. Although technically it’s two clicks, it’s a whole lot of annoyance. I was surprised by how long it took to attempt to correct the muscle memory issues as I continued to try to go directly to PIN entry for signature. Even after 50-plus patients, I still wasn’t handling the transition smoothly all the time.

I’m often the proverbial canary in the coal mine since I work mostly weekends and our vendor likes to roll updates on Saturday nights. I talked to our EHR champion and she wasn’t aware of any way to turn off the auto-populated checkbox or to get the cursor to default to the PIN field.

By way of calculation, we can take my 50 patients, multiply it out to the 750+ patients seen daily in our practice, then times all the practices serviced by our vendor. It’s a significant amount of waste. It’s definitely enough to make one wonder whether the EHR vendor does any focus group work or user acceptance testing at all when they ship these changes to the masses. Since we’re on a Web-based product, the updates are automatic, meaning it’s impossible to pick and choose. If there were any actual improvements in the release, I’m not sure what they were since I wasn’t able to tease them out during 12 hours of patient care.

It was a rough shift overall, especially since I was working at one of our expansion locations that is still under construction. We purchased an independent urgent care facility whose owner wanted to retire, where they were seeing roughly 8-10 patients per day. Our owners figured that the low volume would allow us to do some renovation and expansion while staying open. The ongoing shortage of primary care physicians in our area has fueled a boom in our business, which we sometimes aren’t staffed to handle. Couple that with an office being in disarray due to construction and you have a recipe for a chaotic workplace.

I arrived today to find two of three bathrooms out of commission for construction, which made it tricky to handle patient needs at times. One exam room was doubling as a staff break room, with a refrigerator crammed in the corner and the microwave propped on the exam table. The dedicated laboratory area had been relocated onto one of the nursing station counters, throwing a wrench into some of the workspace efficiency.

Sometimes you forget how well your practice runs until something pushes it off kilter. Although we’ll benefit from swapping the business office and oversized lab for four new exam rooms and a right-sized lab, growing pains aren’t much fun. I was having flashbacks to the last emergency department I staffed, which completely renovated the department over an 18-month period while we continued to see steady volumes of patients and also deployed a new EHR. It was fairly traumatic for the staff, as we struggled to enter orders when we couldn’t even find supplies and were pressed into smaller quarters during the build-out. The construction chaos was bad enough, but adding in the frustration of the extra clicks in the EHR didn’t help.

The shortage of primary physicians is also causing more patients to come to the urgent care who don’t have urgent care problems. I’m glad that we’re less expensive than the emergency department and fill a vital after-hours need, but we’re not equipped to handle complex medical situations or social issues.

About 15 minutes prior to closing, a patient arrived who was seriously ill. She was in the middle oncology treatment and was afraid she had pneumonia. We made a quick decision that she needed to be transferred to the hospital, but we had the complicating factor of the minor children who were with her. We were reluctant to call for an ambulance transfer without someone to care for the children, knowing they couldn’t ride with her, but her condition was worsening. We also can’t have children in the office without a parent or guardian, especially after closing.

As we worked with her to quickly try to find someone to pick up the children, the rest of the story unfolded, revealing an even more tragic explanation for why she was caring for her grandchildren. At least if we could get her to the hospital, social workers could assist. We finally found a solution when one of our patient care techs called the ambulance district and convinced a dispatch supervisor to head over with the ambulance so he could transport the children to the hospital.

These are the situations that can’t be captured well with discrete data, and when you’re trying to problem-solve well outside the box and get the patient ready for transfer, every click counts. We have to complete our H&P documentation so it is printable for transfer and finally I gave up and just free-texted most of it. By the time our patient was stabilized and loaded, the staff was mentally and physically exhausted.

It’s important for team members who work on the IT or billing side of the house to understand the kind of situations we’re facing in patient care. I’m pretty sure I didn’t code the visit as accurately as I could have or gather as many quality measure data points as I should, which would count against a lot of physicians. I won’t take too much heat for it, but it will definitely skew my treatment cycle time metrics. As I reflected on the day overall, I started to question myself on continuing to practice clinically. Although it’s important to see patients to keep me grounded, it’s significantly more stressful than just being on the IT or consulting side and I completely understand why we can’t keep physicians in primary care practices in my community.

Hopefully my next shift will be more in the box than out, but you never know any more in healthcare.

If you’re a CMIO and don’t see patients, how do you stay grounded? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/28/17

September 28, 2017 Dr. Jayne No Comments

Hot on the heels of Anthem and Express Scripts as they work to curb the opioid epidemic, CVS Health announces restrictions on coverage for certain opioid doses and durations. The Caremark unit of CVS is one of the largest pharmacy benefit managers, covering nearly 90 million patients. Starting in February, patients requiring short-term opioid therapy will be limited to seven days of medication.

I was surprised to learn that some patients with short-term pain needs were receiving 20-30 day supplies of medication since I don’t see a lot of that prescribing behavior in my community. Patients requiring long-term treatment will be limited to a dose of 90 morphine milligram equivalents. Patients must also demonstrate that they’ve been treated with immediate-release medications before they will be allowed to fill prescriptions for extended-release medications. Physicians will be able to appeal the restrictions through a prior authorization process, and employers and insurers can opt out of the restrictions. They’re basing the restrictions on recommendations from the CDC, issued last year. CVS is also adding medication disposal units in 750 of its pharmacies.

The healthcare IT season is starting to heat up, with the Epic user group underway and the Cerner conference approaching. From a vendor standpoint, the buzz ebbs and flows until it reaches its apex at HIMSS, but I’m starting to see some activity among health systems and larger medical practices. Maybe it’s the potential relaxation of some of the regulatory burdens that people were anticipating, or perhaps there are other forces at play, but groups seem to be talking about making technology and systems investments when they had previously been keeping their purses closed.

I’ve been asked to give input on a couple of RFP documents, which could result in some large purchases that I didn’t see happening in the next couple of years. It could also be that organizations want to use the relative regulatory lull to get ready for any future crushes. I’ve worked with a couple of groups that have done rip-and-replace system transitions across reporting periods and shifting regulatory requirements, so I agree it’s smart to move things forward now if you think you’re ready to make a change.

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I’m not mourning the demise of the 2014 NCQA Patient Centered Medical Home Standards, which are nearing their end. Practices who had already purchased the 2014 survey tool can use it through September 30, but after that, organizations have to transition to the 2017 standards. This has been a confusing time for many of my clients and I’m certainly looking forward to being able to support groups on a single set of standards. Patient-Centered Medical Home efforts continue to get quite a bit of attention, even for practices that aren’t trying to maximize their payments under MIPS.

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I’ve been trying in vain to contact a colleague in Puerto Rico, not only so I can know that he’s OK, but also to ask if there is anything I can do to help other than sending money. The reports I’ve seen are personally heartbreaking and professionally unfathomable. A week after Hurricane Maria’s landfall, most of the island is still without power, including more than 50 of the island’s hospitals. A little more than half of the residents have access to drinkable water.

The hospitals that are still open are running on generators and attempts to connect them to the power grid have resulted in a few hours of success followed by a return to the generators. Patients are seeking emergency care in larger numbers than facilities are prepared to handle — partly due to water, power, and supply shortages — but also due to the fact that many facilities are also damaged and unable to operate at all. Those facilities that are able to run are not at full staffing levels and surgical case volumes are limited.

Some descriptions liken it to a war zone, with healthcare providers making due with whatever then can find. It sounds like pharmacy stocks are holding out, although there are glitches with electronic payment systems and technology infrastructure. Patients are being evacuated to Louisiana and South Carolina, with the Navy’s hospital ship USNS Comfort expected to arrive next week.

The Comfort is no stranger to natural disasters, having been on station in Haiti following the 2010 earthquake and in the Gulf of Mexico following Hurricane Katrina in 2005. It can staff up to 1,000 hospital beds and has 12 operating rooms. Still, patients with critical needs, such as open heart surgery, are being encouraged to travel to the continental US for surgery, although travel off the island remains an issue.

The Department of Health and Human Services has relaxed rules on physician licensure, allowing physicians to practice in the emergency area under an unrestricted license from another state rather than requiring them to be licensed where services are rendered. HIPAA penalties are also being waived with regard to distribution of privacy practices documents and sharing medical information with family members. It could be six months before power is fully restored and the needs will be great to combat public health crises related to the storms and flooding.

The One America Appeal, originally launched by the five living former US Presidents to support recovery from Hurricane Harvey, has been expanded to include areas devastated by Irma and Maria. Donations will go to a fund managed by the George H. W. Bush Presidential Library foundation, which will distribute them to existing disaster relief funds supporting affected areas. The Foundation will ensure that 100 percent of donations will go to hurricane recovery, and donors can specify which recovery effort they want to support, if desired. I’m hoping I hear from my friend soon and that he and his family are safe.

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Curbside Consult with Dr. Jayne 9/25/17

September 25, 2017 Dr. Jayne 1 Comment

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One of the more useful clerkships I completed during Medical School was one in Occupational Health. It provided me the opportunity to visit a variety of different workplaces and to learn about the health-related challenges faced by different types of workers. I worked with employees at a zinc refinery, a radiation-contaminated EPA Superfund site, at our affiliated health system’s laundry facility, a soap manufacturing plant, and several other locations. One of the workplace types we didn’t visit was the typical office setting. Although we learned about the repetitive motion injuries common in decorative butter-ball rollers, we didn’t learn much about health conditions caused or aggravated by computer use.

Since then, we’ve heard more about carpal tunnel syndrome and repetitive motion injuries. In addition to hand-related conditions, those of us who spend the majority of our days in front of a computer can encounter complications of decreased mobility along with symptoms such as numbness and tingling of arms and legs. Headaches, neck pain, and back pain are also common. Although many of those symptoms can be combated by ergonomic interventions, many companies lack the knowledge or resources to pursue special positioning devices, supplemental hardware, or new work areas. I have several colleagues with standing desks and those can make a difference with the mobility issues, but sometimes introduce additional problems when individuals embark on an activity plan that is different than what they have done previously.

The American Optometric Association also notes issues with what they call “computer vision syndrome,” which is a cluster of visual problems resulting from prolonged use of computers, tablets, cell phones, or e-reader devices. Symptoms can include blurry or double vision, eye burning, itching, and red eyes. It extends a little farther than the “eye strain” of old, and is also more prevalent due to the large number of workers exposed to computer work throughout the day. Some estimates cite a figure of up to 70 million workers who are at risk. The journal Medical Practice and Reviews recently published a paper on the condition, explaining some of the physiology behind the symptoms. Prior to reading it, I hadn’t really thought about the fact that computer work is known to reduce the frequency of blinking, leading to dry eyes and irritation. Although the paper specifically looked at the condition in Africa, it cites computer vision syndrome (CVS) as “an emerging global epidemic, which if not clearly understood and appropriate interventions designed, may have negative impact on productivity and economic development.”

Risk factors for CVS include working with a monitor that is too close (20 to 28 inches is ideal) or monitor height that is too high. Placing the monitor in a lower line of vision causes the eyelids to be open a smaller distance, which reduces the frequency of dry eye symptoms because less of the surface of the eye is exposed to the air. Having a slightly lower monitor is also supposed to promote neck relaxation. Anti-glare filters are also recommended when glare is an issue. Since computer use is a major risk factor on its own, the authors note that due to the increased use of computers among students and children, symptoms are also present in that population.

Many of us in healthcare are highly focused on conditions that inject the most cost (and most comorbidity) into the healthcare system, such as diabetes, heart disease, obesity, and chronic pulmonary diseases. I was surprised to read that the estimated expenditure on eye diseases in the US is $16 billion each year, more than twice spent on breast cancer when you look at another disease to place it in proportion. In addition to the ergonomic recommendations, experts also recommend simple preventive steps, such as taking a break every 20 minutes to stare at an object at least 20 feet away. This recommendation poses a challenge for those of us doing close-up work in an exam room, which is rarely larger than 10×10 feet in many offices. It’s not clear whether switching back and forth between the screen and the patient adds to or helps eye symptoms. Workers with dry eye symptoms can also use moisturizing eye drops.

Eye symptoms and musculoskeletal issues aren’t the only things we have to worry about in the modern workplace, especially those of us that bring work home with us or work on highly flexible schedules. It’s been suggested over the last several years that exposure to artificial light at night may be linked to depression. One study in the journal Molecular Psychiatry showed that hamsters exposed to dim light at night over a four-week period had changes in brain chemistry that were linked to depression. The good news is that the effects could be reversed by returning the hamsters to a normal light-dark cycle for a couple of weeks. The fact that the study was done with hamsters made me think about the fact that many of us feel like we’re on a hamster wheel on a daily basis, so perhaps the results are more relevant than we might think.

CDC, through its National Institute for Occupational Safety and Health, lists additional challenges in the office environment – temperature, humidity, light, noise, task design, and psychological factors such as personal interactions, work pace, and job control. In the world of healthcare IT, I definitely hear about the latter three. CDC also mentions that “job stress that results when the requirements of the job do not match the capabilities or resources of the worker may also result in illness.” In the world of ever leaner workplaces and job consolidation, there is no shortage of that type of stress.

I’d be interested to hear from readers in various sectors about how their employers are or are not addressing occupational health issues. Does your employer encourage you to check your bags so you don’t have to hoist them in the overhead bin? Are you allowed to relax while traveling or are you expected to work with your laptop balanced on your knees because it won’t fit between the tray table and the seat in front of you? Do home-based employees get a budget for ergonomic workstations or at least comfy chairs? Is it better in academia versus industry? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/21/17

September 21, 2017 Dr. Jayne 1 Comment

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I took time out from consulting this week to attend the first-ever Smartsheet user conference, held in Seattle. I’ve been a user of Smartsheet for some time, primarily because it makes it easy to share project plans and documents with clients in a way that I can control without having to deal with versioning issues. I like the ways people can collaborate and it just feels easier to me to use than other Web-based collaboration tools. When I heard a few months ago that they decided to host a client conference, I jumped at the chance to see what it looks like when a company decides to make that happen. I’ve heard plenty of tales from the EHR world about clients who attended the first user group for a given vendor, many of which take the "bunch of guys and a couple of cases of beer" story form.

I suspected Smartsheet had progressed well beyond that narrative based on the agenda, which included a wide variety of sessions and social events. The conference kicked off on Monday with a meet-and-greet at The Parlor in Bellevue, just a hop, skip, and a jump from the conference hotel. Pool tables and ping-pong competed for attention with Monday Night Football, along with a variety of snacks and drinks. For those of us who are perpetually jet lagged, it was a nice way to start a conference. The conference went into full swing on Tuesday with over 1,000 people in the audience for the keynote session. They brought in local DJ Darek Mazzone to introduce the crowd to the Seattle music scene and it definitely set the tone for the morning. Prior to the conference, I didn’t know anything about the company’s leadership, but found them engaging and passionate about the work they’re doing. Based on the staging and lighting budget, it was clear they had spared no expense in aiming for a first-class entry into the user conference space.

The company used the event to launch several new features, some of which were literally rolled out immediately prior to the conference kickoff. I hadn’t been aware of their mobile app before they discussed it at the keynote (not sure how I missed that little tidbit) but quickly downloaded and started testing it. After the pumped-up buzz of the keynote, everyone headed out to breakout sessions. The halls were crowded, which was a testament to the sold-out status of the conference, which seemed a little large for its surroundings. The first few breaks between sessions were crowded with videographers trying to capture footage of the crowd along with client interviews. I took advantage of one of the breaks to talk to one of the mobile developers, who was very interested in hearing what users think of his product and who didn’t give me any sass about the fact that I didn’t even know it existed until a few hours prior.

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Breaks were also prime time to continue on the "swag journey," which drew participants to various booths highlighting different product features. The swag was outstanding, with a high-quality messenger bag for everyone (although I was surprised that it didn’t have a Smartsheet logo). I bypassed some of it but did snag the conference survival kit with its band-aids and mints along with a tech case with some headphones that my teenage house-sitter will like. I took a pass on the fidget cube and tattoo stickers. The swag hunt punch-cards led to some jokes among attendees who had difficulty figuring out which booth had which swag (or whether a booth had swag at all) until they learned to "follow the hole punch crumbs." We’ll see if that gets changed out for next year.

One conference element that I hope does get changed out is their preregistration and attendance scheme. Attendees had to preregister for sessions and then have their badges scanned for admittance to a session. If you were one of the unlucky attendees like me who didn’t receive the preregistration email, you had no idea you had to preregister for sessions, and were consigned to a second-class "standby" lane just outside the meeting room. Others who did preregister weren’t showing a green light when scanned, and were sent to the end of the standby line. The way it was handled at some sessions was less than customer-friendly, and I hoped that after a couple of rounds of this silliness the conference organizers would have tried something different. It continued throughout however, with room monitors ranging from just letting people in regardless of whether they scanned green or not, to being belligerent with attendees. I resigned myself to the standby line but was able to get into every session I wanted to attend. The bottom line though, is that for a company that talks a lot of about reducing wasted time and streamlining work, they added some major inconvenience (and dissatisfaction) for their attendees. Pro tip: Have people pre-register to get a feel for the room size you need for each session, then bump that by X percent and just let everyone in without a bunch of silly lines.

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Some sessions featured a sketch artist creating story boards during the sessions, which was fascinating to watch if you were lucky enough to get a seat in the front. My favorite session was one on collaborative work, led by Margo Visitacion of Forrester Research. She addressed a lot of issues that I cover in some of my change leadership courses, including helping people understand the new ways that work is done today and how knowledge workers operate compared to traditional work methods. My second favorite session featured Amy Sovereign from the City of Detroit discussing how their Program Management Office uses Smartsheet in their Lean Six Sigma efforts. The presentation format was more of a fireside chat, but with vibrant photos of the city projected on the big screen as they talked. They’ve done some interesting things with the technology including end-of-shift debriefing surveys when they deployed body cameras to the police department. She got several chuckles from the audience, talking about people who are "allergic to Lean Six Sigma" and how much people love their paper. I also enjoyed her comments about making sure that you have buy-in before deploying new solutions, because you "don’t want to put technology in a catapult." It’s vivid images like those that can captivate an audience.

I was less-than-captivated by another session where the male panelist was introduced with all of his credentials and accomplishments, and the female panelist was introduced as "the lovely Miss Jane Doe." I’ve never heard a man in a professional setting introduced as "the handsome Mr. John Doe" so I’m not sure why that is acceptable, and I wasn’t the only person it grated on. This phenomenon has actually been studied before, and I would encourage presenters and moderators to take a gander at the paper before preparing your next set of introductions. The session was also marred by horrible feedback between the speakers and the microphones and a constant humming, so I didn’t get much out of it. Speaking of ruining the audience experience, I’m not sure why people still think it’s OK to answer phone calls in the middle of the session and talk all the way down the aisle and out the door. Nor do I understand why someone would do a conference call in the hallway on speakerphone and not with headphones, but I saw that at least twice.

The lunch breaks were designed to be networking sessions, and on Tuesday I wound up at a project management-themed table with people from all kinds of companies. I don’t want to unmask my secret identity by saying who I sat with, but people I met at various points were from Target, Centene, Oregon Health & Science University, Comcast, MGM Hotels and Resorts, health systems, hospitals, EHR vendors, Microsoft, DocuScan, local school districts, municipalities, Salesforce, and more. It was a great conversation and very gratifying to hear about the way some of these groups were solving the same problems I run into with my clients. Of course, explaining my vague-sounding consulting firm always garnered some interesting looks.

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Tuesday’s client event was at the Chihuly Garden, and on the hour-long bus ride (love that rainy rush hour Seattle traffic!) I met some fun people who had some great advice for doing different things with Smartsheet. The event featured not only the glass, but food and drink from various local vendors along with seafood, pasta, and an all-potato buffet with parmesan French fries, tater tots, kettle chips, potato skins, and a baked potato bar. The dessert tables had been picked clean by the time I figured out they were in a separate little greenhouse area, so I missed out on the eclairs. The featured cocktail included moonshine from 2Bar Spirits, but I steered clear.

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Wednesday’s keynote included a panel of Smartsheet leaders taking audience questions, followed by Captain Chesley "Sully" Sullenberger, who I found riveting and one of the best of the many professional keynote speakers I’ve seen over the years. If you’re looking to be inspired to greater things such as duty, honor, dedication, and service, he’s your man. He had some great insights into how people and technology interact, along with the true nature of innovation – changing before you’re forced to. I do have to say though that watching the recap of Flight 1549’s journey at the beginning of the speech was haunting. I’ve made plenty of life or death decisions in very short timeframes with patients on the table in front of me, but I can’t imagine being in his seat with 155 passengers on board and figuring out a solution that saved everyone. He recounted how hearing the flight attendants shouting "Brace, Brace, Brace" to the passengers functioned in a sort of cheerleading capacity to help him through the situation. He highlighted the performance of his team during the incident and how everything in their careers before that helped prepare them for the situation. One of his statements really resonated with me as he discussed how 208 seconds has come to define his entire career as a pilot. I thought about that several times the rest of the day – if we had three minutes that would define our careers, what would that look like?

Overall, I was happy with my choice to attend, although the registration fee plus a couple of nights of Seattle-area hotel rates put a dent in my budget. Smartsheet did a great job with their inaugural client conference and I’m looking forward to seeing things grow. They’ve certainly come a long way from their startup in a little yellow house in Kirkland, WA.

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Curbside Consult with Dr. Jayne 9/18/17

September 18, 2017 Dr. Jayne 4 Comments

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I recently spent some less-than-quality time at my local Department of Motor Vehicles office. Since the lines were long, I had the opportunity to observe many of the processes that were occurring, coming to the realization that some of the issues we are battling in healthcare IT aren’t unique to our industry.

The first thing I noticed was a confusing registration kiosk, which had been implemented since the last time I was there. There wasn’t any clear signage to direct people to the registration kiosk, so people came into the building and stood there looking for the old “take a number” dispenser without much luck. Eventually other waiting patrons would direct people to step up to the kiosk, and then you could see more confusion occur as they tried to figure out how to use it. When I approached the kiosk, I could see that it was designed to handle two different registration processes (titles and vehicle licenses vs. driver licenses) and the language on the screen was ambiguous, resulting in a post-it note at the bottom of the screen that provided additional instruction. Once you registered, it printed out a number slip, but the printer wasn’t anywhere near the kiosk; it was instead mounted around the corner on the half-wall supporting the service counter.

How many times in healthcare IT do we implement new technology but fail to change the physical space to maximize adoption? I have nightmarish visions of all the physicians I’ve watched juggling laptops on their actual laps, because they don’t have an adequate surface on which to use it while also facing the patient. Have you ever seen a computer on wheels that’s on a cart so big it barely fits through the doorway, leading nurses to leave it parked in the hall rather than bring it into the patient room? How often do we ask users to navigate a poorly designed system that requires external “job aids” and “cheat sheets” to know what to do because it’s not obvious from the screens?

I made it through the registration gauntlet, but then had to listen carefully to the numbers being called because they were using the same number series for both driver licenses and vehicle licenses. It wasn’t always clear whether they were calling “number 8 for titles and licenses” or “number 8 for driver licenses” and so on. As I tried to observe the flow, I was even more confused by the fact that the “titles and licenses” clerks were subdivided into those that only did vehicle and boat licenses, and those that could process vehicle licenses and titles but not boat licenses. It took me at least a couple cycles to figure out which staff members were working on which issues. It reminded me of situations I’ve seen in hospitals where patients have to visit with multiple registrars to get situated prior to a laboratory or radiology procedure, depending on what kinds of services they needed. As the patient, it makes one feel shuffled around and that your needs aren’t being met, and as a consumer at the DMV I didn’t feel any different.

I also had the opportunity to watch the clerks try to straighten out several customer service issues, where patrons didn’t quite have the right information they needed to complete their transactions. Several of them involved elderly individuals trying to obtain driver licenses in a new state of residence, who might be missing a critical form of ID such as a birth certificate or Social Security card. More than once I heard clerks asking customers if they had their “red, white, and blue” card with them, which I quickly figured out was the Medicare card. In the absence of a Social Security card or proof of SSN, they were accepting the Medicare card as a proxy. I couldn’t help but wonder if anyone was educating the DMV about the Social Security Number Replacement Initiative, which is now called the New Medicare Card initiative. Certainly DMV staff will need different scripting when the new Medicare cards hit the streets, and I’m sure there will be an uptick in customers making multiple visits to get their licenses squared away.

While waiting, I noticed that they had installed a video screen that was supposed to display helpful information about your visit, not unlike educational programming in a physician or hospital waiting room. However, they had the screens set to advance so quickly that it was difficult to read all the content on the screen, requiring multiple cycles through the information to be able to absorb it all. I’ve done similar work for medical practices, both in the waiting room context and with employee workstation screensavers. I’m pretty “DMV literate” but I still couldn’t follow all the information they were trying to impart. It got me thinking about whether organizations are adequately considering elements such as health literacy and accessibility when delivering this kind of information.

When I finally made it to the counter, I had some extensive back and forth with the clerk, who tried her best to try to convince me that I didn’t need to file the forms I was there to file. It reminded me of my recent journey through trying to get approval for a colonoscopy from my insurance, who couldn’t see past the fact that I am not yet at the “typical” age for the test. Both clerks were so stuck in policy and procedure that they couldn’t see the documentation being put before them so that they could do what was right for the patient/customer. In both cases a supervisor had to be called, with the information repeated multiple times to different staffers, only to ultimately accomplish what was asked for in the first place. How many times do we see this in healthcare, where rules often cost us efficiency and patient satisfaction?

Even though I had convinced the supervisor to file my paperwork, I still wasn’t convinced that the state would mail me what I needed in four to six weeks as promised. I wasn’t sure that the information I provided had been keyed in accurately or that it described my situation, and just had to hope for the best. It was like sitting and waiting for your Explanation of Benefits statement to see if your procedure was going to be covered after all or rejected. Barely a week later, I was pleasantly surprised to receive my finalized documentation in the mail, exactly as I had expected it. Much like healthcare, despite the barriers placed in front of us, we still get good outcomes. It’s just a shame there has to be so much chaos leading up to the end point.

What other parallels to healthcare do you see in other industries? Are they solving the problems better than we are? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/14/17

September 14, 2017 Dr. Jayne No Comments

The Patient-Centered Outcomes Research Institute Board recently approved $97.9 million to support clinical effectiveness research. Eleven studies will compare different approaches to improving care for conditions that stress patients, caregivers, and the healthcare system. Issues addressed in the studies include opioid use for chronic pain, improvements to treatment of multiple sclerosis, and treatment for young sickle cell disease patients who are moving to adult care. They also approved $32.8 million for studies with pragmatic design; one for therapies to help patients with head and neck cancer swallow better; one to evaluate antiseptic skin washes used prior to orthopedic surgeries; and another that looks at effective prevention of dental cavities. Practical studies like this help to emphasize the need to continue spending research dollars to see how we can better improve health promotion, disease prevention, and the treatment of burdensome illnesses.

With all the intrigue around repealing the Affordable Care Act, I missed the fact that the Children’s Health Insurance Program (CHIP) must be reauthorized by Congress. CHIP covers nine million children from low- and middle-income households. Legislators are considering the duration for which they will reauthorize the program as well as whether other initiatives will be attached. There are a couple of other priorities Congress is grappling with, such as the debt ceiling, which also have to be addressed before the 30th. The last CHIP reauthorization was for two years and was passed months before the expiration date as part of a larger Medicare package. I’m all for ‘just in time’ delivery but this is cutting it close. Some states would run out of money as early as December, although others might have enough funds to get through the spring. Since many states already planned their budgets assuming the CHIP funding would be there, a loss of funding could trigger extensive cuts.

For those of you looking for your next gig, the FDA is accepting applications for its Digital Health Entrepreneur-in-Residence program aimed at supporting and developing the Software Precertification Pilot Program. The fellows will work with the FDA Digital Health Unit at least three days per week and will work to analyze software industry processes and key performance indicators to aid in predicting product quality. The goal is to look at the technology developer rather than at the finished product, as the FDA currently does for medical devices. Fellows will work with data modeling and will interact with stakeholders, pilot program participants, and internal FDA staff. Candidates must have at least five years of experience in software design, process improvement, metrics development, clinical trial design, post-market surveillance, or other related fields. During the six-month to two-year commitment, fellows will be based on the FDA White Oak campus in Silver Spring, MD. Applications will be open through September 29.

Patient engagement is a priority for many organizations, and CMS has announced a Medicare-Medicaid Coordination Office (MMCO) sponsored webinar titled “Involving and Supporting Family Care Givers in Care Planning and Delivery.” This is a timely topic for organizations looking to involve and empower the family members who are involved not only in assisting patients with activities of daily living but also in trying to manage multiple medical conditions, ensure medication compliance, watch for deterioration in patient status, and navigate the maze of healthcare. The webinar will also cover strategies for engaging families while respecting cultural diversity and will include geriatricians as well as a family caregiver. A close friend of mine just lost his spouse after a longstanding illness, and the stress on caregivers can be significant. Involving them in the care plan can help them focus on what they are able to do to improve quality of life for their loved ones rather than feeling helpless and alone, as my friend sometimes did while navigating the system on his wife’s behalf.

As a provider in flyover country, I didn’t know there was such a thing as the CMS Hurricane website; it’s got a lot of information about exceptions and exemptions for Medicare providers impacted by storms and flooding. Exceptions are being granted under quality reporting and value-based purchasing programs for hospitals, inpatient facilities, rehabilitation centers, home health agencies, hospices, and more. Exceptions are automatic based on location in a FEMA-declared major disaster county, without the entity having to submit an exception request. Additional options for impacted organizations include waver of hospitalization requirements prior to skilled nursing facility coverage if patients are evacuated, transferred, or relocated due to hurricanes; temporary expansion of bed counts at Critical Access Hospitals; waivers to permit replacement of lost or destroyed Durable Medical Equipment; and replacement prescription fills for covered Medicare Part B drugs. Other waivers are specified by state and entity. In addition to temporary relief from administrative burdens, CMS announced that US Public Health Service Commissioned Corps members have been deployed to affected areas, including physicians, nurses, and dieticians.

In other CMS news, a recent Proposed Rule would cancel two new bundled payment programs set to begin next year, and would overhaul the Comprehensive Care for Joint Replacement model that is currently mandatory in 67 geographic areas. It would become voluntary in 33 of those areas, underscoring a plan by CMS to boost participation in voluntary programs rather than requiring participation in episodic payment models. While CMS might be reducing burdens, other governmental entities are introducing new ones, namely a proposed House bill that would require e-prescribing of controlled substances under Medicare. The Every Prescription Conveyed Securely Act (HR 3528) is largely in response to the opioid crisis and would require e-prescribing for controlled drugs under Medicare Part D. Electronic prescribing of controlled substances is legal across the US now, with some states having their own additional controlled substances requirements. Although it specifies Part D requirements, it could push a lot more physicians to adopt the technology, as many will not want to have separate workflows for controlled and non-controlled drugs.

I had a couple of client engagements that were impacted by the hurricanes, so I’m about to head out on the road for a couple of weeks. None of my clients were in the areas of direct impact, but one did have some secondary flooding and a power outage. Fortunately, their failover systems worked as planned and their downtime procedures were in place, so the business was able to get up to speed as soon as the road to the office was accessible again. The recovery from these storms will be going on for months to years, so I know those who escaped with minimal impact are extremely grateful.

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Curbside Consult with Dr. Jayne 9/11/17

September 11, 2017 Dr. Jayne 2 Comments

Over the last several years, I have worked with a number of organizations that are trying to improve their corporate cultures. I have to give them full credit first for realizing that they had cultural issues, and being willing to reach out for help. I do most of my work in this area as a subcontractor for another consulting firm, which likes to bring me in because I can not only do the work but I have the MD behind my name. There are a lot of physicians who need coaching (and sometimes coaxing) who respond better to a peer with the same degree, regardless of their understanding of your level of experience behind the credentials. Some of their clients are large health systems and some are smaller, but everyone is facing similar stresses brought on by the pace of change in healthcare.

Many of the issues that we deal with are “light” cultural issues – basically having a set of rules, whether written or not, about how teams work together and how meetings are run. These are some of the low hanging fruit-type items, such as making sure meetings have agendas, that we work on scheduling policies and procedures, and that we work on managing meeting dynamics. Often, people are resistant to change for the sake of resisting change, or because they’re stressed about getting their work done. Having agendas and scheduling protocols can help reduce the overall burden of meetings. Once workers start to see that following the rules of engagement helps get them out of meetings and back to other activities, they begin to buy in to some of the larger changes that we need to make.

We typically have to get people to that place where they know they’re not going to be undergoing “death by meeting” as much as they’re used to, before we introduce some of the more challenging concepts such as device-free meetings. One has to move carefully towards that goal, especially with organizations that have been through layoffs or reorganizations. In these cases, teams may be understaffed and employees figure they’re running a hundred miles an hour and can’t keep up. They multitask during meetings, working on email and texts either overtly or under the table. Eventually we need to get rid of those distractions, but you’ve got to have some breathing room first. When people know the meeting will finish on time or early and they will have time to check email, get something to drink, and hit the restroom, they’re more likely to play along with other changes you need to make.

The goal is to get everyone to focus on the meeting at hand – not on their next meeting, or all the other things they have to do when this one is over. In other words, to be fully present and attentive to what is in front of them. It’s difficult enough to do when people are so used to multitasking or being instantly accessible to others, but it’s even more difficult to do when you try to do that kind of a transformation without a plan. I worked on an HIE project a few years ago with an organization that handed out custom challenge coins with the phrase “Be Present” to every employee without any kind of background or lead up to the initiative. The first thing that people speculated on was how much money the organization had spent on it, especially when staff hadn’t had a pay increase in several years and people had been downsized.

A couple of weeks later, when the actual initiative was rolled out, it was regarded as a joke. I would be on conference calls where people were blatantly ignoring what was going on, and rather than even try to cover with an “excuse me, can you repeat that” or “I missed the question” they’d actually say, “I’m sorry, I wasn’t fully present” as if that absolved them from being disrespectful. The first time I heard it, I was just grateful that I was also on the phone and that I wasn’t in a room full of people who could see my expression of horror. I encouraged management to address the comment directly with the employee in question, but they didn’t want to “ruffle feathers.” Since there were no repercussions, others felt emboldened to do the same thing, and the idea of “not being fully present” actually started to work its way into the corporate culture. I was glad to be working on the HIE project and that I wasn’t wearing my change leadership hat for that one. Watching their efforts implode was painful but taught me a great deal about what not to do when working on cultural transformation projects.

I hear similar tales of woe from some of my physician colleagues whose practices have been acquired by larger organizations. A couple of them are part of an organization that is focusing cultural transformation around the idea of assuming positive intent. There are plenty of leadership experts that support this philosophy as a way to help move organizations forward through difficult times. When you’re being asked to change, assuming that it is for the better can smooth the way. Groups trying to change rapidly may not have time to explain the full who, what, where, when, why, and how, so the phrase aims to encourage people to trust those that are leading them and working with them so that everyone can advance. It can be a great productivity booster as people free themselves from worrying about the ulterior motives of others.

Depending on who you talk to or whose materials you read, however, there’s another piece to the phrase: Assume positive intent until proven otherwise. This means that when negative intent is identified, people who are creating chaos need to be dealt with so that they no longer have the ability to disrupt or harm others. It’s hard to do that tough work though, and none of us particularly enjoy dealing with disruptive people. I’m hearing more and more about organizations that seem to be looking the other way or that are unwilling to deal with difficult people, asking their co-workers to just go along with it for the sake of assuming positive intent. I’ve heard stories about other organizations who have used the concept as a way to counter poorly-led or hastily-planned initiatives. Asking your employees to assume positive intent when you don’t have your leadership act together is not the way to build trust or move towards success. Changing corporate culture is incredibly difficult and it’s best when coming from both the top and bottom.

Is your organization working on corporate culture? Has your team asked you to assume positive intent? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/7/17

September 7, 2017 Dr. Jayne 2 Comments

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I was interested to hear of Cerner’s formation of an Advisory Group “to provide insights and recommendations in support of Cerner’s work” on the VA EHR program. Although it’s “comprised of distinguished former government, military, and private sector leaders sharing a common interest in Veterans health and wellness,” it’s lacking any “regular” veterans. My former hospital was very progressive in having patients represented on a variety of steering committees and project teams – sitting right alongside the CEO, hospital board members, department chairs, service line directors, and other stakeholders as we made a variety of decisions that impacted patient care. I didn’t fully understand the gravity of having patients (and their caregivers) on those committees until I experienced it myself. Staring a patient in the face while making difficult decisions about EHRs and the management of patient data is very different than making the decision in a room of IT experts. Even though there are distinguished veterans in the group, I would submit that the electronic health needs of the “average” veteran are different from one who is a former Senator/Governor; even though Senator Kerrey does have experience receiving care in the VA system. My local VA is seriously challenged with leadership turnovers, staffing issues, and poor patient care experiences that our veterans do not deserve. Let’s get some patients in the room and see what a difference it makes as Cerner works to move their care forward.

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Speaking of patients, just a reminder that all of us will be patients at one time or another. Let’s avoid being patients with influenza – the vaccination season has already started. The CDC website has information on projected strains – my employer requires all staff members to receive a vaccination by the end of next week. The best part of being vaccinated during my last patient care shift was watching my staff decide who was going to get the short straw and have to play “pin the vaccine on the physician.” The worst part was realizing several hours later that my band-aid had fallen off and I had bled through my scrubs and white coat, probably causing patients to wonder what was going on with my arm (although no one mentioned it). The paramedic who administered my vaccine was horrified, but accepted my explanation that it was much more likely due to the daily aspirin I’m taking rather than her technique.

CMS released a new fact sheet that covers mass immunization events and so-called roster billing. Most of my experience has been with traditional office-based immunizations, but I always enjoy learning something new. Definitely something to think about for organizations who provide mass-immunizations and whose practice management or billing systems will support that type of billing.

We’re struggling a little at the office with physician coverage, as several of our physicians recently relocated with spouses that were finishing medical school or residency and moving on to fellowships or other training programs. We’ve always done our own recruiting, but are thinking about using a firm to broaden our reach. Since primary care physicians are in high demand, I often receive recruiting materials and had to bring in a post card from one recruiter as an example of why we shouldn’t consider using them. Rather than lead with the usual comments about patient volume, procedures, availability of scribe coverage, and hospitalist use, it started with “features two private lakes in a wealthy suburb.” Sure, I’d love to relax by the lake between patients, but I’m thinking it’s more likely that some copy editing is in order.

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If you’re on the hospital side, CMS will offer a webinar on September 12 covering the Fiscal Year 2018 Inpatient Prospective Payment System (IPPS) Final Rule. This includes clinical quality measures for the Inpatient Quality Reporting (IQR) Program and Medicare/Medicaid EHR Incentive Programs for eligible hospitals and critical access hospitals. It’s difficult to keep up with all the changes to these programs, so having someone help digest the content might be helpful.

If you’re on the vendor side, CMS has opened the self-nomination process for vendors who might want to be recognized as a Qualified Clinical Data Registry (QCDR) or as a Qualified Registry. The window closes November 1, 2017 for the 2018 MIPS performance period. Candidates have to not only submit a self-nomination but also must email CMS when their application is ready for review. There is quite an array of registries out there, and I’ll be interested to see what new organizations come to the table and whether they’re offering anything truly unique.

Things are starting to pick up in the healthcare IT world, and the user conference season is in full swing. Allscripts hosted its clients in Chicago August 8-10, followed by Aprima, which welcomed its customers August 18-20 in Dallas. Epic will host its clients on-campus September 25-28 with a theme of “World of Wizards.” The EClinicalWorks national conference will be held October 6-9 in Dallas; following that, DocuTAP will hold its User Summit in Nashville October 10-12, overlapping Cerner, which will hold its annual conference October 9-12 in Kansas City. NextGen rounds out the season with its annual user group meeting November 5-8 in Las Vegas.

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Some year I would love to take a sabbatical from consulting and just go from conference to conference to conference. Pulling off that kind of a feat would require a lot of wardrobe planning and a serious amount of shoes. The other alternative would be to work with my friends at Heelusions to accessorize a pair or two and give them unique looks for the different vendors and events. I’m impressed by their Cerner-specific creation and wonder if anyone will be sporting them in Kansas City. Brand is everything, and this would certainly let employees embrace the company from head to toe (not to mention, it’s rare to see vendor-logo footwear.) HIMSS is coming, so if you’re looking to take your shoes to the next level, you might want to check them out.

What’s your favorite vendor-logo item? What’s the worst you’ve seen? Email me (and of course send pictures)!

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/31/17

August 31, 2017 Dr. Jayne No Comments

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I’ve received quite a bit of correspondence lately, so it’s time to open the reader mailbag.

From Coastal but not Coasting: “Re: great article. It came at the perfect time for my practice. We just received PCMH recognition, level 3, so we are currently beaming! But it has not been easy. There have been many challenges, including staff burn-out and frustration over all of the change. We had to get them to buy in to it without always knowing WHY the change needed to occur. Sometimes the WHY is very involved and time-consuming and we were trying to fast track recognition.” I agree that sometimes sorting out the “why” and the “what’s in it for me” can be challenging, especially when trying to work through things quickly or when trying to meet specific regulations that don’t always mesh 100 percent with how the organization has been running. There are times when I’m working with clients where I just want to say, “Because I said so, and your boss is paying lots of money for my expertise,” but that would rarely go well. There’s an art to balancing buy-in vs. top-down rulemaking and I applaud organizations that have figured out how to do it well.

From Back to School: “Re: huddles. Have you ever met anyone that runs a family huddle? Thinking about my family and children and the chaos of school around the corner made me pause to consider if we might benefit from a more set time / agenda to nail down logistics. We communicate well, but sometimes it’s frequent and distracting with our own work days.” Why yes, I do! One of my good friends from Big Health System takes her process improvement work home with her. They have a family huddle during dinner where they run through the activities for the next day and outline what equipment, supplies, and transportation are needed. Thinking back to the one I witnessed, it’s a lot like a practice huddle. They also maintain a family Google calendar so everyone can see it from their phones. Time management is an important skill that many of the client employees I work with struggle to master. Developing those skills during the adolescent and young adult years would definitely serve one well in the working world.

From John Showalter: “Re: staying sane. I thought you might be interested in learning more about a book I helped write. I think focusing on shared outcomes helps keep everyone sane. I totally agree with you about the meeting skills.” Several of the topics covered in the book caught my interest. What motivates physicians, why a lack of education about revenue cycle and population health impedes their ability to see how improving administrative processes positively impacts the patient, and approaches to creating actionable knowledge that will enable increased collaboration. I struggle regularly with providers that aren’t in tune with the business side of healthcare and don’t fully understand how their world will be impacted by big data. May be a good read for my next book club.

From Cowtown: “Re: private equity in physician practices. Interesting that you notice this pattern. I have had in mind that health systems buying up doctors seemed to be getting fairly smug fairly quickly. It kind of feels like the hospital leadership thinks, we’ve got 300 head of PCP out grazing in the North Region. This attitude belies the fact that doctors (non-competes notwithstanding) hold their own licenses and can take their acts elsewhere. Perhaps there seems to be little will to break away amongst the traumatized mid-career types and the debt-ridden youngsters. Nonetheless, the ongoing evolution of IT, along with the availability of capital as you note, make it entirely comprehensible.

It is a shame, though perhaps expected, that the first forays you’re seeing are aggressive, hubristic moves that misunderstand power – market and otherwise. I believe that successful ventures for primary care will center around:

  • Building physician culture, with an eye towards work-life balance.
  • Operational excellence, with an emphasis on IT and measurement through data.
  • Patient satisfaction, leading toward the basics of customer experience – business hours, asynchronous communication, basic physical plant and services.

Oh, and did I mention, I think these should be primary-care only entities? The specialists can build out their own models, with operational excellence centered on procedures with bundled payments – it’s a different business. PE is the flavor of the day because of the tax advantages for the fund partners. It is usually looking for an exit, which if it is selling out to the hospital, likely becomes a destruction of value event. I hope that capital remains available to physicians, especially PCPs who want to do this the right way.” In many markets, physicians at all levels feel trapped, not just those with debt or feel beaten down. Although they can theoretically take their panels and licenses and go elsewhere, sometimes the choice is between bad and worse. My region has several major health systems; although some used to have distinguishing features (such as the willingness to enter into joint ventures with physician groups for surgery centers or diagnostic imaging) they’ve become fairly homogenized with their relative unwillingness to negotiate with physicians. Narrow networks are making physicians nervous about losing market share, so I see them staying in situations they wouldn’t have tolerated several years ago. The hospital-owned medical groups definitely don’t seem interested in building physician culture or work-life balance although they are trumpeting “operational excellence” through statistics pulled from their EHRs. They’re also treating subspecialists the same as primary care physicians (albeit with larger paychecks) which is adding to the negativity as the procedural subspecialists get a taste of what the rest of the physician base has been experiencing all along.

As a result, we’re starting to see increasing numbers of physicians headed to the direct primary care model. Those who are remaining in traditional physician groups are starting to opt out of Medicare in an attempt to regain autonomy. I’ve heard people talk about it for years but it seems to be actually happening, which will be interesting with the aging patient base in our community. I don’t make it to the hospital physician lounge very often but when I do, the conversations are always lively.

Has private equity shown interest in your practice? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/24/17

August 24, 2017 Dr. Jayne No Comments

In keeping up with Physician Compare and Hospital Compare, CMS has launched the Hospice Compare website for those looking to evaluate end-of-life care options. I’m fortunate to live in a community with some very well-regarded hospice organizations, but I recognize that there are people out there who prey upon families during a highly vulnerable time. In addition to showing quality metrics for pain management and treatment of other symptoms such as shortness of breath, it also displays whether a hospice is for-profit or not and when they were certified.

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I had the privilege of being in the path of totality for this week’s total eclipse. Although I wasn’t able to get any photos on my own (this one is courtesy of NASA) it truly was spectacular. I’ve seen a partial eclipse before (back in 1979 with a trusty cereal box pinhole viewer) but I have to say, seeing it through filtering glasses was a very different experience. I did make a pinhole projector and showed it off to a couple of kids who needed a dose of low-tech magic. Even with some pre-eclipse reading, I saw things I didn’t expect to look the way they actually did, such as the crescent shadows through the trees and the shadow bands right before totality. The coolest pinhole projector I saw was a colander, which projected dozens of mini-eclipses on the ground.

I do completely understand how people damage their eyes, because as the eclipse progressed past the totality phase, I wanted to keep looking at the corona. The brightness made that idea a short-lived one and I went back to my viewing glasses after taking another good look at the shadow bands on the ground as they appeared again on the eclipse’s way out. I’m not ready to become an eclipse chaser, but if you have the opportunity to see a total eclipse, I definitely wouldn’t miss it. An ophthalmologist friend from residency practices in the eclipse pathway and had several patients call his office Monday evening and Tuesday morning wondering about retinal injury. Fortunately, he didn’t see any significant damage.

Tuesday, it was back to the grind, working with a client in the advertising space. I’ve worked with advertising and PR firms before, usually in the context of helping a healthcare organization rebuild their brand, but a couple of times with product launches. This is the first time that the marketing firm has been my client. They engaged me because their efforts to build a healthcare business line have stalled. It seemed like an interesting challenge and they were referred to me by a solid client who convinced them that they needed some tough love from someone in the healthcare trenches. Initially I thought that they just didn’t understand the healthcare business, but as I began to shadow them on calls with their clients, I realized that the root cause may be that they don’t understand marketing.

My past experiences with marketing and advertising firms have followed a fairly predictable course. They begin to understand the client’s business and the client’s goals, then take a survey of the current state. Was the client working with another agency? Were they trying to do their own marketing? What kinds of media were used? What was successful? What flopped? As part of understanding the client’s business, they interviewed stakeholders to understand how the business saw itself, then used that information to build a marketing plan for the organization.

My advertising client is working with a practice that is trying to launch an ambulatory surgery center (ASC), but the project has been one barrier after another and they’re challenged by some occupancy and rezoning issues. Regardless, they want to move forward with a plan to get their name and brand more visible in the community so they can bring providers on board and then launch the services to the community. I thought it should be pretty straightforward, and had no idea what I was about to hear on the call.

My client didn’t go into any of the background about why the practice wants to move into the ASC space and what they hope to achieve. They also didn’t ask what the organization is doing for marketing and what has been successful in the past. They launched straight into a checklist of “what date do you want to start running ads in the newspaper” type items that were completely ineffective.

It was clear that the practice was frustrated since they’re not marketers and that’s why they hired someone to assist. It was clear that the marketing firm had done no research on the client’s current web and social media presence. When the client balked at the checklist approach, my client effectively scolded their own client for their lack of understanding of the process.

They then proceeded to go through a patronizing explanation of the marketing process that was so full of jargon that it was making my head hurt. The practice had no idea what to make of statements like, “You need to give us information that will prime the pump” and “we need you to give us content that will hit the sweet spot.” I was in continuous contact with my client via instant messenger and tried to steer the conversation to keep the practice from hanging up on them, hoping that they could take a step back and get the client talking about why this expansion was important to them.

One of the marketing team actually asked, “What does ambulatory mean?” and I think I laughed out loud. If the practice wasn’t confident about their choice before, I’m sure this sealed the deal. (Pro tip: Google is your friend. Do some prep work.) I struggled through the rest of the hour making plenty of notes for my post-meeting discussion with the marketers. Although they were going to get an earful, I wish I could have given some coaching to the practice as well. First off, I wondered if they even checked references on this marketing firm or whether they went with the cheapest offer, or how they came to work with my client. My client currently has zero referenceable clients, which is why they hired me, and although it’s possible they could have fabricated something, I doubt it.

One of the reasons I went into consulting was to help small to mid-sized practices that were struggling with technology and working with vendors and who wanted outside advice on the best ways to move forward. I’m rarely surprised by lack of business savvy among healthcare providers because it’s not something they typically learn during their training. But I continue to be amazed by the cluelessness of the many vendors that are trying to find the pot of gold at the end of the healthcare rainbow.

How does your organization handle marketing? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/21/17

August 21, 2017 Dr. Jayne No Comments

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My practice values service to the community and often does workshops for scout groups. Sometimes we’re teaching essentials of CPR and sometimes it’s first aid.

This weekend, I had the chance to help one of my partners put on a workshop for the Medicine merit badge for his son’s Boy Scout troop. He’s an official merit badge counselor and asked me to help a couple of months ago. My brother is an Eagle Scout, so I remembered seeing the merit badge booklets around the house and thinking that they had all kinds of interesting information. Apparently now they’re full color and you can also get electronic copies, so I was glad to see that scouting is keeping up with the times.

There are also a host of unofficial sources for information. My partner steered me to a website that had a PDF workbook for the items that the boys were expected to cover. I grabbed a copy of the actual book from the library, but ended up procrastinating the actual preparation until a couple of days ago, thinking I could just do my parts of the presentation off the top of my head

When I finally hit the merit badge website Thursday night to prepare and cracked open the paper booklet, I noticed that the last update to the book was 2002 (although the website mentioned that the requirements were updated in 2005). I figured I’d be in for some entertainment as I read about how medicine was portrayed to scouts 15 years ago. I was surprised, though, with how well the materials have held up. The healthcare professionals portrayed in the booklet represent a diverse workforce and are filling a variety of roles in medicine. I realized as I was reading that much of the information provided should be required reading for people entering medical fields or for people who want to better understand the medical people they work with.

Game time came too quickly for someone who had procrastinated their preparation. I found myself Saturday morning in our break room in front of a group of teenagers eager to show their knowledge medicine. During the first part of the requirements, the scout has to do a great deal of research on historical medical figures – individuals like Hippocrates, Florence Nightingale, Louis Pasteur, Jonas Salk, Marie Curie, and more. I was impressed by the boys’ ability not only to throw out interesting facts about their subjects, but to talk about why those contributions are important to healthcare even today. (A note to the Boy Scouts: if you consider updating this, let’s think about throwing in Larry Weed for his contributions to patient care and healthcare IT).

We next moved into my part of the morning, which was to teach the boys how to take a pulse and perform a blood pressure measurement. I was quickly cast aside by an older scout who asked if he could teach the group because he had volunteered at a blood pressure screening. I’m not sure why I was even there (other than to prevent them from doing goofy things with the blood pressure cuffs, which may or may not have happened) because the scout did a great job using the EDGE method, which includes explaining, demonstrating, guiding the student, and enabling their success. Since I spend a great deal of my time dealing with processes that have gone wrong, it was so gratifying to see a teenager taking charge and getting things done. Frankly, he was a better teacher / trainer than some of the folks I work with on a daily basis. I suspect that he is going to have a great future regardless of the field he chooses.

I was also tasked with talking to them about the instruments we use in the office, including EKG machines, pulse oximeters, spirometers, and more. We talked a little about electronic health records and how information sharing works in healthcare today, and I gave a little plug for careers in healthcare IT. I don’t think any of them had ever been exposed to a clinical informaticist before (not that I would expect them to have been) and I could see a couple of the boys perk up when we started talking about the technology. They perked up the most when we talked about defibrillating people and what that process actually entails. The drama of shouting “clear” and shooting electricity through someone’s body is well-portrayed on TV and they were definitely interested in learning more about it.

Another requirement is for the boys to discuss what makes a good screening test and why tests aren’t always perfect. Listening to them tell me about specificity and sensitivity and how patients had to be informed consumers so they didn’t spend a lot of money on tests that wouldn’t do them any good truly warmed my heart. These kids are clearly growing up in a world where being an informed patient is going to be critical to staying healthy and they were embracing it.

They branched off into a little discussion on the Affordable Care Act and how people didn’t understand that it was the same thing as Obamacare and why it was a mess. I knew these kids would be informed (one of the other requirements is to research the healthcare delivery systems in Sweden and China and compare them to the United States health system) but I was impressed. I know some of them have been working with my partner individually on the requirements, but they’ve clearly done their research.

The badge also requires the scout to discuss the roles of medical societies, the government, and the insurance industry in how they influence the practice of medicine in the US. From the presentation one of the scouts gave, I suspected we had a ringer in the group who had a physician in the family. It turns out that his mom is a family medicine physician, and he talked about how much his mom’s group struggles with Meaningful Use and other programs. That was an eye-opener for some of the other boys, whose only exposure to healthcare may have been at their own doctor’s office or through what they had read in the merit badge booklet and at our workshop.

They also have to explain how their state monitors healthcare quality and how it provides care to patients who don’t have insurance. These are pretty deep subjects for the average adult, let alone for a 12-18 year old boy, and I was impressed by the fact that the badge dug into it. The boys also had to present on different types of healthcare providers along with their training and educational requirements, as well as different subspecialties and what it takes to become a physician in those disciplines. It was entertaining to hear what the boys thought some of the specialties do vs. what we actually do – paperwork and charting were never mentioned in any of their synopses.

The scouts also had to research the Hippocratic Oath and explain it, along with comparing the original to a more modern version. They had to “discuss to whom those subscribing to the original version of the oath owe the greatest allegiance” (for those of you who haven’t read it lately, it’s not the patient). That led to a discussion of the patient-physician relationship and how it’s important in delivering quality care.

We also discussed the role of patient confidentiality and HIPAA. A couple of the boys in the group are 17 and will be adults soon, so I was able to talk to them a little about deciding whether to include their patients to be able to receive information when they go to the doctor and who they would want to make decisions for them in the event that they couldn’t. These are topics that most parents don’t cover with their young adults before they head off to college. It was a little bit outside of requirements, but it was a valuable discussion.

The scouts also have to volunteer at a health-related event in the community that they’ve had approved by my partner. Some of them have already done their volunteer work and it was interesting to hear what they did – handing out health flyers at a community event, volunteering at a free clinic, and working as a teen aide at the hospital. A couple more are planning to work at an upcoming blood drive and then they’ll be able to earn their badges. Looking at the information they had to explain, discuss, and tell about during the workshop (more than an hour and a half of discussion for each scout) plus the additional research to prepare for their presentations and the documentation they all brought, it seems like this might be one of the more intense merit badges the boys are exposed to. According to my partner, the Public Health merit badge has even more requirements.

It was exciting to see the leaders of tomorrow motivated to learn about our field and willing to spend time serving their community. It gives me hope that even as complicated as healthcare is, we have bright young people eager to try to figure out the best ways to serve patients in the coming decades.

Have you talked to young people about your career in healthcare IT? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/17/17

August 17, 2017 Dr. Jayne 1 Comment

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The Office of the National Coordinator continues to advocate for strengthening the health IT workforce. The September 6 webinar will review workforce training materials that were available to the more than 9,000 people who participated in recent programs on population health, care coordination, interoperability, and analytics. Registration is open, and as a participant in one of the educational programs, I’d say it’s worth a look.

In other government news, the Medicare Quality Payment Program hardship application for the 2017 year is now available. Applications must be submitted by October 1, 2017 to avoid payment adjustments in 2018. I continue to run across providers that aren’t sure if they qualify for a hardship exception or not, so if you’re in the practice management or operations space, do your docs a favor and make sure they understand.

Physicians who are in the know have been very happy with the CMS final rule that makes the use of 2015 Edition certified EHRs optional for Medicaid Meaningful Use in 2018. Depending on vendor status, many practices were looking at having to upgrade their EHRs prior to January 1 so they could complete full-year reporting on a 2015 Edition system. The requirement now calls for a 90-day reporting period for Meaningful Use measures. Although Clinical Quality Measure reporting is still full-year, providers can now use 2014 Edition, 2015 Edition, or a combination of Certified EHR Technologies. It’s a welcome reprieve for organizations that are suffering from change fatigue and who may lack the resources to manage an upgrade along with other clinical and business initiatives. Although that change was documented in a final rule, unpublished guidance seems to indicate that practices that are part of the Next Generation ACO program can use either 2014 Edition or 2015 Edition CEHRT.

It’s been a relatively busy time in governmental circles, with the Department of Veterans Affairs also announcing their new telehealth project, “Anywhere to Anywhere VA Health Care,” which will permit VA providers to treat patients across state lines using telehealth technology. Providers can practice across the country within their designated specialty scope of practice. They also released their new VA Video Connect app. Veterans can use their mobile devices to access 250+ VA providers at nearly 70 sites across the country. Although solutions like the app have the potential to reduce travel hardships for veterans, they assume adequate capacity. If providers don’t have adequate time for patient care, simply shifting away from in-person encounters isn’t going to be a solution.

There’s also been action in the Senate to authorize a CMS Innovation Center project to boost use of certified EHRs in the behavioral health space. Psychiatric hospitals, community behavioral health centers, clinical psychologists, and social workers would be encouraged to expand EHR use along with residential and outpatient mental health and substance abuse treatment facilities. The 2009 HITECH Act didn’t apply to many mental health treatment organizations, which may help explain low rates of information sharing between behavioral health and other providers. A parallel bill has already been introduced in the House. Hopefully both will begin to work their way through the House and Senate committees soon.

One of the exciting parts of being in the healthcare information technology space is watching researchers come up with innovative solutions to difficult problems. Laboratory medicine is a big part of clinical informatics, so I was glad to hear about a new technology for Zika virus testing in the field. Researchers from Washington University in St. Louis are using nanorods to develop a test that can provide results without electricity or refrigeration. Proteins attached to the nanorods change color when exposed to Zika virus-containing blood. Although the initial study was very small, it shows a great deal of promise. I was also glad to see the varied affiliations of the authors – mechanical engineering, anesthesiology, and biochemistry/molecular biophysics. The engineering and biophysics fields are expanding rapidly and make great areas of emphasis for premedical students who aren’t sure about their future in patient care.

Speaking of laboratory medicine, LOINC is looking for experts to join four new special topics workgroups. The groups will meet monthly and provide recommendations to the LOINC Committee. Workgroup topics include: Document Ontology, which looks at the framework for displaying clinical results; LOINC ShortName for addressing situations where LOINC codes need to be stored or exchanged but the ShortName is not appropriate; Cell Marker Naming for review of ambiguous terms; and High-Sensitivity Troponin, which will look at the best way to model cardiac assays in LOINC. Workgroups start August 30 and more information can be found on the LOINC website.

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I haven’t been able to attend the MGMA conference in years, the last time being when it was in San Antonio. For those who can’t make it to Anaheim for MGMA17, there is an opportunity to attend remotely via MGMA 2017 Monday Live. Registration is $350 for MGMA members and includes access to the general session and several breakouts. Advertising collateral mentions the opportunity to not only listen to sessions but to “network with your peers,” which might be a little challenging given the virtual environment.

Virtual environments are less of a barrier for the one-on-one contact of telehealth. Employers are gravitating toward inclusion of telemedicine services in employee benefits plans. The Large Employers’ 2018 Health Care Strategy and Plan Design Survey estimates that nearly 96 percent of employers will offer telemedicine services in states where it is permitted, with more than 50 percent including behavioral health as part of the offering. More employers are also offering on-site health centers. My local school district is piloting an on-site employee clinic that received a fair amount of traffic in its first year. They haven’t made a decision to expand, but will continue to pilot during this academic year.

Do you have access to an employer-based health center? Have you had the occasion to use it? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/14/17

August 14, 2017 Dr. Jayne No Comments

I work all over the country, so I see both national and regional trends. For a while now, we’ve seen private equity firms sinking money into larger practices, particularly in the profitable subspecialties such as dermatology and oncology. In these larger organizations, the private equity involvement usually starts around capital expenditures, such as opening surgery centers, infusion centers, or purchasing equipment. The organizations themselves are already fairly well developed and may be looking to expand or merge with another practice, but they’re typically pretty savvy about running a business and how to interact with financial backers. Recently though, I’ve seen a couple of scenarios play out where smaller organizations have gotten themselves involved in with private equity money and the practices are clearly in over their heads.

The first organization I saw this with was a primary care group that had a decent number of physicians, but at 50 or so providers, was in no way a large group. They were located in Texas and had delusions of expanding their group statewide and had gotten some backing to do so. I was working with them peripherally through a consulting subcontract with their laboratory vendor, so was able to watch it play out from the sidelines. I watched the practice administrator threaten leadership from their EHR vendor, using phrases around their plan to “triple in size” and to become “a force to be reckoned with.”

First off, even if they tripled in size, that would put them in the 150-physician range, which their vendor doesn’t even remotely see as a “large” client. The practice had failed to realize this before making their demands for free services and free software in preparation for their growth. They also failed to understand that primary care practices rarely have the footprint or financial ability to become a force as they envisioned unless they are very large or have very tight ties to key subspecialties.

The practice administrator had sold her physicians a bill of goods and they were all buying into the illusion that someday they would be the pre-eminent primary care practice in Texas, and by bringing in some PE financing, they were on their way. The physicians didn’t understand that once you bring PE into the mix, you lose a fair amount of control because you’re spending someone else’s money. I never had the opportunity to read the agreement, but it was clear that either they gave away more rights than they understood or that the PE group was taking advantage of them.

The administrator, who is from Detroit, and the PE leader, who hailed from New York, also failed to understand Texas culture. They never could quite figure out why small practices and independent providers weren’t interested in merging with them. Having spent several years living there and dissecting the culture as a relative outsider, I could have given them some pointers.

First off, although Texas is legally a single state, when you travel around it and meet lifelong residents, you quickly realize that it might as well be multiple states. I know people who live in Dallas and Fort Worth who have never been to the other city despite them being only about 30 miles apart. For those folks, crossing that gap might as well be a trip to the moon, which is a shame when you consider what each of the cities has to offer.

When you look at the cities that are farther apart physically, the differences are even more striking. The drive from Brownsville in the South to Texline in the north is almost 900 miles and you cross through multiple cultural traditions on the way. Parts of Texas think they’re in the old south, parts of it think they’re in the Old West, parts of it think they are in old Mexico, parts of it think they’re “big cities,” parts of it ooze small-town charm, and parts of it are just weird (Austin, you know I love you). Oh yeah, and then there’s the Gulf Coast.

To think that you’re going to be able to understand and accomplish expanding to physician practices across that broad of a spectrum within 12 months seems like a long shot. Some of us can’t even get physicians to agree across county lines, let alone across cultural divides and geographic barriers. I’m not saying it can’t be done, but it’s going to be expensive and psychologically exhausting as you try to address the distrust that people have of each other when they’re coming from different perspectives.

Eventually, the practice burned through a lot of money trying to figure out the expansion and the PE group became frustrated. In the end, they were snapped up by a hospital system that they had previously shunned.

Another group I worked with more recently was a procedural subspecialty practice in the Midwest. They had been wooed by a PE firm promising market dominance and expansion, which resonated with the practice’s leadership. Although they’re just trying to achieve regional expansion and grow from their 30-physician size, they didn’t understand that the face they were presenting to the market they were trying to conquer wasn’t a nice one.

My first exposure to them was a meeting where the head of the practice opened with expletives and started shouting at the vendor in front of the PE team. Never a good sign. This guy would go out to practices they were looking at “merging” with (code for acquiring) and behave inappropriately. I once watched him threaten prospective partners and promise that they would be sorry if they didn’t align with his group. I felt like I was in a 1920s-era gangster movie and expected to see Robert De Niro walking around the room with a bat.

I was somewhat gratified to see both his administrative and IT teams begin to ally themselves with the PE team against him. This continued for weeks and he never had a clue that the axe was going to fall until they walked him out the door. In the aftermath, the physicians feel hoodwinked, and frankly I don’t think they wanted to expand that much at all but were relatively powerless to block the actions of the administrator because of their previous corporate setup. They clearly didn’t want to give up as much autonomy as they did for the promise of being the top dogs. If they thought their schedules were oppressive before, they are certainly not enjoying the MBA-level micromanagement that is now going on behind the scenes. I don’t doubt that the practice will eventually grow, but the PE managers have a vested interest in tightening the collective belt so that they spend as little of their own money as possible.

Anyone who doubts that medicine has become a business needs only to look at these types of examples to understand what is going on. Medical schools have done a great job adding courses in patient engagement and complimentary / alternative medicine to their curricula. Now they need to add solid business courses. If they don’t, then physicians need to seek this knowledge on their own just like they would learn a new procedure or therapeutic regimen. There are plenty of smooth-talking individuals looking to work with physician groups and all too easy for them to be on higher ground.

How does your group learn about trends in practice management? Have you had private equity interest? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/10/17

August 10, 2017 Dr. Jayne 1 Comment

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My HIMSS planning is officially underway and I’m happy to report securing my preferred hotel for my preferred dates for the first time in several years. The shifted schedule (Monday through Friday) always throws me off when we’re in Las Vegas. The updated schedule now shows Magic Johnson as the closing keynote speaker on Friday, but I’m sure that quite a few of us will be departing before then.

Much of the agenda is similar to years past, but I did note the addition of a fee-based session for Thursday. “Rock Stars of Emerging Healthcare Technologies” is a $295 additional charge and purports to cover disruptive and innovative technologies. I’d be interested to see who is in the lineup, but I’m not eager to spend that much money.

I’ve been catching up on medical reading and continuing education. Many of our readers would be happy to know of a new report linking moderate drinking to cognitive health in old age, at least for some demographic groups. Although it found that patients who consumed a moderate amount of alcohol on a regular basis were more likely to live to age 85 without cognitive impairments or dementia, it’s hard to know the exact nature of correlation vs. causation. The study ran for 29 years and used the standardized Mini Mental Status Examination to gauge cognitive health. Adults with “moderate to heavy” alcohol intake five to seven days a week were twice as likely to stay cognitively intact than those with little alcohol intake. Wine-drinking tends to correlate with higher income and education levels that are accompanied by reduced rates of smoking and greater access to healthcare. The majority of study participants were Caucasian and from a middle-class suburb of San Diego.

The Agency for Healthcare Research and Quality (AHRQ) is seeking nominations for public members of its National Advisory Council. The Council advises the AHRQ Director, the Secretary of Health and Human Services, and other bodies on national health services priorities. Nominees must be willing to serve a three-year term, meeting in Washington, DC three times per year. Desired qualifications include medical practice, other health professional experience, researchers, healthcare quality experts, and health economists, attorneys, or ethicists. Additional information is available in the Federal Register.

There has been a lot of chatter in the physician lounge about Anthem’s recent statements that they will not cover non-emergency conditions when patients seek care in the emergency department. Primary care physicians who have a large number of Anthem patients are starting to worry about capacity and creating plans to care for an influx of patients. Retail clinics and urgent cares are eager to accept the overage. Anthem has piloted this in several states and is in the progress of expanding it to others.

We already see plenty of patients in the urgent care setting who could be easily treated with over-the-counter remedies, so it will be interesting to see how this impacts the patient mix in states where it is a factor. In my area, a visit to the local pharmacy’s clinic runs 40 percent less than a comparable physician office visit and about a quarter of what is charged in the urgent care setting. All are significantly less than the $800-900 typically charged for a basic visit in the emergency department.

Wearing both my family medicine and urgent care hats, the missing piece is education and triage. It’s one thing to simply tell a patient that their bill won’t be covered unless it’s a true emergency, but it would be even better if the payer spent a little bit of the anticipated cost savings educating patients and providing after-hours nurse lines where patients could seek advice. Lots of people surf the Internet for information or get their advice from Dr. Google, but education is still a great value in the long run. My insurance carrier has serious limitations on emergency visits, but offers nothing in the way of other support to triage patients to the appropriate care setting. At our urgent care, we sometimes see patients who started at the retail clinic but couldn’t be treated there due to limited scope-of-practice agreements, which leads to an additional and more costly visit with us.

There has also been a fair amount of chatter around the recent JAMA research letter about Maintenance of Certification (MOC) and Board Recertification fees. Although the medical specialty boards are supposed to be non-profits, they’re taking in significant amounts of money from examinees and those required to demonstrate participation in MOC activities. According to the research, the amount of income from exam fees is out of proportion to the amount it actually costs to administer the exams.

For those of us who are board certified in multiple subspecialties, the expenses can add up. Even for those of us board certified in clinical informatics, we are required to maintain a primary specialty board certification. This seems rather unfair to the large number of clinical informaticists who no longer see patients and might be inclined to allow their primary certifications to lapse. Current policies also exclude a number of clinical informaticists who had already discontinued their primary certifications before the clinical informatics certification became a reality.

I’m due to retake my primary boards in 2019 and figure I’ll have to take them at least twice more before I retire unless something changes. I’m not looking forward to the time commitment or to studying information that has no bearing on my practice, such as obstetrics. I failed to buy a lottery ticket for this week’s Powerball, so it looks like I’ll be in the trenches for the foreseeable future.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/7/17

August 7, 2017 Dr. Jayne 2 Comments

I’ve been working on a project involving laboratory interfaces for a mid-sized multispecialty practice that is trying to integrate with multiple local hospitals. They’re valiantly trying to stay independent, which is quite a challenge given the rampant consolidation that is going on in nearly every healthcare market.

The practice’s leadership figures that if they interface with the hospitals in addition to the reference labs they already send to, it will make it easier to manage patients regardless of where they are admitted. As they were putting together this plan, however, they didn’t understand the complexity of working with organizations that aren’t entirely focused on earning the practice’s laboratory business like the national reference labs are.

Since the practice’s previous interface projects took 30 to 45 days, they assumed that working with the hospital would be the same. They also assumed that the hospital laboratory representatives who regularly come to the practice to tell them about new tests would be able to assist them in navigating the entire process, not realizing that those reps were more sales agents than true account managers.

The first surprise came when Hospital One told them it would be a minimum of three months before they could even talk about a timeline for starting a lab interface project, so they would have to stay on paper for the foreseeable future. It would be a fairly straightforward process to create a printable laboratory requisition so we could move the practice away from the hospital’s carbon-paper form and into EHR-based ordering. However, the lack of an interface had already created a significant amount of extra work for the nursing staff who was expected to manually key all lab results that were related to reportable clinical quality measures.

Even though we couldn’t fix the interface problem, I helped them create a new workflow for keying the results, which involved their medical records staff in addition to the nursing staff, so the workload could be better distributed. Cross-training is always a good thing, and assuming adequate training and quality assurance review, there was no reason why the medical records staff couldn’t be part of the workflow. Still, given the nature of the one-off workflow to key results, compared to the interfaces with the reference labs, I didn’t foresee the practice sending any more orders to Hospital One than they had been with handwritten orders.

Hospital Two was a significantly more accommodating, probably in part due to the fact that the practice hadn’t been sending business to its lab previously. Although they didn’t have available staff to assist with a bi-directional interface project, they were willing to set up a results-only interface that would at least allow discrete results to come into the patient chart without the staff needing to be involved.

Unfortunately, the client’s EHR handles this type of situation by creating two orders in the patient chart — one for the actual order and one that is created when the unsolicited result hits the system. This leads to extra work because someone has to reconcile the orders and match them up, and it would leave the practice with the same amount of extra work as the first hospital. When I mentioned the inconvenience and asked if they were willing to help us implement a workaround that would function as a semi-solicited interface, they were eager to hear about what it would take.

Having done it with other clients, I knew the hospital’s lab system was capable of holding the client’s internal accession number, and that keying it on each order would solve the problem. Usually only about half the hospitals I interact with are willing to do this, often citing the risk of error or the magnitude of the extra work for their lab staff. However, this facility jumped at the chance to see if they could make it work in order to obtain a piece of the practice’s business.

They were so eager to move the project forward that they agreed to send someone to the practice to key in the orders for testing so that the practice didn’t have to hardly expend any resources. Once the orders were keyed, they resulted them promptly, faster than almost any hospital lab I’ve ever worked with. The entire testing phase took barely more than a week and they resolved any issues that were found by the end of the next business day. I have to admit, it was a dream project and the entire thing was done in less than four weeks.

Many of us in healthcare are a tiny bit superstitious (never say the word “quiet” in the emergency department) so I knew that given the success of the project with Hospital Two that the next project was likely to be a nightmare. My vague suspicion grew into actual worry when I met the IT project manager the hospital had assigned to the interface project. I could sense the rarified air around him as soon as I walked in the room and had to suffer through his overly complicated explanation of what an interface project entails. I think he assumed that as a physician I didn’t know anything and he totally missed the part where the practice administrator explained that I was their consultant and had assisted multiple clients with interface projects.

He went on for a good 20 or 30 minutes that seemed like a lifetime, talking about all the important work the hospital IT team would be doing to make the interface happen and how little the lab and practice teams would impact the process. When I finally was able to jump in and explain my experience and the practice’s goals and objectives, I was treated to a rainbow of colors on his face as he went from angry red to bilious green to white. I think it had honestly never occurred to him that anyone on the practice side could have a clue how things should be done.

Since he claimed he didn’t have a sample project plan to review with us, I provided him with my own, which produced an outstanding level of pallor as he realized he wasn’t going to be able to put one over on us. We asked him to review the proposed timeline and comment on it and he said he would be able to get back with us in the next couple of weeks. That’s never a good sign, but I couldn’t tell if he was actually backlogged or just being passive aggressive. As time went on and he haggled about everything from the selection of components for the test scripts to the way in which labs would be resulted, I knew it was the latter. The project has been stalled in every imaginable way, with various resources being unavailable or on vacation at various times despite the hospital having agreed to a project plan and timeline.

The practice’s pleas to hospital leadership have fallen on deaf ears. This week I’ll have to have a serious discussion about halting the project. We’ve been using too many resources with little return, and if this is how a hospital acts when a practice wants to send them their business, I doubt they’ll be responsive if there are issues. The other hospital’s semi-solicited interface has been working like a dream, and to the end users, it functions just like the reference labs’ bi-directional interfaces. There are a couple of kinks for the practice’s IT staff every now and then, but overall, it’s been a big success. There simply isn’t much reason to continue working with a competitor hospital that just puts roadblocks in the way.

It will be interesting to see whether the first hospital ever circles back to us or whether a halted project will bring the third one in line. I suppose some hospitals are simply so big that they forget about their base, or maybe leadership just lets certain constituencies run amok. I can’t say that healthcare IT will ever be dull and am grateful that organizations like this create job security for people like me.

How does your hospital earn business from independent practices? Email me.

Email Dr. Jayne.

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