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EPtalk by Dr. Jayne 8/3/17

August 3, 2017 Dr. Jayne No Comments

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The Food and Drug Administration releases guidance allowing Institutional Review Boards to waive informed consent requirements for clinical studies that have minimal risk. This is a major win for researchers trying to use big data to look at populations as well as those working on precision medicine investigations. Informed consent has been in issue when you’re looking at large banks of biological specimens and the clinical data that goes with them, or just large volumes of clinical data that are needed to identify trends and other areas for potential research. The FDA reserves the right to modify its guidance as needed, but this is a good thing for many of us.

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In other government news, CMS announces that it has changed the name of the Social Security Number Removal Initiative (SSNRI) to “New Medicare Card.” Seems like something that should have been an obvious solution from the beginning, but who wants to miss out on another non-pronounceable cluster of letters?

CMS also recently released the 2016 Open Payments data. A couple of my colleagues are apparently raking it in, but most of the folks I work with all had less than $100 in annual payments. Looking at the local landscape, Novo Nordisk and Pfizer were the cheapest lunch players, followed by GlaxoSmithKline. Salix Pharmaceuticals led the pack with an average lunch cost of $24. I’m sure their mealtime presentations on their diarrhea and constipation drugs was a real showstopper.

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I know I’m a card-carrying member of the Grammar Police force, but I want to again stress the need for people to be proficient in writing. I’ve been doing a little CMIO augmentation work and was presented with some documentation from a recent consulting engagement. Not only were there font and spacing issues in the document (to the point of being distracting), but there were basic grammar issues that never should have seen the light of day. There is a difference between “it’s” and “its” and also between “there,” “their”, and “they’re.” If you’re only doing spell check and not a grammar check, you’re missing out. And if you embed Excel cells into a Word document, you’re going to miss out there as well.

These are small errors, but frankly they reduce the credibility of your work. I know I’m guilty of sometimes letting a blog get out the door with some errors, but I don’t have the luxury of peer review and am usually writing from a plane, train, or automobile if I’m not writing from a half-crashed state in a hotel room. If you are charging $300 per hour for your work, you had better read it carefully and consider having a friend look it over before you send it to a CMIO. I can’t take you seriously when your work looks like it was styled by a middle school student.

The CMIO whose shoes I am filling passed away unexpectedly and at a young age. It’s been a heartbreaking assignment, because she was clearly loved and respected. Despite the depressing circumstances, people have been extremely accommodating as I begin to get up to speed and work through my plans to sort through the projects that urgently need my attention.

A search process is in full swing, but I suspect they will have challenges trying to fill the position based on how it is funded. It’s cobbled together with 40 percent administrative funding, 40 percent IT funding, and 20 percent clinical funding. The ideal candidate needs to not only have experience and knowledge, but be willing to try to serve three different masters whose needs are sometimes at cross purposes. I’m just covering the administrative and IT functions and that’s been hard enough.

We have some interviews scheduled over the next several weeks, so I am interested to see if they find someone who is up to the challenge (and also wants to relocate to a mid-sized market and to a role that does not have an associated academic appointment). If you’re on my interview schedule, may the odds be ever in your favor.

At HIMSS17, I was invited to join a virtual book club with a great bunch of women from across the country. Every month we read something and then get together on a conference call to talk about the selection. It’s a diverse group of people, with several from the healthcare IT space, one from engineering, a couple of entrepreneurs, and a retired educator. One of them mentioned that she just started reading the most recent MACRA offering in the Federal Register. She said she was thinking of making it her book club selection and giving everyone a section to read and provide a cheat sheet and their interpretation. I’m pretty she just subconsciously wants to be ousted from her book club president role, but I know most of us who have had to read it wish we could have assigned it to someone else. This month we’re discussing the book I picked, so I hope it hit the mark and they don’t vote me off the virtual book club island.

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I spend an insane amount of time on the road, so I keep my eye out for services or products that can make my life easier. I have to say I am seriously intrigued by DUFL, a service that stores your business wardrobe and then ships it to your destination. As you depart, you ship it back to them for laundering so it’s ready to go again. The DUFL app displays photos of your catalogued clothes so you can pack your virtual bag for shipping. They charge $99 per trip to pack, ship, retrieve, and launder your clothes and $9.95 per month for storage. Depending on whether you’re going to have to pay to check a bag and how many items you may have to have dry cleaned when your trip is finished, the return on investment calculation looks pretty good. That doesn’t even include the time needed to pack your clothes so they don’t end up a wrinkled mess. They also offer a sports service to ship your equipment with care. I’d be interested to hear from any readers who may have experience with DUFL, because I hate going to the cleaners, as the pile of clothes on my dining room chair can attest.

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Curbside Consult with Dr. Jayne 7/31/17

July 31, 2017 Dr. Jayne 1 Comment

I wrote a little in the last EPtalk about the interview Atul Gawande recently did with Tyler Cowen. I find Gawande fascinating and appreciate his measured, real-world thoughts around some of the challenges we face in healthcare. There’s a lot of push to try to have technology solve everything and his respect for simple solutions, such as checklists, is refreshing.

One of the topics covered in the interview was medical education, specifically what is missing from the way we train doctors. Many of us recognize that there has been quite a bit added to medical education in the last few decades – genomics, precision medicine, and the concepts of clinical quality and patient engagement. I started my medical education at a time when schools were first realizing that non-science majors could be physicians and that we had other knowledge to bring to the table.

Gawande notes that there isn’t any education “around the fact that we are no longer a craft. It’s no longer an individual craft of being the smartest, most experienced, and capable individual.” He goes on to say that medicine has “exceeded the capabilities of any individual to manage the volume of knowledge and skill required” leading to care delivery via teams. Students need to know how to function as a team, how to manage when the team isn’t being effective, and more.

I’ve found that it’s not just in medicine that people are missing out on functioning as teams. Our culture has become so competitive, even down to the ranks of toddler soccer, and activities that promote teamwork and team development seem to sometimes fall by the wayside. Although sports can be an avenue for teamwork, I see more push towards individual performance and trying to advance to more exclusive teams than I see towards working to make sure the team is the best it can be.

I’m working with a client right now that is a case study for this. They have a small stable of individual contributors working on process improvement projects. They can each recite a long list of their achievements and how they have climbed the ladder, but they are struggling to grasp the concept of themselves as a team. Some of it resolves around trust in the team, and teaching people to trust each other is a lot harder than people think. With this group, I’ve never seen as many eye-rolls as I did when I asked the group to read “The Speed of Trust” by Stephen Covey.

He shares his thoughts on physicians of the future needing to operate more as trusted counselors who have increased dialogue with patients about their goals and needs. During my career, I’ve watched the physician-patient relationship evolve from a more paternalistic model to one of shared decision-making and patient empowerment. Being in a more consultative role makes sense, but unfortunately our current framework for compensating physicians doesn’t support that. Even with the transition to value-based care, physicians are being paid for outcomes, which means following population-based protocols that may or may not be right for a specific patient.

He mentions the mismatch between treatment and patient priorities as being a cause of suffering. Additionally, he notes that the change in how healthcare is financed has altered care: “Just the payment incentives alone dramatically affect whether my tendency is to give you overtreatment in certain situations and undertreatment in others.”

I did find it funny and a little bit ironic that Gawande said, “The most powerful tool that a clinician has is their pen, and has the power to order medications to test, to doing an operation.” I haven’t used a pen in the exam room for years and usually I only use one to sign return-to-work notes or controlled substance prescriptions. It just doesn’t sound as exciting to say the most powerful tool you have is your computer, although I think it’s true. For many of us, it’s not just about ordering tests – it’s about having immediate access to information from around the world and to be able to bring that information to the discussion at the point of care.

Gawande was asked about the FDA and whether the new drug development process should be liberalized. Some of us weren’t around when there was no such thing as the FDA and he has some good reminders in that regard. Although it was a time of innovation, it was also a time with horrendous medical endeavors such as the frontal lobotomy and the Tuskegee experiment.

He notes that the process of regulating medical treatments has been sped up by patient engagement efforts around HIV and has led to more discussion of the balance between risk and speed of innovation. Increased speed has led to more drugs being withdrawn as a result of post-marketing surveillance and he supports balance in the approval process. He also mentions his thoughts on the FDA not only regulating drugs and surgical devices, but in tracking outcomes for surgical procedures. Although procedures can have some variability based on the patient and the circumstances, he feels there is a fair amount of institutional variability that could benefit from tracking and analysis.

The interview was a far-ranging discussion, including Gawande’s thoughts on Stevie Wonder (was overrated, now underrated); Michael Crichton (both over and underrated); and Karl Knausgard (overrated). He tags wearables as underrated, largely because they don’t do terribly much right now.

He also talked about his work as the director of Ariadne, an academic center that is part of Brigham and Women’s Hospital and the Harvard Chan School of Public Health. The center looks to study how science and innovation impact healthcare delivery. They recently did work with the state of South Carolina studying how to encourage surgeons to use a surgery checklist without regulations or mandates. Their program achieved 40 percent adoption, but he noted that it would likely take mandates or another process to bring the other 60 percent of surgeons to use it. I have to admit, the center has been running for five years and I hadn’t heard of it, although it sounds like something I’d be very interested in. I have a good friend starting her MPH at Harvard this fall, so I’ll have to see if she can get me an insider view.

There were some other interesting statistics in the interview. The average American has eight operations in his or her lifetime. He’s particularly interested in that because surgery is “the highest-risk, highest-cost, highest-failure moment in your lifetime.” Personally, I think the idea of having eight surgeries is something to be explored in its own right and would love to dig into those numbers.

I also appreciated Gawande’s thoughts on building his team and hiring the right people. He encourages the hiring manager to come up with a list of accomplishments for the next two years and hire someone who can meet the goal rather than hiring someone that is likable or fun. He notes that people should Intend: “Do what you intend to do, and do it with intention. Over and over, that’s what people fail to do.” I see a lot of that in my own world, people treading water or going with the flow, and moving with intention is significantly less common.

The interview closes with Gawande’s thoughts on indie music. He recommends Scottish band Frightened Rabbit, who he describes as “bards of sorrow and nonetheless sticking it through.” He warns that “they’re Scottish, so there’s a whole lot of cussing going on.” Based on that recommendation alone, I’ll have to check it out.

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EPtalk by Dr. Jayne 7/27/17

July 27, 2017 Dr. Jayne No Comments

I stumbled across a story on Amazon’s “secret” team that is supposedly looking at healthcare, including electronic health records and virtual visits. It’s supposedly called 1492 (if they chose that as an homage to Christopher Columbus, they had better rethink some of the cultural baggage around his “discovery” of North America). It sounds like they’re exploring interoperability as well, along with figuring out whether they can use the Amazon home-based devices like Echo in a healthcare capacity.

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I’ve been a big fan of Atul Gawande ever since “The Checklist Manifesto” and enjoyed reading a transcript of a recent interview with Tyler Cowen. His opening comments on artificial intelligence were realistic and balanced, which was refreshing given the hype we’re used to seeing with headlines like “Dr. Watson Will See You Now.” He concisely explains how challenging it can be to fully understand what the patient is telling you.

Those of us in the trenches know this, but folks on the technology side underestimate the power of the story vs. data points. Patients often point to problem areas or sources of pain and have trouble explaining whether the problem is more external or internal. Some can’t offer descriptive words at all. Then there is the issue of individual perception of pain or problems. Of course, algorithms could probe into that, but there could be hundreds of questions needed to include or exclude various decision points.

He disagrees with the IBM Watson decision to address this problem and notes that the issue is complicated by the fact that the patient data changes over time. Not only discrete data, but the patient’s perceptions change, as does the patient’s willingness to bring new symptoms to the clinician’s attention and also the understanding of the interviewer. He sees technology as more of an adjunct.

I think most of us caring for patients agree. I’m tremendously fond of clinical decision support and systems that help me ensure I’m not missing anything I should be thinking about with complex patients. I think automated checklists are fantastic, and rather than making me practice “cookbook” medicine, they are helping me deliver the same quality care to every patient every time, regardless of how rushed or distracted I might feel at any given moment. They help level the care we deliver when we are trying to see patients in six-minute increments rather than the 30 minutes many of us wish we had.

He specifically mentions Isabel, which I’ve had available in a couple of EHRs that I’ve used in the hospital setting. Isabel prompts you to think about diagnoses you may be missing in rank order based on the data.

Cowen asks his thoughts on the potential of gene editing with CRISPR, which he finds concerning due to the “unpredictable things that people will discover that you can try to do with gene editing.” When those edited genes are propagated in living organisms, they can spread rapidly, and he doesn’t “think we’ve thought through that in the least.” There’s also the risk that people will want to genetically select against characteristics that they feel are undesirable without fully understanding the implications. On the other hand, he notes that many conditions are the result of the interaction of multiple genes and aren’t something that CRISPR will be able to significantly modify.

Gawande also goes on to talk about safety in the operating room and how the rise of procedures where the patient is awake is changing culture. That patient can now be part of the team and not just a passive participant. These procedures have been common in neurosurgery, where brain mapping is needed to try to protect the speech and movement centers while working on other areas. He notes that he’s seeing them in non-brain surgeries, where the team can interact with the patient about their medical issues and goals for the surgery.

Other patients don’t handle awake surgeries very well, so he does note that sometimes you have to adjust on the fly. I know this firsthand since I once had a procedure under “light sedation” and the surgeon asked the anesthesiologist to put me out a bit more because apparently I would not shut up and was getting sassy with the scrub nurse, who I recognized as having hazed me during medical school.

He notes that while checklists have been effective in reducing errors, there are still barriers to success because people either check the boxes by rote or end up not using the checklists at all. The first problem is something that I’ve seen in many organizations I’ve worked in. It can be as simple as running out of a supply and discovering that someone initialed an inventory form just hours before that the exam room was fully stocked.

As a busy urgent care, that’s a major concern in our practice, but fortunately we don’t have a lot of problems with people falsifying their inventory checks. One of our execs is a former Naval officer and “gundecking,” where someone says they did something that they really didn’t do, is a cause for termination. Leadership makes it clear that when you falsify logs, you undermine our mission of care delivery and it is not tolerated.

The idea of people blindly marking a surgical checklist is frightening. He mentions that organizations can take checklists to extreme, taking one 19-item checklist to an 81-item level that was unusable. Administrators rather than clinicians had bloated the content, which essentially led to people ignoring it.

They go on to explore the disconnect between healthcare and health outcomes. He notes that data from coverage expansions like the Massachusetts healthcare reforms has shown that some interventions are more powerful than others – namely primary care, chronic illness care, and mental health care. He also notes the difference between death reduction and changes in quality of life. Still, we’re not getting the biggest killers under control, like high blood pressure. Organizations like Kaiser have been able to improve outcomes through more assertive management of barriers to care.

I see issues with coordination of care and comprehensiveness of care daily, as patients come to the urgent care for situations that would be better handled by a primary care physician. Some days I struggle with the fact that I’m part of the problem – perhaps if we weren’t as accessible, or convenient, or fast, patients would put more pressure on their primary care physicians to re-engineer how they’re delivering care. I still see plenty of physicians who don’t leverage the technology they have in front of them or who refuse to change their office policies and procedures to better support their patients. I have experienced botched prescription refills, botched appointments, and general chaos when trying to get care myself.

The interview also covered the state of medical education, the FDA, and his thoughts on indie music, but I’ll have to leave you hanging for my summary of those topics. Tune in to next week’s Curbside Consult for the rest of my recap.

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Curbside Consult with Dr. Jayne 7/24/17

July 24, 2017 Dr. Jayne No Comments

One of the great things about consulting is developing long-term relationships with clients. I have a couple of clients that I’ve assisted for almost a decade, starting with some side engagements when I was a CMIO. When I transitioned to full-time consulting, they began engaging me for larger projects. Although we initially started with EHR optimization and organizational development work, they’ve seen the value of having outside help and we’ve been able to move into change leadership and strategic planning.

One of them is particularly great to work with, and not just because they’re located in a great city for live music and outdoor activities. Some organizations are nervous when working with consultants, afraid to expose parts of their operation that they think are problematic. Over the years we’ve developed a great deal of trust.

It’s one thing to let a consultant work on a process that has obvious problems, but it’s another to proactively bring functional-appearing processes to the table and ask for them to be examined in detail. Being given carte blanche to assess the organization at all levels, including the C-suite, has allowed us to identify many areas for improvement. As we’ve moved from department to department with standardization, increased technology adoption, and active management, we’ve stabilized their core practice areas while helping them through a time of unprecedented growth.

Part of their success can be attributed to the vision of their leaders, who are committed to playing the long game. Although they understand the need to keep up with regulatory requirements and to maximize incentives, they consistently put patient needs at the front of decision making. Effectively, they’ve tripled their size over the last five years, not only from a provider headcount perspective, but also when looking at patient volume.

As a Medicaid provider, they’ve seen an expansion of their patient panels due to increased coverage. Although they initially had to use locum tenens physicians to cover the surge, they’ve worked diligently to hire a good mix of both new and seasoned physicians who are committed to the organization’s mission. They’re not afraid to let a provider go when it turns out he or she is not a good fit and they’re not willing to be held hostage by staff with unreasonable demands.

We recently finished revising their plan for provider compensation. First, we did an analysis to look at how their provider compensation fits into their overall financial situation and their budget for growth. We also looked at provider salaries compared to industry benchmarks and to other healthcare employers in the region. It’s tempting to just use national or state data, but when you’re in the middle of a high-tech corridor that has a significantly different economic profile than the rest of the state, then you need to take a much more focused look at how employees are being paid.

We also had to dig deeply into the true cost of care delivery vs. the payments received, which was a project of its own. My client has historically received a lot of grant money and the employee culture was that they shouldn’t charge for certain services because they were “free.” This led to some financial underperformance, as front-line staff didn’t realize that grant money is sometimes tied to documentation of services provided, which can’t be demonstrated via reporting if it wasn’t documented. Although there were some significant findings from the analysis, we decided to pend a project to address them until we were done with the task at hand.

It’s tempting for organizations to dive headfirst into situations like this when they are discovered. Although I’m sympathetic to the fact that they were losing money, they appreciated my support of their plan to address this after the provider compensation project was finished so that the new project could have appropriate organizational focus and so that they could cultivate buy-in from site managers and clinical team leaders. The reality is that waiting another four to six weeks to get our plan together is likely to achieve a faster correction of the problem than if we tried to do it in a half-baked fashion.

I’m especially glad we waited, because our analysis of the missed charges led to discovery of some other workflow processes. Had we tried to have multiple training sessions and process changes, we would have lost a fair amount of productive time. By waiting and doing deeper discovery, we were able to retrain multiple processes at the same time and only pull people away from their clinical duties one time.

Now they’re getting ready to embark on a couple of facility expansions, which has led to the need to look creatively at how (and where) people in the organization do their work on a daily basis. It’s hard to completely remodel office space when people are working in it, and midsize medical practices don’t have a lot of experience with remote work. I’m spending time shadowing a variety of workers to determine exactly what happens during their work day.

It’s often surprising how much people’s day-to-day work doesn’t actually match up with their job descriptions. Employees are often assigned special projects that become part of their regular duties without them being documented. It turns out that staffers we thought could work remotely with little impact are in reality performing tasks that require more face-to-face interaction than would be possible with a telecommute. My goal is to see if we can identify ways to bundle those tasks and consolidate them among a smaller set of workers who would remain in the office, or arrange them so that people could take turns rotating into the office so they maintain the skill set.

The other challenge is to prepare people who haven’t worked from home for the challenges that are ahead. It always sounds great to be able to work in your pajamas, but the realities of working at home sometimes take people by surprise. I’m putting together some training programs to discuss how to set up a home work space, how to manage being away from your co-workers, and how to address the scheduling temptations that come with being a home-based worker. It’s great being able to throw in a load of laundry while you’re on your break, but I know a lot of people who need good advice on how to manage barking dogs when you’re on calls or how to manage when others are in the house with you when you’re trying to work.

It’s been rejuvenating to deal with problems that are a little outside the realm of healthcare IT and to help the organization realize that these issues are no less important to their overall success than interoperability or reporting their clinical quality measures. Figuring out how to best leverage your workforce and motivate your providers might even be more important at times. Too many organizations forget the people part of the equation. I’m excited that this group has been willing to be a laboratory for setting up the practice of the future.

How are you positioning your practice for the next decade? Email me.

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EPtalk by Dr. Jayne 7/20/17

July 21, 2017 Dr. Jayne No Comments

I thought the travel gods were going to be favorable this week, starting when the rental car clerk gave me a free upgrade on a super-sporty car since I had a one-way rental and they needed to reposition it to my destination airport. Once I made it out of the rental car facility and got a few miles down the road, I discovered that the radio didn’t work. Or at least didn’t work in the conventional way, as it randomly turned itself on and off every 10 to 30 minutes and remained stuck on a static-filled station with some fire and brimstone preacher yelling at me. Did I mention the volume controls didn’t work either? There was clearly something wrong with the electrical system and the display would randomly show the back-up camera view even when I was streaking down the highway slightly in excess of the speed limit. By the end of my trip I was just glad to be back at the airport in once piece.

I had been traveling with a customer laptop, and when I got home, I discovered that my trusty Microsoft Surface had undergone an automatic upgrade while I was away. It was stuck on the “updating, please do not unplug your computer” screen and when I restarted it the endless boot cycle started. This led to a multi-hour trip to the Microsoft Store, where everything seems to be the user’s fault regardless of what prompted it. They were able to undo the upgrade and redo it segmentally, and everything seems to be back on the up-and-up. Still, I’d rather have those hours back because now I’m woefully behind. It’s days like this that make me miss the corporate world, where a magical Desktop Support representative would have dropped off a loaner within an hour or so.

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HIMSS has opened nominations for its “Most Influential Women in Health IT” awards. This is only the second year for the program, designed to recognize “influential women at all stages of their career progressions.” Nominees should demonstrate an ongoing commitment to using IT to positively transform health and healthcare as well as providing active leadership in organizational use of IT in support of strategic initiatives. HIMSS never does anything without a hook — nominees must agree that if they are selected, they will contribute two pieces of content to HIMSS via blogs, podcast interviews, roundtables, etc. Nominations must include a biographical sketch and two letters of recommendation and will remain open through August 28.

ONC is continuing its “Interoperability in Action Day” series with a half-day webinar on “Advancing Interoperable Social Determinants of Health” on July 26. The session will focus on the current state of screening tools in care delivery and how they will play into new payment models, along with resources to increase tools around interoperability of social determinant data.

Social determinants have been used in primary care for a long time, especially in community and public health clinics. For some vendors, they’re relatively new additions to the EHR platform, feeding clinical decision support and quality measurement content as well as population health functionality. There are still challenges with communities agreeing on common vocabularies for data sharing. Other challenges include the fact that social determinants change over time and have variable impact on patient health quality. They’re often less quantifiable than physical or laboratory characteristics and combine in a multifactorial way to influence health. Discrimination, social support, and environmental factors can be hard to document in a discrete way, although other factors, such as insurance status, are easier to identify.

My EHR has some optional tools to document social determinants of health. We do gather some of them, but since surrounding health systems aren’t too interested in partnering with their competition, our data doesn’t get a lot of use.

CMS recently announced plans to delay implementation of the Appropriate Use Criteria (AUC) program by one year to 2019. The program mandates that physicians use clinical decision support when ordering certain types of diagnostic imaging, such as MRI scans. The clinical decision support information has to be included on billing claims. Physicians ordering too many tests without appropriate justification could be penalized through reimbursement cuts and radiologists performing studies identified as unnecessary would have claims rejected. Several advocacy organizations recommended delays. Based on some of the clunky EHR workflows I’ve seen created to handle this mandate, I hope vendors use the extra time wisely and for the benefit of their end users.

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The American Medical Informatics Association has expanded the publication of its Journal, to be available monthly and as an all-digital publication starting in January 2018. The publishing world has changed dramatically over the last several decades, so I’m not surprised by the change, especially from a technology-focused organization. Research is also occurring more rapidly, making the extended preparation cycle needed for a paper journal more burdensome than beneficial. I’ll miss the paper copies, which I often loaned out to students and residents interested in clinical informatics. It’s a little harder to share an electronic copy. I’ll also miss the stack of journals that motivates me to dig in and read by sitting there and mocking me. An electronic “stack” of journals doesn’t quite get the shaming done as well as paper. AMIA is also looking for a new editor for the journal, as Lucila Ohno-Machado plans to leave the position after her eight years at the helm.

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My thoughts go out this week to Senator John McCain and his family, after his recent diagnosis with glioblastoma. It’s a nasty kind of tumor that often persists despite surgery, chemotherapy, and radiation. Regardless of your politics, McCain’s reputation as a maverick has kept government activities interesting over the last several decades. He’s fortunate to be able to get care from a top-notch team and I wish him a speedy recovery. It just doesn’t seem fair that a guy who has made it through all life has thrown at him should have to deal with this. I hope the folks looking to cut funding for medical research and prevention think twice when they think of their colleague.

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EPtalk by Dr. Jayne 7/13/17

July 13, 2017 Dr. Jayne 3 Comments

I’m going on Hour 8 being stuck in an airport and I’m getting a little punchy. My flight has been delayed a couple of times and I’m now looking at getting to my destination airport at 2:45 a.m. I’ll then have another hour drive to my client, assuming I find an alert taxi driver at that hour since a rental car will be out of the question.

My road warrior readers know what this is like, but for those of you who haven’t spent a good chunk of your lives at the whim of the airlines and the weather, please have pity on the rest of us when we arrive tired and perhaps a little bedraggled. Hopefully the old residency adage that “a shower is worth two hours of sleep” will hold enough to get me through the day.

The airport I’m in has a number of seating areas with electrical outlets, but unfortunately none of them work. Airport decision makers that are OK with that sort of thing should be forced to spend a couple of days stranded at their workplace, left in limbo without charging their phones or using electronic devices yet still being responsible for their daily work.

As long as my battery lasts, it’s a good opportunity to catch up on some vendor updates and try to make a dent in my email backlog. I’ve unfortunately already finished the novel I brought for emergencies, so I may have to break down and go back through security to hit the bookstore, which is bafflingly not in the actual gate area where all the captive people are.

CMS released an article about the “modernized National Plan and Provider Enumeration System (NPPES)” which is used for providers to obtain and maintain their National Provider Identifier (NPI) number. The document is heavy on detail, but from what I gather, they’re making the process around non-individual providers more secure and efficient. Not surprisingly, people responsible for maintaining the IDs of hospitals, nursing homes, and physician groups were sharing credentials, which helped lead to the changes. New fields have been added to PPES to document provider-specific information such as languages spoken, race, ethnicity, accessibility, hours, and the provider’s direct email address.

I’m fine with most of that information being collected since I have to provide it every year on various credentialing applications. Hopefully it will be shared somehow so I don’t have to fill it out over and over. I’m not about to provide my direct email address, however, without understanding how it’s going to be used and who will have access.

CMS also published the 2017 CMS Quality Reporting Document Architecture Category III (QRDA III) Implementation Guide Version 1.0 for Eligible Clinicians and Eligible Professionals Programs. For anyone suffering from insomnia, I highly recommend it as an alternative to the Federal Register or Ambien. For those of you who aren’t familiar with the document or who have never heard QRDA, it’s the recipe for electronic exchange of clinical quality measure data. Vendors must keep expert resources on staff who not only know the material, but who can expertly digest updates to the specifications and deploy them to developers, engineers, and more. It’s incredibly dense information and I admire the people who master it and make the world safe for those of us who need to report quality measures.

I’ve received some feedback on my recent piece on training and adult learning. Most of it has been of the “right on” variety, but one shameless vendor used it as an opportunity to try to guess what hospital system I use and market their simulation software. There wasn’t even a decent introductory greeting, just a link to HIStalk and straight into the sell. Any vendor who thinks that kind of approach works is sad. 

One reader noted, “I have deployed and trained everything from a full EHR to portals to secure messaging to population health. The percentage of clients who let me apply even basic adult learning principles was sadly very, very low. Yet, as we know, the downstream impact of poor and/or incorrect or irrelevant training lasts for years.” I have good data on the costs of retraining as well as the loss of productivity after poor training and I drag it out frequently to convince reluctant practice leaders to do the right thing.

Early bird registration is now open for the AMIA 2017 Annual Symposium in Washington DC in early November. This year’s theme is “Precision Informatics for Health: The Right Informatics for the Right Person at the Right Time.” I like the fact that they used “person” rather than “patient” because we need to continue to understand the impact of technology on the users, not just on patient outcomes. There are days where I feel like I’m a human participant in an unregulated study that some deranged Institutional Review Board approved without regard to the safety of its subjects.

AMIA has also opened submissions for the Workshop on Interactive Systems in Healthcare (WISH) program, which aims to bring research communities together around the challenges of designing, implementing, and evaluating interactive health technologies. The theme for WISH is “Citizen Science: Leveraging interactive systems to connect to our data, our families, and our communities.” Submissions are open through August 7.

There are entirely too many conferences going on during October and November, so it’s going to be a challenge to decide where to spend my travel dollars. In addition to industry meetings, several friends are headed to a patient safety conference in New Orleans and it’s awfully tempting to select that over the technology offerings, especially when gumbo and beignets are on the line. I also have to start thinking seriously about my primary care board certification, which is coming due faster than I hoped, so that will factor into the conference shopping process as well.

One trip I did decide on is my semi-annual pilgrimage to put my toes in the sand and think about little more than whether I am reapplying sunscreen often enough. I’ve got my coverage arranged and am looking forward to being disconnected from my clients, at least for a couple of days.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/10/17

July 10, 2017 Dr. Jayne 3 Comments

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I saw this CPR training kiosk in an airport on one of my recent travels. It got me thinking about how we train people for various tasks, whether in the healthcare IT world or just in general.

There has been a tremendous amount of research over the last several decades about learning styles and individual strategies for education. Part of this has stemmed from the recognition and diagnosis of more conditions that require adaptive strategies. Other forces shaping it include various pieces of legislation, such as IDEA, the Individuals with Disabilities Education Act. Most of the discussion in these areas has been around children and young people, however. The body of knowledge looking at adult workers and adult education is still there, although smaller.

Some people can absorb knowledge readily from printed material and others need to see a demonstration. Some need to learn by doing, and others by doing a task over and over until they feel they have mastery, especially if they work in a high-pressure environment or one with many distractions. Some people shut down in a group environment, where others thrive in that type of collaborative setting. Others need to learn in a very focused environment with few distractions to do their best.

I’ve worked with dozens of healthcare and vendor organizations over the past two decades and have only encountered a couple that seriously considered the idea of different learning styles or learning abilities when creating training for their adult employees. It seems like most training is designed with efficiency in mind – namely, efficiency for those presenting or delivering the content.

Another pressure is the ability to track consistently in training, which leads to more packaged offerings. I can attest to the fact that it’s harder to ensure consistency in training when you’re sitting with a physician in his office eating spicy chicken wings while covering the finer points of the EHR rather than in a classroom environment. Sometimes, however, creative strategies are required to ensure that physician makes it to training at all.

When I was a CMIO, I had to push for approval to offer training through multiple modalities. Let’s face it — some people don’t do well in a classroom setting and others don’t do well with self-directed learning. Regardless of individual learning styles and abilities, others are going to just goof off regardless of how or where you try to deliver training.

I had a boss who loved the idea of conference calls, especially for a geographically distributed organization where managers didn’t want to pull people out of the office. Although some people can learn on a conference call with a couple of dozen people, others find it a recipe for distraction and lack of engagement. My experience is that most adults know what type of training is better for them, and if given the option, they will gravitate towards an environment where they will be successful.

In addition to providing training through multiple modalities, organizations have to work hard to make sure that the people delivering training are strong educators, not just subject matter experts. There’s an assumption that is sometimes made that because someone is knowledgeable, that they have the skill to share information with others in a way that is engaging and effective. I could provide testimony from a good majority of my medical school class that found they learned more efficiently from reading course transcripts than from sitting in a darkened lecture hall. These people are now out in our healthcare IT classrooms, and given other work pressures, are looking for the most efficient and effective way of learning material.

Due to these pressure, many organizations turn to e-learning options. Some of these are little better than recorded webinars with some questions thrown on at the end. Others are fully-baked interactive sessions where attendees are required to replicate workflows and prove some level of mastery before they can advance. I do enjoy the latter kinds of sessions, although they have to be constructed carefully with the emphasis placed on the right portions of the workflow.

I recently QA’d a client training module where the physicians were forced to replicate a complex set of steps around laboratory processing, which wasn’t even part of their workflow. But due to the cost and labor intensity of creating those types of sessions, the organization had settled on a single track for clinical resources, which ultimately wasted the time (and cognitive energy) of many of their end users one way or the other. In all, when you looked at the number of wasted training minutes, it would have been better to put together separate sessions. But since those wasted training minutes fell on the cost centers of the end users rather than the IT budget, the decision was made strictly based on IT resources.

I do a lot of work with organizations that are threatening to switch EHR vendors or who feel that their software isn’t up to par. When we actually roll up our sleeves and assess the clients, we find there are operational or training issues at play the majority of the time. Particularly with stalled EHR adoption, a lack of training and/or proof of mastery leads to reduced schedules that never quite get ramped back up or to features that never quite get implemented.

Often when we look at causality, we find that providers were not required to attend training or show mastery, even when other users may have been held to those standards. I understand dealing with physician attitudes, but letting them take a pass on training isn’t the answer.

The other issue I see frequently is that there has been staff turnover and the new staff hasn’t received the same level of training as others did at go-live, or that they are just expected to try to learn the system during an on-the-job orientation. Often these organizations seem surprised when I recommend what seems like a straightforward solution to ensure everyone in the organization has received an appropriate amount of training.

Another area where we help clients is in formulating training strategies,  not only on what types of modalities they should use, but also how to deliver the training content in a way that is engaging and includes the right kinds of clinical pearls and examples that will keep the attendees engaged. Sometimes when you’re presenting the driest material, having a good story can make the difference. I’m happy to share my tales from the trenches and let the clients take them as their own.

Most smaller organizations (and many large ones) don’t have anyone on staff who is an expert in adult learning and may not have even heard of the idea of differing learning styles, so we’re happy to fill that niche. Like the CPR training kiosk in the airport, we have to strive to meet our students where they are.

What strategies does your organization use to maximize training impact? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/6/17

July 6, 2017 Dr. Jayne 1 Comment

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I’ve been watching a dialogue about medication reconciliation unfold on one of the AMIA email lists. The general consensus seems to be that medication reconciliation is a “wreck” and that there is tremendous variation in how/when organizations apply it.

In the various EHRs that I’ve used, there are many existing choices in reconciliation pick lists, and they may not always apply to a given care setting. For example, “substitute per formulary” might make sense for a hospitalized patient when they may go back on the original medication at discharge. But in the outpatient setting, if you’re doing a formulary interchange, you’re actually going to discontinue one medication and start another, which requires a different set of documentation.

There are also situations where you need to hold a medication because it’s not essential or could lead to complications (for example, oral contraceptives or daily aspirin) but still want it reflected as something that might have an ongoing influence on the patient’s current state (ongoing clotting or bleeding risk), but I have yet to see an EHR medication list that manages this well.

One respondent commented that there are options needed that don’t traditionally appear as choices during the medication reconciliation process, such as “the patient was never on this medication.” There are other choices such as, “patient’s family member says they are taking it, but patient claims they have never seen the pill,” and “patient taking every other day due to cost” that we’ll never see reflected on a reconciliation list but have to be added as a free-text or “other” type comment.

There are many patients for whom medication reconciliation is an impossibility due to dementia, psychiatric issues, or other medical conditions impairing memory and thought processes. Some of these patients have caregivers who can provide the information, but others don’t.

In the urgent care setting, we rely heavily on the medication history information available through our EHR, but unfortunately, it doesn’t always have the information for cash prescriptions since it often feeds from pharmacy benefit managers. The state prescription drug monitoring program helps fill that gap for some medications, but as a provider I often end up looking in multiple places or asking staff to call pharmacies or family members to try to get an accurate history.

For us, every patient is a transition of care for regulatory purposes as well as an opportunity for error when a medication gets lost in translation. The need for a formal reconciliation varies with the patient and their complaint. What if a visit is a transition of care but doesn’t require prescribing? Clinically a reconciliation really isn’t needed for an episodic complaint (laceration closed with glue), but there are challenges associated with saying staff can do it sometimes but not others.

The discussion brought other points about lack of functionality in EHRs in general, including the ability to trend increasing or decreasing doses over time. I know it took the better part of a decade for my previous EHR to get functionality that allowed prescriptions for different doses of the same medication to link, so that you could see the patient who started on 10mg of blood pressure medication and was gradually worked up to a higher dose. This was tricky because the system relied on NDC numbers initially, which are different not only based on dose, but also on how the medication is supplied. Personally, I don’t care whether the medication came in a blister pack or a stock bottle, but that’s how NDC worked. It was only after the system converted to RxNorm codes that things started making sense. Still, it’s hard to track things like when the patient is taking half of a 20mg tablet then starts taking a whole one, etc. That kind of documentation often winds up as unstructured data that can increase patient risk unless that unstructured data is kept attached to the medication list, which some systems don’t allow.

There were also comments about the fact that some providers don’t have any concept of ownership of the medication list. I saw this often in my past life as a primary care physician, when I would receive dictated letters from consultants that were missing most of the medications the patient was actually on. When transitioned to the EHR, these providers still didn’t feel the need to participate with the medication list, let alone try to perform a reconciliation. I saw at one hospital when they made reconciliation the job of the admitting physician of record that the procedural subspecialists (particularly orthopedic surgeons) developed a new habit of having the patients admitted under the PCP with themselves as consultants. In that case, no good policy goes unpunished.

At the same time this discussion was unfolding, I was contacted by a client who recently implemented functionality that allows them to electronically cancel prescriptions. Unfortunately, their local pharmacies don’t yet support this feature, which led to several days of confusion until they figured out what was going on and returned to their phone-based process. Until the pharmacies upgrade their systems, there’s little more I can recommend other than calling the pharmacies and discussing the impact and asking them to lobby their corporate bosses for an upgrade.

This has been the plight of physicians for some time now, as EHR vendors are forced to add functionality that isn’t supported in the real world. Despite electronic prescribing of controlled substances being required in several states, it’s not required in my particular locale. As a result, only a little more than half of pharmacies support the functionality. It’s kind of like being required to have LOINC codes for interfaced lab results but there not being a requirement for vendors to send the codes with the result transmissions.

I’ll be interested to see what comes of the medication reconciliation discussions and whether there is scholarly activity that might push vendors or regulators to change how they hope to steer medication reconciliation in the future. I was encouraged by the number of people willing to engage in the discussion or collaborate in future projects. A group of motivated clinical informaticists is a powerful thing indeed.

How do you feel about the current state of medication reconciliation? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/3/17

July 3, 2017 Dr. Jayne 2 Comments

No surprise here. A recent survey by the American Medical Association finds that physicians don’t feel they are prepared for quality reporting rules. The survey reached out to 1,000 practicing physicians who have been involved in discussions and decisions related to the Quality Payment Program within their practices. Nearly 90 percent of the physicians find MACRA’s requirements burdensome, with fewer than one in four feeling well prepared to meet those requirements in 2017. Specific areas cited as burdensome included the time required to report performance, understanding requirements, MIPS scoring, and the cost to capture and report data.

The AMA data notes that a little more than half (56 percent) of physicians plans to participate in the Merit-based Incentive Payment System (MIPS) with 18 percent expecting to participate in Advanced Alternative Payment Models (APMs). There were also some interesting statistics on how well physicians feel they understand MACRA and the QPP. Although 51 percent of physicians feel they are somewhat knowledgeable about the topics, only 8 percent describe themselves as deeply knowledgeable.

Although previous participation in quality programs such as PQRS and Meaningful Use seems to have helped physician readiness, only 25 percent of those with prior reporting experience feel well-prepared for the QPP. There were also concerns raised that those who may be prepared for 2017 reporting may not have the long-term financial strategies in place to succeed in 2018 and beyond. Small practices were called out as needing more assistance to be prepared, where large practices were more likely to be concerned about the organizational infrastructure needed to effectively report data.

Where the larger practices were more likely (79 percent) to have previously met Meaningful Use Stage 2, the smaller practices were mixed with 45 percent yes, 44 percent no, and 12 percent not knowing whether they had previously complied or not. Not surprisingly, primary care specialists were more likely to participate in APMs than non-primary care specialists (22 percent vs. 15 percent respectively). Multi-specialty practices seemed to be better prepared than hospital-based, solo, or single-specialty practices with greater participation in Advanced APMs and more optimism around a positive payment adjustment in coming years.

The report notes that its findings support assumptions that although some challenges are universal, small practices will need more assistance in meeting their goals. There is opportunity for CMS, medical societies, and other stakeholders to educate physicians and to help practices prepare for success.

Although the report doesn’t mention them specifically, some of those other stakeholders include vendors and consultants. I’ve seen a pretty significant uptick in messaging from the latter, although nearly all the emails I receive seem to be for clients on Epic. The vendor emails I receive are mostly targeted towards smaller practices who may not be on an EHR or who are looking to switch. These communications make everything look pretty rosy as far as ability to report on their platforms, but neglect to mention the amount of work needed to complete a conversion or bring a practice live on EHR in the first place.

My vendor is actually pretty good at providing information around the various quality and regulatory programs out there, even though it’s a niche specialty vendor and many of its clients have opted out of Meaningful Use in the past and plan to opt out of quality programs in the future. Whether your practice has opted out or not, there needs to be an ongoing dialogue and analysis to make sure that their plan still makes sense. Payer mixes can shift over time, especially with an aging population, and what may have made sense a couple of years ago may not make sense moving forward.

For independent practices, ongoing dialogue is also needed with local health systems or hospitals to determine how their strategy for value-based care will impact everyone else. There are several major players in my area, and none of them seem particularly interested in sharing data with the little guys, especially when smaller groups are potential competitors for procedural volume. It still seems to be less about the patient or controlling costs than it is about market share. I have yet to see any medical staff meetings devoted to helping admitting physicians stay in business by learning how to handle Meaningful Use or MIPS. I do see a lot of attempts to purchase practices, however.

CMS does seem to be trying to do its part to educate physicians, and recently released some new resources on its Quality Payment Program website to try to help us through the maze. At least two of the new resources – MIPS Measures for Cardiologists and Advancing Care Information Measure Specifications/Transition Measure Specifications – are updated versions of previous documentation. This highlights the difficulty in staying up on everything, and the fact that even when you think you have the game figured out and have put processes in place, the game can change. Other resources include vendor lists for Qualified Clinical Data Registries (QCDRs) and Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS. This highlights the complexity of the program, where many participants need to work with multiple vendors to even have a chance of doing it right. The list of new documents is rounded out with an Introduction to Group Participation in 2017 MIPS and a MIPS Measures Guide for Primary Care Clinicians.

I was a little disappointed in the primary care document, which seemed to be overly general and was described as a “non-exhaustive sample of measures that may apply to primary care.” It seemed to be more of a filler to point physicians to the main QPP.CMS.GOV site for more information. Even for those of us who have been steeped in the content, requirements are pretty complex and implementing them is daunting if you haven’t done the pre-work to get all your clinicians on the same page and operating as a cohesive organization. The majority of the consulting work I’m doing these days seems to be in the change management / change leadership space, where I spend a fair amount of time trying to convince reluctant providers that having standardized care plans and office processes really is a good idea and not an infringement on their individuality.

Regardless of our feelings about it, MIPS, the QPP, and Meaningful Use (Medicaid-style, at least) are not going away. It will be interesting to see how physicians feel about their level of understanding a year or two from now.

Are you ready for MIPS? If not, why? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/29/17

June 29, 2017 Dr. Jayne 1 Comment

Several readers who have ties to consulting or staffing firms have reached out to me regarding my recent Curbside Consult that covered a friend’s layoff following her employer’s migration to a new EHR platform. I am very appreciative of the gesture and it sounds like she has some promising leads.

The piece had several reader comments, with one calling me out for using a full consulting schedule as an excuse to not do business with her former employer rather than telling them I didn’t want to work with them because of how they treated their people.

Like so many large organizations, I suspect here that the proverbial right hand doesn’t know what the left hand is doing, and there is going to be some reorganization that takes place. Eventually someone with their head on straight will be in control and they’re going to need qualified help.

I recall a similar situation with another employer who downsized a division in a way that strongly smelled of age discrimination. Several team members took early retirement. One of the analysts had the last laugh when she came back as a consultant making double her salary while also collecting her pension. She continued working there for another four years. Had her new employer refused to work with them on principle, she might not have had that opportunity for payback.

It’s human to want to sock it to bad people on the way out, but it seldom works out well. I recently coached a former colleague on how to write his resignation letter. He wanted to tell the truth about how the employer was abusive, negligent, and reckless, spurring his decision to leave. I counseled that the standard “This letter serves as my notice, my last day of work will be X” approach would be a much better way to go. He went with the emotional response and ended up being perp-walked through the office without even a chance to pack his cardboard box of personal belongs. His former boss also immediately started attempts to sully his reputation. It’s not to say that the boss might have acted that way regardless, but I don’t think my friend having his say helped the situation.

Even when you’re leaving a job voluntarily, it’s often difficult. Depending on your role and the amount of privileged information you have access to, there are concerns as to whether your resignation will simply be accepted or whether you will be escorted from the premises.

When I left one hospital position, I was fairly confident they were going to do the latter since I had access to their recruiting and acquisition strategies and was going to a relative competitor. I prepared for the resignation for several weeks, slowly moving things out of my office, but keeping enough personal items for it to not appear suspicious. On the day I was planning to deliver my resignation letter, the file cabinets were empty and the medical texts in the book case had been replaced by random binders, coding books, and training manuals.

I had gotten myself to a place where I was mentally ready to be walked out, so it was surprising when they asked me to work through my entire four-week notice period. Several days later they told me that they were going to use my resignation as an opportunity to change the role to a part-time position that would only cover about 20 percent of my job duties. They didn’t plan to continue the kind of change leadership and process improvement work I had spent most of my time doing. They didn’t expect me to perform any knowledge transfer since they hadn’t identified anyone to take the remaining portion of the role.

I spent three weeks doing little to nothing, attending meetings like the walking dead just to have something to do. Finally, they identified someone to take the remaining part of the role and we had three days of frantic hand-offs and a request to extend my employment.

Now that I’m in consulting, I’m constantly in a state of either starting a new job or leaving one. When I really connect with a client, it’s hard to leave, even if we’ve accomplished the goals we set out to meet together. Sometimes, however, the leaving is pretty easy, as it was this week with a client I can only describe as extremely challenging.

They brought me in to do a stakeholder assessment and to look at why they are still struggling with EHR adoption six years after go-live. They’ve got some serious leadership deficits and don’t seem too keen on doing the work needed to move to a place where the physicians have buy-in on what the parent company wants them to do.

Even though I was supposed to be winding things down this week, they spent my last day on site arguing with me about when the physicians should complete their documentation. They allow 10 days for the physicians to finish ambulatory visit notes, which is absurd. They have all kinds of reasons why the physicians can’t complete their notes in a timely fashion and aren’t interested in learning strategies to remediate the situation.

It was like dealing with an argumentative teenager. I think they actually believed I would change my opinion if they continued to badger me. They never seemed to understand that it’s not my opinion that counts — it’s that of CMS, auditors, and their medical liability carrier. I wish them luck defending their policies when an audit or subpoena reveals charts completed more than a week after the fact.

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We talk quite a bit about healthcare technology, but sometimes it’s the low-tech solutions that really matter to physicians. I experienced this first hand over the weekend when my stethoscope gave up the ghost. I should have known it was coming since I already had to replace the ear tips and diaphragm. Although I had some spare parts at home, I didn’t have the diaphragm retainer ring that had failed. According to the websites that usually carry spare parts, mine was so old they didn’t stock replacement kits.

I started to despair. I own half a dozen stethoscopes, some of them special purpose (from those neonatal ICU and pediatric rotations) and others that I’ve bought to have a spare or a less-expensive version to take on volunteer trips. But I’ve always been partial to my first stethoscope, my constant companion since the beginning of clinical rotations.

I made a last-ditch effort by emailing 3M about options and was pleasantly surprised to find out that a certain model repair kit would do the trick even though it isn’t officially listed as being compatible. They also sent the handy Amazon link to buy it, so I should be back in business in a couple of days.

What’s your favorite piece of healthcare technology, IT-wise or other? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/26/17

June 26, 2017 Dr. Jayne 1 Comment

A reader recently reached out with some thoughts on life after a large go-live:

Our large academic medical center went live with ambulatory EHR several years ago. The clinicians and residents were used to many of the system features already from inpatient, but we still had a lot of configuration decisions, setup, training, reduced volumes, then a fair amount of post-live elbow-to-elbow support in decreasing amounts. Though there were a few frantic phone calls with crying and screaming clinicians or administrative staff at the time, it went fairly well all things considered.

However, many post-live optimizations were never completed and it was assumed that new hires could just be trained by existing staff. There is minimal formal training and no discussion of the individual configuration options that we helped people set up during rigorous pre-live training. We lack discussion of workflows and regulatory requirements that have shifted or are no longer tracked, and other changes have been made to the system that have broken prior customizations. Documentation of our individual decisions was by vendor consultants and I don’t think any coherent documentation was left behind at the end of the engagement. We aren’t even alerted to processes that have obviously become broken because the front-line clinicians and staff don’t know any different, assuming that it’s just the poorly designed software at fault. And the further we are from go-live, the worse it gets. It’s like throwing the frog in boiling water or turning the heat up gradually.

Do other systems or consultants do a better job of managing this as they find themselves several years post go-live?

At least in my experience, many organizations struggle with this. However, I see it more acutely in organizations that treated their EHR projects like IT projects instead of operational or clinical projects. The go-live itself is often seen as the endpoint, with little vision around the ongoing efforts needed to maintain a system and its users at a top tier level of performance. There is a lot of money spent to support the go-live, so groups tend to economize on ongoing support.

It sounds like your approach leading up to the migration was fairly tried and true, making the most of existing knowledge from the inpatient system while tending to the decisions that needed to be made specific to the ambulatory system. You had a good amount of elbow support, which many clinicians appreciate. Beyond that, many groups find a greater level of success spending more resources upfront to encourage (and/or force) providers to complete a set number of test patient scenarios prior to the go-live, which potentially makes for an easier go-live with less reductions to the schedule or less elbow-to-elbow support.

I personally like requiring physicians and their care teams to document a good number of patients with their most common chief complaints, along with documenting sample visits on some of their most complicated patients. That tends to prepare them a bit better and they have better mastery than if they try to learn during go-live. I’ve found the stress of the go-live itself tends to make learning difficult.

As you mentioned, post-live optimization is where things often fall apart. Some organizations don’t even budget a post-live optimization program into their implementation, which is a grave mistake. Budget permitting, I like to perform circle-back visits at two weeks, 30 days, 60 days, and 90 days after go-live. This allows the support or implementation team to see what processes are working well in the office and what processes have become ripe for bad habits. Even with the most rigorous training and practice, it’s hard to retain all the nuances of different EHR workflows, especially for patient care situations that you don’t see every day.

For those groups that did budget a post-live optimization program, I frequently see those resources shifted to other initiatives that have taken priority for one reason or another. Maybe the group shifted into acquisition mode, maybe they joined an ACO, but optimizing the EHR and practice operations seems to frequently fall by the wayside.

You mention shifting regulatory workflows and that is an issue I see frequently, especially with practices that participate in multiple grant programs. Once I worked with a group that was insistent that they needed to document the date of the last dental exam on all patients. I continued to ask “why” to every reason they gave until we distilled down to the fact that it was originally mandated for a grant in which they hadn’t participated in more than three years. They had been on the brink of customizing a template to capture that date, not knowing that it wasn’t important except for a sub-group of patients for whom that information was already captured in the system’s health promotion templates.

Institutional memory can be a blessing and a curse in situations like this, the latter when people remember things being one way but not the underlying reason and are so dedicated to keeping things the same that they lose sight of what they are doing. It can be a blessing when you have a stable workforce that can do things like train new workers, but that is certainly the exception in many ambulatory workplaces today.

The idea that workers will just train the new people as part of their ongoing daily duties doesn’t tend to produce desired outcomes. In practices where I’ve worked, on-the-job training has been a bust as trainers don’t have time to focus and trainees don’t understand what is best practice and what is their trainer just making it through the day. Fortunately, in my current practice situation, our version of on the job training actually has a rigorous schedule behind it with checklists and skill proficiency. The trainer and trainee are added to the office schedule on top of the normal staff, so that the training process can be focused. It costs more up front to take this approach, but it’s been more than worth it.

Training of new employees has to include training for user-level preferences and configurations because these are the things that make EHR workflows efficient and personal. When I perform EHR optimizations (or EHR clean-up missions, as the case may be), these are the first elements I emphasize. They’re often the proverbial low-hanging fruit that gets users into a more receptive state of mind for when you come back to cover more challenging workflows.

I cringed when I read the comment about the documentation of decisions being done by consultants who didn’t leave coherent documentation. That’s one of the things that pushes me over the edge. Documentation and hand-off should be part of every engagement, to ensure that your client hasn’t simply been handed a fish, but rather taught to tie his own flies, cast the line, reel it in, fillet it, and cook it over a fire that they have built.

In my consulting engagements, the decisions are documented not only in a spreadsheet-style matrix, but in a corresponding executive summary slide deck. It’s not enough to know that a customization was made, but you need to know why so that you can determine whether it needs to be maintained. Customizations should be reviewed with every major upgrade and evaluated to see if they need to be retained or if they can be retired in favor of new functionality. It’s also a great opportunity to make sure the physicians for whom they were built still work in the organization. Otherwise, as a general rule, the customizations can be put to rest as long as no one else has adopted them.

In those situations, I like to use database queries to determine if the customizations are even used. I once worked with a physician who was ready to fight tooth and nail to keep a customization until I showed her the queries that proved that out of every 100 times she used the template in question, she only used the “have-to-have-it” checkbox one time. In that situation, free-texting would not have killed her.

The comment that users assume the software is at fault rather than looking at the process also resonated. I’ve found that the organizations that handle long-term sustainable process improvements the best do so because they have dedicated teams that continue to work with practices to make sure changes are adopted and incorporated in an ongoing fashion. They make sure users have ready access to training in a variety of formats, whether written, recorded, live, or 1:1. They recognize that users have different learning styles and often crazy schedules and may need accommodation to become truly proficient with an application. And they’re willing to challenge whether it’s a problem with the user, the training, the content, or the technology. They’re not afraid to ruffle feathers getting to a root cause or trying to do the right thing for patient care and user satisfaction.

I work daily with clients who aren’t aware that their vendors have documentation around not only best-practice EHR workflows, but best practices for running the office in general. Several vendors have in-house consultants who are available to help clients with these issues, although I’ve seen come clients give them the cold shoulder because the feel the vendor-employed consultants are inherently biased. I’ve seen them argue with vendor educators who are trying to emphasize well-documented and published clinical best practices, belittling them and dismissing their wisdom just because their paycheck comes from a vendor.

The best example I’ve seen is a group that argued with the vendor about hanging signs to encourage diabetic patients to remove their shoes and socks for a foot exam. They told the vendor it was outside the vendor’s scope, despite the vendor rep being a registered nurse and having citations from articles proving the approach as effective in improving foot exam performance metrics.

The bottom line is that some groups do handle the ongoing maintenance of a system better than others. Those that have a plan accompanied by leadership buy-in and a corresponding budget do best. Others that don’t meet those criteria often become easy prey for vendors trying to sell replacement systems. It’s amazing to me when a client won’t sign a $50,000 proposal for optimization, but ends up paying millions for a new system when their previous system would have been just fine had they maintained it. It’s like never changing the oil in your car and then being surprised when the engine seizes.

How does your organization handle post-live support and optimization? Email me.

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EPtalk by Dr. Jayne 6/22/17

June 22, 2017 Dr. Jayne No Comments

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The HUMAN Project calls for New Yorkers to “help power the scientific research and societal solutions of the future.” The initiative is looking for 10,000 participants who are willing to share virtual reams of personal information, including cellphone locations, credit card habits, and blood samples over the next 20 years. Researchers plan to use the data for insights into health, aging, education, and more. Baseline data for accepted participants includes everything from basic laboratory panels to IQ and genetic testing with repeat labs every three years. Participants are eligible for a payment of $500 per family.

The mention of the word “family” made me wonder if they’re going to include children for all of the projects. Although minors are included in research studies, it’s usually for a defined goal rather than for a large set of projects. What happens when minors reach majority and no longer want their data shared? Can they opt out? The website mentions the need for research beta testers and will accept participants age 13 and older.

The project has paid a lot of attention to data safeguards including encryption and firewalls, but as we all know, nothing is non-hackable. They claim outside researchers won’t have access to raw data, but we’ve seen past efforts to re-identify anonymized data sets that have worked. The effort is being coordinated by New York University, and I would love to be a fly on the wall for institutional review board discussions. It looks from the website like they handle the consent process for their beta testing through an online consent portal that allows potential participants to watch videos about consent, which it says are “quicker and easier” than reading the full text of the informed consent document. Personally, I’d want to read every word, but that’s out of the question since I don’t live in New York City and that’s one of the primary screening criteria.

On the other hand, the National Institutes of Health is looking for 10,000 beta testing participants for its “All of Us” precision medicine research program. The beta program is the precursor to a plan to power their research with a cohort of 1 million patients as they look at genomic, clinical, and lifestyle data. The beta program will be coordinated by the University of Pittsburgh Medical Center, which plans outreach at more than 100 locations during the next five months. Ultimately, NIH plans for the program to last for 10 years, and it doesn’t appear to have any geographic restrictions.

Compared to the HUMAN Project, All of Us looks a bit more like a traditional research platform, open to adults in the US who are able to consent on their own and who are not in prison. Participants have to be over 18, although they may allow minors in the future. Also in contrast to the HUMAN project, participants aren’t required to have smartphones to participate. That’s likely to give it a broader cross section, although they’re narrowing it down to English and Spanish speakers currently with a plan to expand to more languages in the future. I don’t have an invitation code so I couldn’t get very far with the website. It’s a little less sexy than the HUMAN project but feels more accessible.

Given the nationwide nature of their 100 beta sites, and the fact that I’m a patient at one of their partner hospitals, maybe I’ll get an invitation. Participating would certainly be an experience. They hope to launch the major part of the national project in late 2017 or early 2018 – once testing is complete. I appreciate a vendor that says their go-live dates are fluid based on the results of testing, because you don’t always get that candor from EHR vendors. Not to mention, the technology isn’t the only thing being tested – it’s the systems, processes, and engagement approaches as well as their ability to build rapport with diverse groups of people in many regions.

All of Us has similar language on its website about data security and safeguards. Given the fact that NIH is sponsoring the initiative, I think it’s safe to say that they understand the implications of a breach or hacking. Thinking back to the HUMAN project and its app, though, it seems that most people don’t give a lot of care to how or with whom they are sharing their data on their phones. Among people I’ve informally polled, most accept all requests for application permissions (and therefore data sharing) because they don’t have the time or interest in determining whether they can use the app they want without allowing permissions. Indeed, we live in interesting times.

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I mentioned last week that my EHR platform was experiencing some API issues, and I was annoyed by the fact that they kept sending us emails about the outage that offered no information. A reader responded, mentioning similar struggles and asked what changes would make the communication more meaningful. First, I’d like more information on what stage of investigation the issue might be in. Are they still gathering data? Are they running traces? Are they to the point of troubleshooting? Have they even identified the problem yet? Once the problem has been identified, I’d like to hear about potential timeline to resolution, whether they’re testing a fix, etc.

I’m sure a lot of customers don’t want that level of detail, although it is nice to know whether they’ve even found the problem and are fixing it or whether they’re still digging. I’d also like a published timeline for communication, like we had when I was a CMIO. If it was a critical outage, we provided an update every hour. Major but non-critical outages led to updates every other hour. And minor issues were updated mid-day and at close of business. Finally, I would want notification that the issue was resolved. In the case of the API issues we were having, there was never a notification that they were fixed. We stayed in the application with some workarounds rather than going to downtime procedures, but had we been on paper I definitely would have preferred a notification rather than having to keep checking to see whether things had been sorted. Since the problems were mostly with pharmacy search and e-prescribing, they were difficult to replicate using test patients.

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Curbside Consult by Dr. Jayne 6/19/17

June 19, 2017 Dr. Jayne 6 Comments

I received some sad news from a friend this week whose employer recently migrated to a single vendor platform. She’s worked for her health system’s IT team for years, primarily supporting the ambulatory practices on the practice management application. When the group initially decided to migrate to a new platform, all IT employees were given the opportunity to either transition to the team that would be supporting the migration, or to remain in their current positions with the understanding that following the migration, they would move to positions supporting the new application. She’s developed deep relationships with her customers over the years, and agonized over the decision. She finally decided to stay where she was, keeping the lights on for the legacy application users while everyone else focused on the shiny new thing.

Plans changed along the way, however, but the leadership didn’t give any hints to the support teams. Literally five days after cutover she was given notice that her employment would be ending in two weeks. She of course is welcome to apply for any of the new support positions, however, all of them were posted as requiring current certification on the new system. Having been a CMIO, I understand how these decisions are made, but it seems like a gutless way to get rid of people. I’m not aware of this particular vendor being willing to accept freelance people off the street to train and certify on their products, nor would it be reasonable to expect a full-time employee to try to train on a new system on the side and at their own expense.

It’s not about reducing headcount, because they actually have more posted open positions than the number of people they’re laying off. More likely, it was seen as a way for the health system to get out of paying for training. Not to mention, getting rid of people with 15 to 20 years experience and replacing them with people earlier in their careers is generally cheaper in its own right. The problem, however, is that they didn’t just jettison the employees, but they also got rid of the relationships and history they have built with their customers. They’ve given no weight to the fact that these support workers know their customers, know how the offices run, and understand the dynamics at play. One might think that could be part of the strategy, if they were worried about the “old guard” creating complications with new processes and policies, or being a barrier to effective change.

However, I know enough people at her employer to understand that they didn’t do hardly any work on people or process, but rather treated this migration simply as a technology swap-out. Based on their outreach to me to see if I’m available for some consulting work, I suspect they’re reaping what they sowed as far as failing to use the opportunity for further standardization and clinical transformation. I hate, though, to see good employees negatively impacted by lack of executive strategy and will. Fortunately, my schedule doesn’t allow me to get involved with them right now, because I’m not sure I could do it in good conscience. Although they may think this was strictly a financial decision, when you factor in the loss of “soft skill” expertise, such as knowing how best to handle Dr. Frazzled’s high-maintenance billing team, and the ramp-up time for new technical employees who don’t know the landscape, I bet there is a negative financial impact.

One could argue that there is also a larger domino impact, looking at a health system that provides a large volume of uncompensated care. They’re about to release quite a few workers in their 50s and early 60s, and based on IT hiring needs in the city, they’re going to struggle to find jobs. Eventually COBRA runs out, assuming former employees can afford it in the first place, and depending on what happens with healthcare legislation, they may not be able to afford individual plans. They may wind up needing uncompensated care, with ultimately greater cost to the system in the long run. Although the logic may be a leap, it’s something to think about especially when you’re talking about a non-profit organization that advertises the breadth of their community-mindedness.

Those of us who have seen the balance sheets for those kinds of organizations know the numbers are a little different from what they advertise. They can afford nearly half a billion dollars for an EHR migration, but they’re going to cheap out on training a couple dozen seasoned employees who have been loyal workers, some for decades. They can afford hundreds of millions in capital expenditures but don’t even provide cost of living wage increases to their low-paid clinical employees, let alone to the support teams like IT. Especially for nonprofits, shouldn’t charity begin at home? As a small business person, I understand that businesses need to make money. Even the not-for-profit ones need money to further their missions. Too often, however, that mission is keeping up with the proverbial Joneses rather than being good stewards. It reminds me of when I was in the hospital this winter, when I didn’t get scheduled medications on time due to a staffing shortage. Is it really cheaper to risk a poor outcome? When did people become less valuable of an asset than mammoth IT systems or another outpatient imaging facility or ambulatory surgery center? And do we really need another glass and marble temple to healing when the actual patient care suffers? Every time I think about going back to a health system or large hospital, these are the kinds of issues that keep me up at night.

Fortunately for my friend, there are plenty of opportunities in her area that use the system on which she is proficient. She has a great work history and strong references, so hopefully she will find something quickly. I’d be happy to bring her on to do some projects, but not enough for a full-time position. I’ll help her however I can though, until she finds something permanent. I’m sure her story is representative of those that happen every time a hospital or health system makes a big change. But just because it happens, it doesn’t make it right.

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EPtalk by Dr. Jayne 6/15/17

June 15, 2017 Dr. Jayne 1 Comment

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Congratulations to the University of Arizona College of Medicine – Phoenix for receiving full accreditation from the Liaison Committee on Medical Education. The school was created more than 10 years ago to help address Arizona’s physician shortage and was originally a branch campus of the UA College of Medicine – Tucson. Now, UA joins the ranks of only a few universities with multiple accredited medical schools. Starting up a new medical school is a daunting process, whether it’s a branch of an existing school or not. I had the pleasure of speaking recently with one of the faculty members at the Dell Medical School at The University of Texas at Austin who shared some of their trials and tribulations. Becoming fully accredited is quite an accomplishment.

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While EHR vendors are working on their certification testing, many are expanding the incorporation of user testing. NCQA is also getting into the act with a website usability and navigation study. I appreciate the fact that they’re trying to make the website easier to use, but I wish they’d make their recognition programs less cumbersome and more affordable for primary care practices. I’ve been contacted by multiple clients who are struggling with the transition from their 2014 program to the updated 2017 program. One of my staffers is attending the course in Washington, DC this week, and at nearly $900 for one day it’s certainly not cheap. Tack on some hotel and travel, and it’s a lot for a small practice to spend for training.

Fortune recently released its list of the 500 companies that generated the most revenue in the last year. Multiple healthcare systems made the list, including HCA Holdings, Community Health Systems, Tenet Healthcare, DaVita, Universal Health Services, LifePoint Health, Kindred Healthcare, and Genesis Healthcare. Health insurers made it on the list as well, with UnitedHealth Group ranking at number six. Other payers making the cut include Anthem, Aetna, Humana, Centene, Cigna, Molina Healthcare, and WellCare Health Plans.

A friend sent me this piece about “Perfect Non-Clinical Income Ideas for Doctors.” I had to laugh at some of the suggestions, especially considering the time pressure that many physicians face. I don’t imagine that many physicians would be up for multilevel marketing, peddling insurance, or renting out their cars. Not to mention, the author fails to appreciate the concept of “passive” income. The only side businesses I see my colleagues involved in are in the property ownership realm, and none of them are personally managing their properties.

My practice opened two new locations in the last 30 days, so I’m working more clinical shifts than I usually do. Unfortunately, that increased schedule came right when my vendor is experiencing an ongoing problem with API errors. The impact is worst when we’re trying to use the e-prescribing functionality or when staff is trying to search for the patient’s preferred pharmacy, which means it impacts pretty much every patient when it happens. Although I appreciate the communication, receiving an email every two hours that essentially says “yes it’s still going on, and no we don’t know how to fix it yet” becomes annoying. Even while I scowled at my inbox, however, I did get a kick out of a marketing email that popped in from our friends at EClinicalWorks. Apparently they’re offering an ill-timed promotion called “Make the Switch” that includes free data migration to the system. I wonder how many takers they’re getting.

A reader sent me this piece about workplace wellness programs. It references some interesting statistics that I wasn’t aware of, such as the fact that 50 percent of companies that have more than 200 workers either offer or require employees to complete biometric screenings. Of those companies, more than half offer financial incentives to employees to participate. Others mandate the screenings for employees who elect company-provided health insurance plans. I’m sure wellness programs will continue to expand, as employers try anything they can to try to control rising healthcare costs.

I’ve written about my concerns around wellness programs before, namely that programs often aren’t compliant with screening recommendations. They may require employees to participate in screenings, such as blood glucose and cholesterol, that are not recommended for their age group and that may lead to distress and interventions that ultimately do more harm than good. Another tidbit I wasn’t aware of is the fact that modifications to regulations around employee wellness programs were nestled into the Affordable Care Act, allowing employers to shift 30-50 percent of employee-only healthcare premiums onto employees who fail wellness tests. I haven’t had to participate in biometric screening since I left Big Hospital, although when you compare the hassle, invasion of privacy, and dubious science against the premiums paid by small businesses, it doesn’t seem so bad.

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I’m always on the lookout for stories of adventures in healthcare, and today I had one of my own. I was calling to make an appointment for a procedure with a provider who has multiple offices. Even though I haven’t been seen there in a couple of years, they were willing to schedule the procedure without a consultation first, which seemed unusual given the opportunity to not only collect an updated history and physical but to also generate some extra charges in a procedure-based specialty. The scheduler then paused and said, “Let me write all this down” and I assumed that she was going to take my request to a surgery scheduler, who would get back to me for the actual scheduling. She “wrote” for over a minute, and apparently used the information as a reference while she looked at the computerized scheduling system. As a process improvement person, I can’t imagine how that works given an average office’s phone volume. I can’t wait to see it in person in a couple of weeks. Needless to say, I won’t be surprised if they call me back and ask to schedule a consultation first, but you never know.

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Curbside Consult by Dr. Jayne 6/12/17

June 12, 2017 Dr. Jayne 2 Comments

Last week, CMS kicked off a multi-pronged outreach program to help providers prepare for the transition to the new Medicare Beneficiary Identifier (MBI). New Medicare cards, to be issued starting in April 2018, will have a new identification code for each beneficiary, which is not based on the Social Security number. Congress mandated that all cards be replaced by April 2019, and vendors have been working on adding functionality to hold the new identifiers for some time. There will be a nearly two-year transition window where providers can use either the MBI or the old Medicare number, as well as secure lookup tools for both providers and patients. The ID will include both numbers and letters – along with many others, I’ll probably still call it a “Medicare number” regardless of the presence of letters.

There are nearly 58 million people on Medicare, and the goal of the program is to fight identity theft, fraud, and illegal use of SSNs. Unfortunately, this doesn’t help the rest of us who are constantly asked to provide our SSNs across the rest of the healthcare space. I checked with a couple of my clients to see if they have plans to phase out use of the SSN in general and they haven’t really thought about it. I’ve had quite a few adventures in healthcare this year, and every single one has asked for not only my SSN but also had fields on their patient data forms to gather the SSN of a guarantor where one exists.

Even with a Congressional mandate, this process has taken years. It was in the works prior to the passage of MACRA, but that law accelerated the timetable. Although CMS has had a website about the project for some time, it’s unclear how much providers understand at this point. Providers and their office leaders have been through a lot of federally-induced change in the last few years, including the prolonged ICD-10 transition and now the distraction of MIPS, along with continued Meaningful Use pressures for our Medicaid friends. It could be that people just aren’t planning to pay too much attention until it gets closer. The other piece of it is that vendors aren’t entirely ready yet, so it’s not yet “real.” Once the new ID field starts appearing in systems, then perhaps it will be worth thinking about. I searched my email archives and found a notice from our vendor a few months ago, mentioning that it will be added to the system towards the end of 2017. One of the benefits (and sometimes challenges of) a vendor-hosted, cloud-based system is that features just appear after a brief announcement, so we’ll have to see what other communication we receive as it gets closer.

The migration to the new MBI is not just a digital change but one that will require operational and process changes as well. Practices may want to consider proactive outreach to their patients to educate them about the new cards and the need to bring them to the office, as well as to allow for additional check-in time on their first visit after they receive their new cards. Sites will need to educate staff about their cutover plan and the need to maintain both identifiers during the transition, and the fact that they can’t simply remove the old IDs from the system since claims may still be working their way through the system. Everyone should be readying a plan, even if it’s just high level at this point. I’d be interested to hear what organizations of varying sizes are doing at this stage in the game.

In other CMS news, Tuesday is the last day to submit formal comments on the FY18 Inpatient Prospective Payment System and Long Term Acute Care Hospital proposed rule. The rule also includes language around Indian Health Service and other Tribal facilities. Most notably, it modifies the EHR reporting period from full calendar year to 90 days, which many of us are eagerly awaiting. Other nuggets include a new exception from the Medicare payment adjustments for eligible professionals, hospitals, and critical access hospitals if they demonstrate that they can’t comply with being meaningful users because their EHR has been decertified. There’s always a path for no payment adjustments for EPs who furnish all their covered services in the ambulatory surgical center setting. Even if you don’t have any comments to offer, the closure of the comment period is a milestone in the countdown to a final rule, which many of us are eagerly awaiting.

I spent some time this weekend at a continuing education conference at one of the local medical schools. I was looking forward to it, since it was targeted towards community physicians and was an opportunity to engage with some of the leaders in the field about the best ways we can co-manage patients. The content was outstanding, with concise presentations offering real-world advice rather than the more esoteric academic discussions I’ve seen in some of their sessions in the past. However, it was marred by attendees behaving badly. The worst example was a physician who was clearly responding to emails and/or transcribed phone messages, and who was using the voice recognition features on his phone to do so. If you have to multitask, you need to either do it non-verbally or you need to step out of the room.

The first couple of times he did it, I’m not sure people understood what was going on, because it looked like he might be having a sidebar conversation with the person next to him and was just being loud. As it continued, it was more obvious what he was doing, yet no one close to him said anything although there were plenty of people giving him dirty looks. Finally, one of the CME door monitors came forward to address the situation and he quit. Still, you have to wonder in what universe someone thinks that’s OK and how we’ve arrived at a place where people’s need to try to do it all interferes with them being a considerate member of society.

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EPtalk by Dr. Jayne 6/8/17

June 8, 2017 Dr. Jayne 9 Comments

There has been quite a bit of reader feedback about my recent Curbside Consult addressing the ECW settlement. Several readers agreed with my assertion that multiple vendors have gamed the certification process, with one mentioning “extraordinary actions” taken to pass the testing, but that the product was “replaced by corrected code before the production code was released.” Given the way testing occurs, I bet that type of maneuver occurs more often than we’d like. Technically that would be fraud, regardless of how they try to mitigate it. Unfortunately, other vendors haven’t been caught (yet) and/or didn’t allow the products of their deception to go into general release. Hopefully those companies are on notice and will toe the line.

Other readers called for zero tolerance for ECW and other vendors who cheat, including jail time or outright closure of the company. Some felt I was soft on ECW, even “tender.” Let me go on record as saying what they did was despicable – however, I’m a firm believer in the American justice system and we have a couple of things called the law and due process. Whether you think entering into a settlement is tantamount to pleading guilty, there has not been an admission of guilt and no criminal action has been filed that I can find, and trust me, I’ve been looking. My lack of a torch and pitchfork should not be construed as acceptance or approval of what was done. Still, I was surprised by the number of emails I received that attacked me personally or suggested I don’t respect patients. As much as I believe in justice, I also believe in redemption and this is an opportunity for ECW to make things right. As one reader said, “No one benefits if an EHR is litigated into bankruptcy.” Let’s not forget the vendors who have closed their doors abruptly in the past, holding their clients (and the data of tens of thousands of patients) hostage.

Another reader who is in the vendor space mentioned that his employer has already received calls from clients threatening to file whistleblower actions unless specific defects were fixed, regardless of whether they had anything to do with certification or not. Product liability law is a specialized discipline and I don’t think adding potentially hundreds of suits to the environment will result in positive change. Look at how healthcare has dealt with harm in the past: Until you get past the culture of fear and penalty, people are reluctant to report issues or to be part of the solution. Another vendor reader mentioned his company is considering being less transparent with their “known issues” lists because of fear of escalation to frivolous lawsuits. That would be unfortunate as well.

One reader offered an interesting thought around analyzing the percentage of budget that top vendors devote to R&D. There could certainly be some interesting data there and you could come up with some conclusions from annual reports and shareholder documentation. Unfortunately, privately held companies don’t have to disclose anything, so we’d be relying on their report. We’ve heard self-reported statements about this over the last year and many felt they were inaccurate, so it’s not likely that we will get “real” numbers anytime soon. I’d personally like to see the R&D budget compared to support compared to marketing and sales. There are several vendors I work with who spend entirely too much on the latter while shortchanging the former.

Others mentioned my lack of attention to the potential impact on clients. Frankly I think it’s too early to discuss, as we don’t have a full picture of whether those practices will be asked to repay incentive money. Any mandatory repayment would almost certainly create the potential of a class action suit against ECW. That’s precisely why I advised my colleagues on the system to sit tight and see how it unfolds and what remediation is offered and how it actually plays out. They’re in an incredibly vulnerable position right now and it would be easy for another vendor to try to take advantage of their situation. Anyone who predatorily goes after these practices should be ashamed, and I know they’re already out there. The last things these practices need is a hasty move or a poorly considered replacement decision.

Regardless of your position on the guilt or innocence of a vendor and whether the punishment was appropriate, this event has the potential to change the healthcare IT landscape in uncertain ways. I hope that other vendors take the advice of one reader and revisit their compliance programs. Ensuring a culture of honesty, accountability, and understanding of the fact that you hold people’s lives in your hands needs to be at the forefront of thought as corporate decision-making occurs. It’s unfortunately not as common in the US today as we would like, whether in healthcare, the automotive industry, or just about anywhere people are trying to make a profit.

Other readers offered answers to the question of what they’d do with the whistleblower payment, with several noting that legal fees will consume a good portion of it. One mentioned that he would donate to non-profits promoting expansion of EHR systems to practices serving indigent patient populations and that cannot afford to buy them. Or to scholarship funds for computer science students willing to commit to working with those practices to help them implement those systems. Both are great ideas, although I’d like to see vendors contributing to those kinds of initiatives outright, rather than having someone do it as a result of a legal action. Or how about scholarships for patient safety training to ensure caregivers and technology professionals know how to spot these kinds of problems? The reader also noted he’d reserve a few dollars to buy a good bottle of bourbon as a reward for a job well done. Based on the level of documentation and time spent by the whistleblower, I’d suggest more than one bottle would be in the offing.

I don’t think this is the last time we’ll see something like this, and the problem isn’t just on the vendor side. I’ve seen plenty of “creativity” and shortcuts from hospitals and health systems with homegrown systems or with vendors outside the CEHRT space, and although they won’t be caught for fraud during the certification process, they are eventually going to run afoul of patient safety. The question is whether organizations will find the settlement motivational and will clean up their houses voluntarily, or whether more headline-generating actions will need to occur to move the industry where it needs to be. The other possibility is more consolidation in an already shrinking industry, which could have unpredictable effects on innovation and emergence of new vendors. The one thing I can say for sure is that only time will tell.

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Curbside Consult with Dr. Jayne 6/5/17

June 5, 2017 Dr. Jayne 14 Comments

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Quite a few people called or emailed this week to find out what I thought of the EClinicalWorks settlement. Two of them were ECW users asking for my advice on whether they should change EHRs and, if so, what I thought they should be looking at. For those practices potentially impacted by the alleged wrongdoing, it’s a very uncertain time. My advice was to pause and let the dust settle before making any decisions. Neither of the ECW physicians I talked to this week had concerns about how the system is actually performing based on their scope of use, and felt fairly confident that they’re not experiencing functionality issues that impact patient care.

As for those that reached out simply curious about what I thought, I’ll share what I had to say. There were several allegations addressed in the settlement. I say “allegations” deliberately because ECW hasn’t admitted guilt nor has it been proven in a court of law. Everyone can speculate on the fact that they settled, but given that I have a plaintiff’s attorney in the family, I understand how expensive litigation can be and how $155 million may be a bargain compared to having to mount a defense, deal with the side effects of having half your company (and your customers) deposed, and having ongoing distraction that impacts your ability to keep the lights on and the business running.

First, let’s look at the kickback issue. The suit alleged that it gave kickbacks to customers for promoting its products, including payments for reference site visits. Many of the vendors I’ve worked with would also fall into this category. During my days at Big Hospital System, we regularly received extra attention from our vendor in exchange for being a reference site, and at times we also received credits against our software maintenance payments. I’m sure that could be construed as a kickback, although our site visits were quite “tell it like it is” rather than pure attempts to induce anyone to switch to the vendor. We always insisted that the vendor reps stay out of the discussion and sit in the back of the room or outside the room altogether. It looks like ECW also paid a bonus when prospects actually signed, and paid individual physicians to do references, which is a little murkier.

The way it’s described in the actual filing, any “manufacturers of products paid for in whole or in part by federal healthcare programs may not offer or pay any remuneration, in cash or in kind, directly or indirectly, to induce physicians or hospitals or others to order or recommend products paid for in whole or in part by Federal healthcare programs such as Medicare and Medicaid.” If you take that at face value, then the medical device reps need to stop wooing the cardiologists and orthopedic surgeons, regardless of whether they’re reporting their meals and tchotchkes in compliance with Open Payments. The language also applies to services, so the people from hospice that bring lunch while they explain the services they offer are guilty as well, even though they’re a nonprofit.

Next, let’s look at the issue of cheating on certification. Although some of what they did (such as hard coding the RxNorm codes for the test scripts rather than having the system access the entire library) is pretty egregious, anyone who’s been part of a certification process knows that there’s a gray area between complying with the test scripts and complying with the spirit of the requirement versus the letter of the requirement. There’s plenty of functionality out there that passes the test scripts but isn’t user friendly or sometimes isn’t even usable.

Let’s also look at the allegation that ECW “released software without adequate testing and overly relied on customers to identify bugs and other problems. Some bugs and problems – even some identified as ‘critical’ or ‘urgent’ – persisted on ECW’s bug list for months and even years. ECW lacked reliable version control, so problems addressed in one version of the software or for one particular user could reappear in other versions or remain unaddressed for other customers.” I’m currently working with half a dozen vendors who could fall into that description, and can name a few more to round out the group. Nearly every vendor I’ve worked with is guilty of this to some degree.

As a customer, I’ve been part of beta testing programs that are more like alphas, and have seen code that doesn’t seem to have been tested by anyone conscious. Sure, the coded functionality may have met the technical requirement specifications, so it passed, but when deployed to the field it’s broken or simply useless. I heard from a couple of friends who work for vendors that they were taking joy in ECWs pain. I challenged them to think about their own situations, and whether they’ve ever let a regression error go out the door. It sobered them up pretty quickly. Developers who live in glass houses definitely should not throw stones, because they could be the next ones in the spotlight.

That takes me to looking at the whistleblower component. There was quite a bit of buzz around the fact that the software technician who filed the original suit will receive $30 million. I’m wondering if this is going to be an incentive for individuals to try to prove wrongdoing across the industry in exchange for a potential windfall. Hopefully, this will spur vendors to pay more attention (and devote more resources) to defect resolution as well as defect prevention, since most vendors likely have a backlog of issues needing remediation. On the other hand, it could lead to a lot of rock-turning during which plenty of creepy crawlies will come to light. If vendors have robust systems to manage their issues they’ll persevere, but if not, potential whistleblowers could create a lot of noise that will create distractions that may ultimately harm customers.

Hopefully this settlement will be a call to action for vendors to get their houses in order, and bring greater transparency to the sausage-making that is the certification process. It’s been interesting, though, to see the number of people putting the blame on the certification process itself. The bottom line is that there are rules; if we think they are unfair, we should seek to have them changed in an orderly way rather than just flout them. It will be interesting to look back on this in six months or a year and see whether it’s changed anything or whether it just goes down as another footnote on corporate wrongdoing.

What would you do with a $30 million whistleblower settlement? Email me.

Email Dr. Jayne.

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