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EPtalk by Dr. Jayne 4/13/17

April 13, 2017 Dr. Jayne No Comments

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I unfortunately had to spend some non-quality time this week at the Microsoft Store. The pen for my Surface Pro tablet has been acting up over the last month and all troubleshooting maneuvers have failed. Since I’ve been on the road a lot, I’ve spent more time than I care to admit perusing various support articles, blogs, and commentaries on how to get it back up and running. Although the button was working, the business-end was not, and then the tip started to actually disintegrate. I had to wait until I was in a city that actually has a Microsoft store, and until I had free time during normal store hours to address it.

The staff at the store was eager to greet me, but then when they found out I was (gasp!) an individual consumer and not a corporate or enterprise customer, it started going downhill. The fact that I bought my device at Costco rather than directly from Microsoft was clearly an issue for them, and they made a big deal about not being able to locate the purchase in their system and having to use another system to find me (which they did, in about 20 seconds, so I’m not sure why we needed the drama). They then informed me that I was out of warranty on the pen. Apparently it’s not hard to be out of warranty when the warranty is only 90 days, which is pretty short in my opinion.

The rep did all the troubleshooting I had already done, then replaced the tip, which didn’t make a difference. He then proceeded to tell me he’d have to make me a tech appointment, but didn’t explain what that meant or what the timeframe might be. I was treated like a child when I asked, as if I should know intrinsically what a “Microsoft store tech appointment” expectation might be. As a consultant, I’m sensitive to my hourly rate and how much time and money I’m burning with exercises like this. Knowing the pen was about $50 and that I had been down for weeks and getting to the store when it was open was an ordeal, I asked if I could just buy a new pen and be done with it. He acted like that was the strangest thing he ever heard, then disappeared “to see if there is anything else we can do.”

I appreciate the fact that he was trying to save me money and resolve my issue, but it felt like an odd piece of “service recovery” after the initial stumbles over being an individual consumer and having purchased from a reseller. Ultimately they agreed to warranty the pen and swap it out, which took an additional 15 minutes of paperwork and back and forth. Counting the drive, the trek through the mall, and the troubleshooting, then getting home and back to work, I spent an hour and a half getting a new pen. Adding in the hours of troubleshooting that I did before even going to the store, you can bet that if this one malfunctions in the least I’m going straight to an online order for a new one.

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I mentioned a couple of weeks ago that I was working with a clinical informaticist that was learning the ropes of actually managing a team – dealing with expense reports, vacation approvals, and the other managerial functions that we don’t learn much about in medical school. This week we waded into the minefield that is the annual performance evaluation. I’m a firm believer in the concept that the annual performance review should never be a surprise. It’s important for managers to incorporate the concepts they’ve been discussing with the employee for the last year, and to make overall comments on progress (or lack thereof) but nothing should be a revelation. When there is a transition in managers or a change in job role, this is particularly tricky because one needs to incorporate any available feedback from the previous manager or role.

The good thing is that the time frame for the review process is usually clear, and shouldn’t be a last-minute exercise. Of course there are exceptions to that, such as when my previous employer decided to move everyone from “review on your anniversary date” to “review the entire company all at the same time, STAT,” which was a horrendous exercise I never want to repeat. But in this case, my managerial trainee had well over a month to track down information from previous managers, peruse previous reviews, assess completion of employee goals, etc. We had been talking about the process for a couple of weeks, and he seemed like he was with the program, so I was surprised when I met with him in person and he looked like a cornered animal. He said he had no idea what to do with some of the feedback he received from employees.

The company asks employees to write a one-page summary of their growth and accomplishments over the last year, highlighting successes and what they have learned from challenges. It’s the employee’s opportunity to offer specific details that can bolster a high-scoring review or give a new manager more flavor for what the employee has been working on and how they see themselves. However, it has the potential to be a mine field, because “one page free text” can apparently mean different things to different people. He has more than 20 people on his team, and let’s just say the variability of the personal narratives was striking. The most effective employees provided bulleted lists or well-organized statements, often with supporting quotes from other employees or customers. Those were easy to get through. The ones he wasn’t sure on handling were frankly ones that I wasn’t sure on handling either.

I’ve done a lot of performance reviews, going back to my time as Chief Resident. I can definitely say I’ve never encountered an employee or supervisee who decided to use the annual review as an opportunity to roast the company or provide openly hostile comments about management in writing. Until now, that is. The employees were clearly informed that their statements would be part of their records as part of the annual review process and would be seen by second-level approvers, yet still elected go down this path. Needless to say, after seeing their statements, their objective rankings on “insight” and “professionalism” just went down the tubes. Additionally, if there was a score for Tasseography, they’d score low on that as well. When you openly throw your manager under the bus, and fail to appreciate that your manager has a significant amount of executive support, you’re not doing yourself any favors.

These are the things that as a consultant make you say “hmmmm,” and also ensure the ability to propose ongoing engagements and assistance for your clients. We definitely need some coaching/education for these two employees, as well as creation of performance improvement plans. It’s also the opportunity to assist with the hiring process should they not be able to right themselves. In the short term, I’m going to continue supporting my new manager, and help him build the skills to get through this, manage these folks objectively, and not give in to his emotions. It’s also an opportunity to reflect on giving direction for future reviews. The idea that a review should not be a surprise goes both ways when employee comments are involved.

What’s your wildest performance review story? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/10/17

April 10, 2017 Dr. Jayne No Comments

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Physician burnout is always a hot topic within informatics circles, especially since clinicians frequently cite the rise of EHRs as a key reason for stress and burnout. In reality, though, it’s difficult to prove causality, especially since increasing requirements for EHR use have generally been timed with governmental regulations, demanding payer programs, and the overall shift from fee-for-service to value-based care. I’m always looking for ideas to help physicians at the breaking point, and a friend recently shared this article about using military training concepts to help physicians build resiliency.

According to the American Psychological Association, resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress – such as family and relationship problems, serious health problems, or workplace and financial stressors.” As physicians, we’re assaulted by these kinds of stressors all the time, and they often cross work/home boundaries as working hours become longer or as physicians bring work home with them, now that they can access charts from anywhere. During residency training, many physicians develop the skills to adapt to the intermittent stress that being a trainee brings – long call nights, resuscitations, emergency surgeries, high-risk procedures, and more. For the most part, residency training doesn’t prepare young physicians for the daily grind of being in an office setting or dealing with the stressors of owning a practice or being an employed physician.

The article discusses statistics for physicians – that depression hits nearly a third of residents, and that physicians have higher suicide rates compared to the rest of the population. It goes on to look at how some Canadian hospitals and medical schools are using training based on US Navy SEAL programs to help build psychological skills. Both populations are under ongoing stress with overlaying episodic stress, sometimes involving life and death situations. I think the latter element is important – the life and death situations. Although many think of those as being in-hospital, emergent-type situations, I see more and more of my primary care colleagues experiencing that “life and death” level of stress even within the boundaries of office-based medicine. When patients can’t afford their medicines and physicians have to cobble together plans to try to ensure compliance, we are in effect fighting for that person’s life.

The diabetic patient who came into my urgent care last night with a blood sugar of 434 wasn’t sick enough to be admitted to the hospital, since his sugars had been high for months and his body had been trying to compensate for it. Yet, he needs intensive therapeutic interventions to get his disease under control. I can send him back to his primary care physician, but then she has to battle to get him to see the diabetic educator, get him a new blood glucose meter to replace his broken one, and try to help him figure out how to get to appointments and take care of his disease when he’s working long shifts as a municipal bus driver. Those situations, which sometimes border on hopeless depending on the patient’s insurance coverage (or lack thereof), job situation, and social supports add to the ongoing level of stress faced by physicians. This is worse now that the primary care physician is going to be penalized for this patient’s lack of blood sugar control.

This problem isn’t unique to our US system. According to the article, studies show that as many as 75 percent of Canadian resident physicians experience burnout. One can anticipate that those burned-out residents are going to carry that baggage into practice. The resiliency training created for the Canadian trainees is delivered as a four-hour course. It encourages trainees to identify how they’re faring on a mental health or stress scale. They grade themselves as green, yellow, orange, or red depending on their current level of stress and dysfunction. Similar to the kind of asthma action plan we provide patients, it also details recommended steps the trainee can take to reduce stress. Another component of the training includes skills to help the body process physical responses to stressors, such as the fight-or-flight response. It seeks to move decision making away from the emotional response and to instead harness the rational thought process.

The article also mentions that “discussions around physician mental health still remain very taboo.” Unfortunately, this is also true in the US. I know of quite a few physicians who have untreated mental health conditions who are afraid to seek help and have it on their records. Our state still asks a question during the license renewal process about treatment for mental health conditions, and people don’t want to risk whatever process might arise from checking “yes” on the affidavit. A friend of mine who is a psychologist specializes in physician care, and doesn’t bill insurance for those patients so that there isn’t a record of treatment.

Although the article doesn’t specifically mention it, we also need to work on skills for physicians to understand that doing their best really is good enough. We can’t really give it more than our best, can we? Although the quality metrics might not support this approach, the idea that we can save everyone or ensure all our patients are compliant is ludicrous. As quality increases, it’s more and more difficult to be “better” when everyone is already earning an A. I’ve lost two colleagues to suicide in my career, and both were brilliant, caring individuals who unfortunately felt their best wasn’t good enough, that they should have been doing more. No one in their lives, including spouse or fiancée, realized how bad things were or that they were at high risk for suicide.

Additionally, this discussion doesn’t just apply to physicians. It applies to all of us working in the patient care arena regardless of your title. Most of my support staff at my patient care sites are paramedics, and many have migrated to urgent care as a solution to the stressors in the field. For those readers not in the patient care space, ask your organizations what they’re doing to address caregiver burnout. Ask your friends and colleagues how they’re doing and offer support when you can. Their lives might just depend on it.

How does your organization address burnout? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/6/17

April 6, 2017 Dr. Jayne 2 Comments

For people breathing easy after completing their 2016 Medicare-related attestations, it’s time to start gearing up for next year. Organizations need to register or update their information via the CMS Web Interface  prior to June 30 if they plan to participate as a group. Organizations that plan to use the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey also need to register. There are many other details on who does or does not need to register, so consulting the website and making sure you know whether an ACO or registry will be reporting on your behalf is recommended. For those not breathing easy because they’re still completing 2016 Medicaid-related attestations, good luck! Some states have extended their attestation windows into May.

CMS has also been busy promoting the value of Chronic Care Management, launching a new Connected Care program to raise awareness through the Office of Minority Health and the Federal Office of Rural Health Policy. Connected Care will focus on racial and ethnic minorities along with rural populations who statistically have higher rates of chronic diseases. The new website includes toolkits with detailed information about CCM, resources for implementation, and patient education resources. CCM requires a patient copay, and that has posed a barrier to adoption in my area. Patients already think physicians should be providing these services for free and don’t always understand the value of why CMS is making a push to specifically address the need for services. Although the copay is small, patients living from Social Security check to check and who may be choosing between medication and food are often reluctant to consent to enrollment. Sadly, those can be the patients who most need the services.

CMS has also been busy with its Social Security Number removal initiative. I’m working with my first consulting client on a project to look at how it uses the SSN within the organization and to assess vendor plans to remove the SSN from software systems. There is a new provider webpage, in addition to the main page, for the initiative. Although this program impacts Medicare beneficiaries and the use of the SSN as the de-facto Medicare ID, organizations use the SSN in a variety of different ways. Not everyone is excited about the removal program, as the SSN has also become a proxy for an individual identifier to a large degree. Kind of makes you think about our lack of a national healthcare identifier, doesn’t it?

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ONC has updated the SAFER Guides, which are designed to help organizations assess EHR safety and best practices. Topics include organizational responsibilities, contingency (downtime) planning, interfaces, patient identification, clinician communication, and test results reporting/follow-up. I really wanted to review the latter topic, but received an error. There are plenty of practices that need this information. I can’t believe the number of groups I run across that either don’t track their laboratory and diagnostic orders from ordering through completion and patient notification, or track but don’t notify. The era of “no news is good news” should be long gone by now. Patients should never be expected to assume results are normal unless they hear otherwise.

Medicomp Systems announces its Medicomp University event, to be held starting April 24 in Reston, VA. Attendees will gain in-depth knowledge of the Quippe products and how to integrate them into EHRs. I’ve enjoyed watching the Quippe offerings evolve since I first saw it at HIMSS11. If you haven’t seen them, they’re definitely worth a look.

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I’m way behind on email again, but it’s been fun to go back and weed through all the premature commentary about the repeal of the ACA. What had us hanging on tenterhooks now seems like a long time ago. For those of you who have never seen them, this is what tenterhooks look like. I’m also catching up on some educational webinars. My new pet peeve is people who use PowerPoint for presentations, but fail to put it in presentation mode, forcing the audience to review shrunken versions of the slides while being distracted by the thumbnail navigation.

I came across this article about what hospitals waste and it’s startling to think about. When patients are discharged, many supplies are thrown out due to concerns about infection control or potential contamination after they’ve been left accessible to patients or visitors. Policies vary dramatically from facility to facility across the country. I’ve worked at places that toss everything and at those where supplies are restocked, and seen all kinds of variations. There’s also the issue of hospitals getting new equipment and needing to get rid of old devices. I once assisted with an effort to send a “gently used” MRI machine to South America – now that was a project.

Scholarly research has been done looking at the problem, with findings that when hospital staff are appropriately incented, waste can be reduced. Many surgeons in one study were unaware of their operating room costs; when they were asked to reduce costs, they met goals where the control group’s costs actually increased. Getting people to be conscious of the true costs of the care provided is central to the concept of value-based care, especially when those costs are obscured, such as costs that are included in a hospital room charge.

During my recent hospitalization, most supplies were kept in a secured cabinet inaccessible to patients and family members, which not only controls costs but reduces contamination and the risk that something would have to be tossed for fear that someone had opened it or otherwise ruined it. Other items that are placed out for every patient (shower products, toothpaste, etc.) are discarded after each patient whether they were used or not, since it’s too difficult to determine if they’ve been opened or used. I specifically asked the staff about this prior to discharge – I hadn’t used anything, since I brought my travel kit with me. But they were going to toss everything, so I grabbed it for a community drive that gathers non-food items to be distributed to food pantries for their clients. You’d think hospital leadership would have considered that when crafting their policies and reached out to a local organization. Maybe they did, maybe they didn’t, but I’m trying to connect the two for some potential community benefit.

What does your hospital do with discarded or excess supplies? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/3/17

April 3, 2017 Dr. Jayne 1 Comment

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I’ve been doing a lot of thinking about my work lately. I’ve been doing consulting for a while now, starting with side work even when I was a CMIO. I left that ersatz glamour to do consulting full time and it’s been an adventure.

My clients are generally good to work with, and that is a side effect of being your own boss and having the ability to terminate clients who are difficult or want to play mind games. Still, they get stressed out like anyone does, and often the consultant is expected to try to fix issues whether they’re in scope or not. That creates some tension around whether I should allow them to change the scope of work or whether I need to send them in another direction, especially when they try to game the system to get their new problem included for free.

Everyone is under significant economic pressures and I understand where they are coming from. Just because you’re in healthcare, though, doesn’t mean that we can give you services for free. Especially as a small consulting firm, even small discounts can make a big dent in our bottom line. We’re in the purest of “eat what you kill” models and even though we have low overhead, we still have bills to pay like everyone else. Fortunately, my partner and I are both fairly frugal and we’re not in this business for the money (although it is nice at times). But with increasing financial pressures due to the shift from volume to value, many more of our client-facing conversations are about money rather than vision, mission, or strategy.

Our clients feel increasingly like they’re in the crosshairs with payer audits, federal and state regulations, anti-kickback worries, medico-legal issues, and legislative uncertainty. Not to mention there are also decreasing contract rates, more bundled payment initiatives, and the ever-present worry about the inefficiencies of EHR. For the most part, we can help clients tackle many of their stressors, but the fact that healthcare delivery continues to be in a state of rapid change is something that we can’t do a lot about. Of course, we can help the clients with strategic planning and trying to future-proof their businesses, but that’s a big change for clients who thought they would be independent practitioners forever.

I work for myself, which has a lot of perks. I can generally control my travel schedule and have no problem saying no, although clients have been less flexible the more they are stressed. We have a solid plan to divide and conquer when our clients have needs for specific expertise, although we can cross cover each other enough that we don’t ever feel we are working without a net. Still, I thought we’d be at a different place by now in the evolution of healthcare. Unfortunately, we’re still grappling with some of the same concepts that we grappled with decades ago. They were challenging then, but throw the technology piece at them as well and they can be even more messy.

I’ve been in the healthcare technology leadership space for more than a decade and I’m still fighting the fact that my clients (and their patients) don’t have full access to their medical records. In a lot of ways, they can’t even cobble together a medical record because of the barriers to sharing that are all around them. I’m personally enrolled in four patient portals. One has two of my physicians on it, but they don’t share any data. It might be better that we’re not sharing data, though — my new primary care physician sent me a summary of care record, but unfortunately it has multiple family history errors and even gave me some new diagnoses that I never knew I had, including a pulmonary embolus and clear cell carcinoma.

Because of the crazy way our payment system works, many providers game the system to gain the maximum reimbursement possible. Anyone who has experienced provider-based billing knows what I’m talking about, as do those who have pushed the boundaries on time-based services to achieve higher codes. This creates a lot of stress in the ambulatory space as everyone struggles to figure out how they’re going to add headcount for care management and preventive services while fee-for-service payments are decreasing. Although there are some programs seeking to provide those payments up front, such as the Comprehensive Primary Care Plus program, providers are constantly under the threat of missing some kind of documentation, reporting deadline, or other hurdle that might mean they have to pay back those monies even though they were trying to do the right thing by their patients and communities.

We’ve thrown a lot of precious time and billions of dollars at a healthcare system that isn’t generating the return on investment that we need it to. Divorced from the payment scheme by insurance and other third parties, the majority of patients have no idea whether their providers are gaming the system or not. Is the price they’re charging fair? Is the patient receiving value? It’s hard to tell. In many parts of the country, the only entity that has even close to a full picture of the patient is the payer, and that’s a shame. I’m watching my friends who are only 20-25 years into their careers plan for early retirement when they realize selling out to a big health system wasn’t the answer to their struggles with independent practice.

When physicians are together, we talk about the predicaments we’re in and whether the primary care physicians can hold on long enough for the balance to tip in their favor, helping them come off the hamster wheel and be able to truly connect with their patients again. I know of many physicians who have gone into politics – talk about going from the frying pan into the fire. Although most of them are altruistic, one in my state makes spectacularly poor decisions about a variety of issues. For those in the trenches, especially after the last election cycle, there is plenty uncertainty around tomorrow even if they make it through today.

Some days it’s harder than others to grind through the muck. Whether you’re seeing patients or whether you’re trying to help practices and organizations survive an obstacle course that would make an American Ninja Warrior take cover, it’s tough. I miss the days when we were adding technology to our lives because it solved problems, not because we were forced to and certainly not if it added hardship. Although I see the bigger picture and try to translate it to our clients, it’s getting harder to convince people to hang in there and keep moving forward.

I relish my office days, when I put on my hourly employee hat and just see patients to the best of my ability. For the most part, I make patients’ bad days better and they’re grateful. It reminds me of why I wanted to be a doctor in the first place. But I know that behind the scenes there is still a seedy underbelly of coding, billing, modifiers, and more. I’m spoiled by how well my partners run our practice and spend a lot of time thinking about how much I’d like to bottle their leadership skills and atomize their fortitude around my clients.

Although it feels like healthcare is behind where it should be, it also feels like we’re on the verge of something big. We do things every day that no one had heard of when I was in medical school, and that’s a good feeling. It makes me want to stay in this game another month, another year, another five just to see what happens.

If you could bottle one thing and spread it all around healthcare, what would it be? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/30/17

March 30, 2017 Dr. Jayne No Comments

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I spent some time this week coaching a physician informaticist on some of the less-exciting aspects of running a team. At first, he was very excited to be the leader of a team of optimization specialists to work with clients across the south. He didn’t understand what he’d have to deal with as far as the actual logistics of managing people though – vacation approvals, travel authorizations, and the dreaded expense reports.

We talked through the idea of creating some team policies and procedures beyond the standard corporate policies in an attempt to manage the chaos. He has more than 20 people on his team, which is a lot to handle when you’ve never managed people.

Some of the problems were simple solutions. For example, processing the vacation requests 1-2 times a week based on a published timeline for the team, and then ad-hoc for last-minute issues. For travel authorizations, processing daily at mid-day so that his team could complete booking tickets before the travel agency closed. That way he felt less fragmented and less like he was in and out of different software applications all day long.

Creating a strategy to manage his team’s expense reports became the highlight of my day. I have to admit that in reviewing some of the problems he is dealing with, I developed an appreciation for the level of shenanigans his employees were putting forward. Several were pushing the limits of the daily meal allowance, logging the wait staff gratuity as a separate line item under “cash expenses” so they could expense an extra cocktail on their dinner checks without hitting the cap.

Another’s expense reports can only be described as stream of consciousness. Despite traveling to the same client every week, he files reports in a random way that doesn’t seem to line up with any of the scheduled trips. A third consultant included airport hotel bills for the night prior to his travel, “just in case the weather was bad” even though he only lives 20 miles from the airport.

The winner, though, was the consultant who repeatedly stops to purchase a single beer at the gas station next door to the rental car pickup. The timing seemed a little odd, especially since he stays at a hotel where you can purchase single beers in the lobby. It makes me wonder if he is drinking it in the car as he heads to the hotel. All things considered, and especially working for a healthcare company, I’d probably just pay for that out of pocket and not try to expense that $2.85 worth of my day. Not to mention that my client may want to encourage his employee to purchase his beverages at the local package store and pass the cost savings onto their customers.

We had to do some back and forth with the corporate expense people to find out whether some of the outlier expenses were prohibited or acceptable but just tacky. Not all of his employees were gaming the system, though. Several use coupons for their airport parking to save the clients’ money, and at least five of his team members were spot on with their expenses. We’re using those good corporate citizens as an example to the rest of the team and plan to leverage a couple of them to teach the others how to file an expense report that doesn’t drive the reviewer mad.

Another challenge was coaching him on what to do with some of his new employees who are having challenges with professional behavior. That’s always rough when you inherit a team from someone else, or when candidates are hired without your input.

One is struggling with professional dress. My client mentioned that he never thought he would have to tell a field trainer that wearing a fishing hat to the client site isn’t appropriate. That was mild compared to the employee that he described as a “predator” based on reports from multiple clients. Apparently, this trainer would meet members of his training classes at bars after class, with all the imaginable bad decisions taking place. Whether you go to medical school, business school, or any other school, nothing prepares you for having to deal with employees on the prowl, especially when they’re propositioning your clients. The employee is currently on a performance improvement plan, but it’s surprising that people are having to deal with that type of behavior after all the stories we hear about sexual harassment and inappropriate behavior.

One of the most egregious examples of unprofessional behavior was the team member who asked a client physician (the CMO no less) whether he could write her a script for some Ambien because she left hers at home. Her previous manager left the incident hanging out there for my client to deal with when he inherited the team, an act which is unprofessional in its own right. Clearly the employee didn’t find asking a client to write a controlled substance script to be a problem, so it’s likely to be an interesting conversation when the inevitable counseling occurs.

I could never work in human resources because I don’t have the poker face to deal with some of the things that come through the door. One of the funniest books I’ve read in the last few years is Let’s Pretend this Never Happened by Jenny Lawson. There’s a chapter about her past life as a human resources staffer that will make your head spin. (Warning: language may be inappropriate for the workplace, although common.)

I sincerely enjoyed working with this new client this week and look forward to several more sessions in the coming months. It’s always fun to see someone who is idealistic and enthusiastic who hasn’t been beaten down like so many of the rest of us. I’ve enjoyed teaching him my favorite Jedi tricks around email management and getting through days with high volumes of meetings and little productivity. I hadn’t imagined myself as an elder statesperson in the realm of corporate survival, but it seems that I may have arrived there. It’s definitely a new adventure.

What’s your best story about bogus expense reports? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/27/17

March 27, 2017 Dr. Jayne 2 Comments

After my recent adventures in healthcare, Mr. H asked me my thoughts about “playing the doctor card” when a physician becomes the patient.

I’ve had some experience with it at multiple times in my career and have chosen different strategies depending on the nature of the situation and the potential risk/benefit equation. It’s definitely more straightforward when you’re dealing with an emergency situation or if you’re in a situation where you’re seeking care at a facility where you are on staff vs. just being a physician. If you’re at your own facility, depending on how large it is, the odds that someone will recognize the fact that you’re on staff are higher, so sometimes it’s better to just identify yourself and avoid awkwardness.

I’ve done that when calling ahead to the emergency department to let them know I’m bringing in a close family member who has an emergency, and also to ask who is on call for whatever specialty care might be needed in case I want to go somewhere else based on the call schedule, or call a colleague and ask them to come in when they’re not on call. To be honest, though, I would do the same thing for one of my patients, so I’m not sure how much that really is playing the doctor card.

If I’m having difficulty scheduling an outpatient appointment, or want a certain time slot (first patient of the day, something like that) I may mention to the schedulers that I’m a physician and looking for a particular time so that I can accommodate patient care hours. I wouldn’t ask them to double book me or work me in, though, but rather add the physician component just so they understand I’m not trying to be difficult, but just need the first available appointment that meets my criteria so we don’t waste time looking at slots that I won’t take. Sometimes this is an issue when offices are performing practice improvement activities, when the staff is pressured to get patients on the schedule quickly, but I need to wait.

When I was recently in the emergency department for acute abdominal pain, I didn’t play the doctor card until I was in the room being seen by the physician. It was more for context since I wasn’t going to mince words about my symptoms and didn’t want to put him in the position of trying to figure out why I was spouting medical jargon. It seemed the best way to expedite care and also to give him the picture that, “Hey, this must be bad if she’s a physician who is going to have to call in for her shift because she’s here” as far as the severity of my symptoms. It turned out that his wife is one of my colleagues, so it was a bit of a bonding moment as well.

The decision to mention you are a physician or not can often be difficult. On one hand, you want to be able to interact with your treating clinicians at a higher level. But on the other hand, you don’t want them to leave things out because they assume you know more than you really do about an issue.

My recent appointment with the genetic counselor was a great example of a visit that went well. Since the patient history forms asked for occupation, I’m certainly not going to hide it — it’s a fact of demographics and social history just like my education level. The counselor asked open-ended questions about why I was there and what I hoped to get from the visit, which let me explain what I knew and didn’t know, and which allowed her to figure out where I was coming from. When we arrived at the discussion of the risk model, she asked if it was OK to skip the overview of genetics and inheritance and go straight to the details. I appreciated the fact that she asked, as well as the fact that we could have a deeper and more specific conversation due to the fact that I already knew most of the background information.

My recent inpatient stay had a couple of interesting interactions around the fact that I was a physician. The nurse who did my intake on the med/surg floor specifically asked if I wanted to be called “Dr.” or something else. I said to use my first name and she made a point of saying she just wanted to check, since I had “earned it” and she was happy to honor my preference. I appreciate that her statement was beyond just the, “How would you like us to address you?” question that all patients should be asked.

Once she put my name on the whiteboard, though, I was back to being Jayne, and no one asked again. I didn’t have to mention it until the craziness with the overnight nursing staff who had difficulty administering scheduled medications on time, and I attempted to be a “normal patient” until the delays became ridiculous and then I played the MD card. In that situation, however, they probably should have been more worried about the fact that my brother is a personal injury attorney rather than the initials behind my name. Fortunately there were no negative outcomes, however, so I didn’t have to play that card.

I’ve also been very upfront about being a physician when I’m about to do something that would be perceived as unusual for a “typical” patient. For example, rolling into a seemingly routine outpatient procedure with a copy of my healthcare power of attorney and living will. It’s more of a, “I’m a physician and I know things can go south even for the smallest procedures, so here are my documents” statement rather than a request for special treatment. I feel pretty strongly about my end-of-life wishes and want them honored, so I’m not afraid to play the card there.

My general thought process around when I say I’m a physician or leave it out is this. Does the person I’m interacting with really need to know? Is it germane to my care? Would I be mentioning it just to mention it, potentially creating an awkward situation? Or would mentioning it help diffuse an awkward situation? Is there something inappropriate going on where it might help correct the issue? Will I get better care if I mention it?

I’ve only had a negative reaction once when mentioning that I’m a physician, and that was in a situation where the care missed the mark so badly that I wasn’t surprised. It was a last-ditch effort to improve the situation and their response to it was very telling.

Putting on my physician hat, I’ve had multiple experiences where I have cared for other healthcare providers and wished they’d revealed their professional background sooner in the encounter. Case in point: I tend to have detailed discussions with my patients about why I’m choosing one medication over another and how it’s going to work to take care of their problem. I wish the patient who was a faculty member at the local pharmacy school would have jumped in earlier when I was discussing the relative effectiveness of various antibiotic families and why I was recommending one drug over another. When he finally did, though, he had a sense of humor and said he would give me an A+ on my explanation.

I’d be interested to hear from other clinicians on their experiences, positive and negative. Being on the front lines of healthcare delivery is like being part of a somewhat bizarre fraternity. No matter where you trained or where you work, you’re still linked by that underlying kinship and by subsets of shared experiences. Sometimes mentioning that you’re a clinician is in lieu of the secret handshake and just intended to say, “Hey, I’m one of us, it’s OK, I understand.”

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EPtalk by Dr. Jayne 3/23/17

March 23, 2017 Dr. Jayne 1 Comment

I get a lot of junk mail in my Dr. Jayne account. Most of it is marketing and public relations related, with varying degrees of personalization.

My favorite ones are those that attempt to sound all chummy and personal, but make it clear that the writer has never read HIStalk. “I was looking at your website that mentioned a mental health topic and am curious if you’d be open to me writing some unique content for your audience on the subject?” shows no grasp of your marketing audience. Of course, it’s easy to hit delete, but sometimes they’re just so bad you have to read them and laugh.

I’ve also recently been inundated with survey requests from HIMSS Analytics. Half the time I can barely make it through the fresh items in my inbox, so I’m not likely to be induced to finish a survey of questionable merit.

Hot topic in the physician lounge this week: the looming physician shortage. These reports come out nearly every year and always predict a shortage, although with variable numbers. Our local paper ran an especially Chicken Little version of the story, promising long wait times for appointments, but failing to interview anyone from the multiple medical schools and training programs we have in town.

As a former primary care physician, I’m not sure how much of a shortage we really have vs. how much of an incentive misalignment problem we have. I’d consider going back to primary care at some point if it wouldn’t mean working far more hours and taking a significant pay cut. Until then, I’ll stick with the wild and crazy world of urgent care and healthcare IT.

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I’m already tired of everyone’s marketing tie-ins to March Madness. The MGMA ad featuring “insane savings” was a little tasteless – as a health professional, I don’t typically find insanity funny. I do still like (and highly recommend) my urologist friend’s March Madness promotion. His practice figures there are a lot of men doing a fair amount of sitting and watching basketball during the tournament, so he offers complimentary pizza delivery for patients scheduling their procedures in that time frame. It’s a significant business booster and he’s been doing it for more than a decade, so it must be effective.

Maybe it’s just the blogs I read or the people I follow in Twitter, but I’ve seen a spike in discussion of physician burnout. There are many stories about physicians retiring from medicine in their 40s (often to choose another career entirely) or going part time as soon as their loans are paid off. A recent study looks at another consequence of burnout – the loss of the sense of medicine as a calling.

The study defines “sense of calling” as, “committing one’s life to personally meaningful work that serves a pro-social purpose” and surveyed over 2.200 US physicians across all specialties. The study had a 63 percent response rate, with 28.5 percent reporting some degree of burnout as measured by responses to six true/false statements:

  • I find my work rewarding.
  • My work is one of the most important things in my life.
  • My work makes the world a better place.
  • I enjoy talking about my work to others.
  • I would choose my current work life again if I had the opportunity.
  • If I were financially secure, I would continue with my current line of work even if I were no longer paid.

According to the authors, physicians who don’t see medicine as a calling see it more as a means to learn a living. That’s what most of us call “having a job” or “earning a paycheck.” Physicians who are burned out are less socially motivated as well.

The authors go on to note that physicians who don’t see practicing medicine as either personally meaningful or as a service to society may see performance impacts, including negatively impacted quality of care. They also interestingly note that monetary bonuses to improve performance may backfire, as they undermine professional autonomy and physicians’ sense of competence.

Due to the study’s construction, it’s not clear whether burnout itself reduces that sense of calling or whether physicians with a higher calling are somehow protected from burnout. More research is needed.

I did some anecdotal research myself, asking physicians if they would stay in practice if they inherited a large sum of money or won the lottery. The only ones who said they would stay in practice would move to a cash-only model and/or work only part time. There were several comments about dreaming of the opportunity to tell Medicare and commercial payers which parts of the posterior anatomy they can kiss.

My friends who happen to be physicians have a variety of strategies for trying to avoid burnout, although some ultimately do leave practice and that’s a shame. Every day there are articles about the catastrophic events that happen to physicians and other healthcare providers: sleep deprivation-related accidents; pre-term labor and birth; stress and anger management issues; and suicide. We lean on our families and friends to try to help us cope or to find a little slice of ‘normal’ among the chaos.

Several of my physician colleagues have taken up traditional handicrafts to try to relax. Two guys I went to medical school with do crochet – I sometimes see them at conferences with their projects. I have three friends who make soap. There are a couple of woodworkers (not surprisingly, neither are surgeons). At least if there’s a collapse of the world’s infrastructure, I know who I can barter with for socks, furniture, and toiletries.

As for me, my knitting skills are marginal, but I wield a mean cast iron skillet, so you’ll find me in the outdoor kitchen if the dystopian future arrives. Until then, I leave you with a recent revision of the Hippocratic Oath for today,courtesy of Paul Simmons, MD:


I swear by Epic, by eClinicalWorks, by Allscripts, by Athenahealth, and by all the coders and accountants, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.

To hold my mouse in this art equal to my own hand; to make it right-click as well as left-click; when my ACO is in need of money to share an “at-risk” portion of mine with it; to consider Joint Commission inspectors as my own brothers, and to answer their questions, no matter how obscure, without hesitation or resentment; to impart coding, billing, quality measures, and all other vital instruction to my own sons and daughters, the sons and daughters of my teacher, and to indentured employees who have taken the physician’s oath, but to nobody else competing with my health system.

I will use mouse clicks to help the sick according to my ability and judgment, but never trusting my own judgment over that of guidelines, directives, policies or best practices. Neither will I administer a poison to anybody when asked to do so, unless the poison is properly linked to a diagnostic code and reconciled in the medication list.

Similarly, I will not give to a woman a pessary to cause abortion, especially if the pessaries aren’t covered by her insurance plan. But I will keep pure and holy both my problem list and my billing codes. I will not use the knife unless credentialed by a committee, not even, verily, on sufferers from the stone, but I will give place to such as are craftsmen therein, and will do my best to decode their two-sentence notes should they choose to leave one.

Into whatsoever houses I enter, I will enter to help the sick, without expectation of payment because no one pays for house calls. I will abstain from all intentional down- or up-coding and premature closing of encounters, especially from abusing the computers on which I labor, for they are my true patients. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets, but mainly because HIPAA says so, and that comes with monetary fines and jail time.

Now if I carry out this oath, and break it not, may I gain forever reputation among all men for my mad abilities to click boxes and buff the chart; but if I transgress it and forswear myself, may the opposite befall me, and may I be banished to a Third World nation where I might labor in obscurity to help truly sick people with my medical skills.

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Curbside Consult with Dr. Jayne 3/20/17

March 20, 2017 Dr. Jayne 1 Comment

I’ve had a couple of questions about my other “unplanned trip to the hospital.” I was due last Monday for my post-op clearance visit. I had seen patients the day before and had been having some leg pain and swelling that was bad enough that I had to sleep with my leg elevated.

As a physician and knowing all the bad things that can happen to a post-operative patient, I didn’t want to just assume it was from being on my feet all day. There’s a small but real risk of deep venous thrombosis after surgery, and that risk can go on for a couple of months. Anecdotally speaking, physicians have bad luck with complications, so I wasn’t taking any chances and wanted to get it checked out.

By mid-morning, most of the swelling was gone, although I still had some weird leg pain. Other signs of DTV were absent, so I decided to not head to the urgent care since I had a post-op visit in a couple of hours and would see what the surgeon thought since I’m fairly low risk.

I headed to the office a little early since it was snowing and I knew I was the first patient of the afternoon and didn’t want to make my surgeon start his office hours late. What I didn’t know was that his last operating case of the morning had taken a turn for the lengthy. Of course, the office staff didn’t mention this when I checked in, so I was treated to 15 minutes of bad infomercials in the waiting room while they answered lots of phone calls but acknowledged no one in the waiting room. I finally learned that the surgeon was still in the OR when I overheard someone mention it to a phone caller.

Just about the time the makeup infomercial was driving me crazy, another patient arrived and signed the clipboard. He was hand-carrying his records and he and his wife sat and read physician notes aloud and generally second-guessed all the care he had received thus far. He was clearly there for a second opinion and I couldn’t help but pity my physician for what he was about to endure. They were loud and opinionated, even when they admitted they didn’t know what they were taking about. It was entertaining to watch them pull out the copies of the scans and try to interpret them against the waiting room lighting.

Finally when I was called to the window, the receptionist argued with me about not having signed a records release. She said I needed to send my records to my PCP. I told her I didn’t have a PCP and she continued to insist that I put someone down to receive the notes. I finally wrote “no PCP” on the release and just handed it back. She finally got the message.

At the bottom of the hour, the TV programming changed to some daytime interview program and the topic of the day was post-traumatic effects of sexual assault. Although I have utmost respect for the topic, it’s not what you expect to have playing in the waiting room and doesn’t set the stage for a calming, healing environment.

The receptionist called me up again to fill out a post-op form, which included questions about my pain, how much pain medication I was taking, etc. Some of it was pretty standard, although the pain scale ran from 1-10 instead of the normal 0-10. As the questions progressed, some of the scales were inverted, with 10 being the least and 1 being the most, which I’m sure might be confusing for many patients. I was confused enough that I missed the back of the form, resulting in me being called to the window a third time.

The surgeon finally arrived and I was called back. He was apologetic. He mentioned a little about his previous case and I understood why he was late. I felt bad that I was about to make him more late after I threw out the leg pain and swelling complaint. Although he agreed I was low risk, I was scheduled to fly in less than 48 hours, so he wanted to proceed with the ultrasound.

His staff called down to the vascular lab, where apparently only one technician showed up due to the snow. He asked for a favor to work me in, which I appreciated, although they said it would likely be a two-plus hour wait. You can’t complain when you’re a work-in, so I took my form and headed downstairs. I guess if your physician doesn’t call in a favor, you would have to wait until the next day, which isn’t an ideal situation for patients with potential blood clots.

When I finally made it to the imaging department, I realized it was nearly 2 p.m. and I hadn’t eaten lunch. The receptionist confirmed that I was an add-on and asked if I knew it would be a couple of hours’ wait, and I said yes, and could I pop out to the cafeteria and come back? She said that was fine. 

When I returned from the café (where only the salad bar remained), I was shamed by the registration clerk, who had apparently been looking for me while I was gone. Despite all my time in healthcare, it didn’t occur to me that this was going to be a quasi-inpatient experience until I was sitting in the registration booth and they had asked the fall risk questions and were getting ready to slap the hospital band on my wrist. Although I had only been discharged two weeks prior and my information should have been up to date, I discovered that my emergency contact had been changed to a peripheral relative who in no way would I want to be my emergency contact. It was baffling until I realized (days later) that he had been in the hospital in the interim and had put me as HIS contact. Still, that should not have changed MY contact information.

It’s unreal that you have to go through the hospital admission process for a straightforward outpatient test. It’s also unreal that there is no accommodation for people’s potential illnesses in the waiting room. How about a footstool for the patient with the swollen leg to prop it on? I got the evil eye from the receptionist for using an empty chair to elevate my leg. While I was waiting, though, I did receive my surgeon’s email message welcoming me to his patient portal (yay, another one!) and inviting me to peruse my records. I now have a total of five portals that I can log into and view my fragmented charts.

After a couple of hours, the tech appeared to take me for my test. I apologized in advance since I knew I was an add-on and said I appreciated that she was having to stay late for me. She was pretty cool about it, although she mentioned she hadn’t had a lunch break and hoped to be able to make it out of the hospital by dinnertime.

I felt bad as a former member of the medical staff that this is how the hospital runs, that two people can fail to show up for work and the third remaining staffer gets crushed with no help in sight. One would think that in a hospital system with nearly 30,000 employees there would be systems in place to prevent these kinds of events from happening. Of note, by 1 p.m., the snow was melting, so bad roads were no longer an excuse.

I didn’t end up having a blood clot. Not surprisingly, once I started treating my leg like a musculoskeletal problem, it got better. Heat and NSAIDs work wonders, but they don’t keep deep clots from breaking off and killing you, so I’m glad I had the test for my own piece of mind.

It will be interesting to see what the hospital charges for an ultrasound vs. what we charge at my urgent care. Rumor has it our prices are about 80 percent less than the hospital, so we shall see. Hopefully this will be the end of my medical adventures for a while, at least until the bills start arriving in a few months.

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EPtalk by Dr. Jayne 3/16/17

March 16, 2017 Dr. Jayne No Comments

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It’s been a whirlwind of a week with two more trips to the hospital, one planned and one not. Long story short, though, I’m back in the air and off to see clients, which is a good feeling.

I’m also headed somewhere warmer than my current snowy state, which is definitely something to look forward to. Many of my spring plants were up or blooming when the snow hit, so the garden will have a bit of a setback this year. I’m just glad I’m not traveling to central Florida, where CNN reports that a cobra escaped captivity and is now in the wild.

In follow-up to my post about having a partial EHR outage this weekend, the vendor never did send an update about the situation. We also had an outage today of the patient portal, and again after 12+ hours, no follow up. If they’re not going to follow up, their emails shouldn’t say they will send follow-up emails as further information becomes available.

In healthcare IT, we tend to think about our work within the contexts of inpatient vs. post-acute vs. ambulatory vs. community vs. population health, etc. As humans begin to spend more time in space, that’s going to be the next frontier of healthcare IT. NPR recently reported on microbiologist/astronaut Kate Rubins, who was the first person to sequence DNA in space. I was interested to learn about the microbiome of the International Space Station, something you don’t hear about much but that opens the door for some unique research activities.

In other news scientists in China have completed gene editing on viable human embryos using the CRISPR technique. Although the study was small and the results were not perfect, they were promising. Gene editing could reduce the incidence of heritable diseases, but we have a lot to learn about the technique, impact, and ethics of doing so.

I’ve certainly got genetics on the mind following my consultation with the genetic counselor earlier this week. Although she didn’t give me the initial speech about the science of genetics, I appreciated that she didn’t assume that I had done a ton of research or had preconceived notions about what we were talking about. We talked about my specific concerns based on family history as well as what kinds of testing are available and the ramifications of having positive testing.

Although the Genetic Information Nondiscrimination Act of 2008 restricts the use of genetic data in health insurance and employment issues, it doesn’t prevent issues with the underwriting process when you’re talking about life insurance, disability, long-term care coverage, and more. One of the first questions she had for me when we were talking about testing was whether I had addressed those types of coverage or not.

Although I’ve worked out the life insurance and disability pieces, I haven’t addressed the long-term care coverage issue. Still, I decided to go forward with the testing, but on a limited basis, looking only for a couple of specific mutations. There are plenty of panels available that test for up to 80 genes, but I’m not going to go looking for something that isn’t a concern and wouldn’t potentially change my management plan for preventive screenings.

Based on the dramatic increase in our knowledge of genetics over the last decade, we agreed it would be prudent to meet again in a couple of years and discuss whether there are new recommendations for testing someone in my situation. To answer the previous reader question, she uses panels from Myriad Genetics.

We also walked through a couple of risk models based on my family history without the genetic testing component. This is where the discussion quickly became academic, because one of my personal risk factors is considered a “borderline” risk factor in that some models consider it a risk and others don’t. When the model is run with the risk factor in place, my lifetime risk of breast cancer is pretty alarming. Without the risk factor, the risk is cut in half. Even with the diminished risk of the second model, it was enough to qualify me for a high-risk screening program, which seems like a reasonable option compared to the alternatives. We’ll have to see what my insurance thinks, however.

Being in the high-risk program at the medical center is tied to their imaging center, which of course involves hospital facility fees for the studies. In my area, though, the cost difference for a screening mammogram isn’t much more than at the independent imaging center where I had my previous studies, so I opted to get mine done at the hospital while I was there. I realized as I was getting dressed, however, that moving my care to the hospital meant giving up the “real time” reads done at the independent center. I hadn’t thought of that prior to the test, which made me wonder how many other patients might not have thought of it. It really is amazing to me how easily your reasoned clinical and analytic process can go out the door when you become the patient.

My experiences as a patient over the last few weeks have given me a better understanding of how hard we make it for patients and their caregivers and how much individual variation there really is in our healthcare system. It also made me realize that despite thinking I had a pretty solid handle on my family history, there were quite a few questions I couldn’t answer. Most patients probably don’t have as much information as I walked in there carrying and that certainly impacts the patient experience and the specificity of the counseling.

It will be a while before I get the genetic testing results back, and in the mean time, I’ll be reading up on some novel genes that the counselor mentioned may have interesting implications for my family but that aren’t being commercially tested yet.

Friday is Match Day, when thousands of medical students learn which residency programs they’ll be headed to for the next three to seven years. Good luck to everyone waiting for their envelope. And to those who didn’t match to the residency of their dreams, keep your chin up and learn all you can wherever you go.

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Curbside Consult with Dr. Jayne 3/13/17

March 13, 2017 Dr. Jayne No Comments

Even though I haven’t had my post-op clearance visit, I returned to patient care work today. Since I only see patients part time, our medical liability insurance is in the form of a “slot policy,” where multiple physicians share a single policy. Although it’s a cost-effective way to handle coverage for part-time physicians, it can make scheduling complex since you have to avoid exceeding the allowable hours for each physician on the policy.

My partners have been covering my shifts and I know it’s been a strain.Since I’m theoretically being cleared tomorrow, I figured I’d work. It helped that I was scheduled to work at one of our less-busy sites, so I wasn’t too worried about being physically overwhelmed.

No good deed goes unpunished, though, because I was greeted with a partial EHR outage. It was very similar to the recent Amazon Web Services outage in that we could document and scan images but couldn’t view any images or letters. The vendor did promise to keep us posted, but after 10 hours we had heard nothing.

Fortunately, we were able to keep documenting and seeing patients, but it’s annoying that they didn’t at least follow up every couple of hours with a status update. Overall, it was a slow day and I had brought some other work to do if things were quiet. Usually that’s a guarantee that you’ll stay busy, but not so much today.

My backup plan was to do some continuing education and watch some of the “on demand” sessions from HIMSS17, but they’re not posted yet. I instead started to enter my CME credits, and was reminded that the system is less user-friendly than I hoped. First, when you set up your transcript of courses you want to claim credit for, there are some usability challenges. When you select a class, it blanks the screen, forcing you to re-select the day every time you select a class. Second, you can’t select more than one class per time block. Once you select a course in that block, the rest of the options disappear. That makes sense for a live-only conference, but not so much for a conference where you can also earn CME from on-demand sessions.

I suspect it probably has to do with the requirements for CME approval. I think HIMSS was only approved for 22 CME hours this year, despite there being well over 100 sessions approved for credit. Many physicians struggle with the cost of CME, which makes me wonder why they don’t approve the conference for more than 22 hours, especially with the availability of on-demand courses. The content is broad and personally I prefer watching the sessions at home because I’m more focused than when I am in a group setting, especially if other attendees are distracting.

Although volumes were small today, they reminded me why I enjoy practicing medicine. When I first went into informatics full-time, I had about a year and a half gap where I didn’t see patients. Not from lack of interest, but from a lack of options for part-time family medicine docs with inflexible schedules. That’s when I started practicing urgent care and emergency medicine.

What we do certainly fits into the “life is like a box of chocolates” category. Where else can you see a patient roster that includes chief complaints of “fall on ice” and “poison ivy” in the same day after temperatures dropped from 70 to 20? Where else do you get first-hand knowledge of the aftermath of mechanical bull riding? (For those playing along with the home game, today’s answer was a fractured sesamoid bone in the thumb rather than the head injury you might expect.)

I also enjoy practicing medicine because I’ve finally found a spot in an organization where people are truly held accountable. Even in our state of rapid growth and geographic expansion, our leadership hasn’t wavered from their mission and vision. They’ve taken steps to reward employees who support those ideals. As a privately-owned practice, they are relentless in their ability to weed out slackers or those who aren’t committed to the mission. We run in a near-military culture and it’s not for everyone, but knowing your staff has your back (and most of the time is out in front of you getting it done before you even get there) makes being at work almost joyful.

We recently implemented a new bonus system. Instead of getting quarterly or semi-annual bonuses, staff members receive bonuses on an ongoing basis. Each month, every employee is given an allotment of “bonus bucks” to award to colleagues who are living the values. Although providers are on a different bonus structure (based on timeliness of care, quality, patient satisfaction, etc.) we have an allotment of bucks to give to staff. Each bonus award has to include specific commentary via hashtag of why the employee earned the bonus. Since providers have a large bank of bucks to give each month, people are eager to work quickly and efficiently and to operate truly as a team. We were doing well with the old system, but the new immediate recognition scheme has really pushed some people’s efforts over the top.

All employees can view a real-time suite of analytics showing top receivers, top givers, percent participation, and more. Bonus flow can be visualized as an activity network or via a word cloud that summarizes all the words used in the hashtag award notices. It’s pretty cool to watch how things flow over the course of time and across various teams – clinical, reception, radiology, and providers. Employees can cash in their bucks for gift cards, workplace swag, and even months without late shifts or in exchange for holiday shifts. Maybe it’s a bit gamified, but it’s working.

I’m glad to be back in the saddle and hope I’m fully cleared tomorrow, so I can get back in the air for my clients. My next two trips are to some of my favorite parts of the country and I’m looking forward to not being grounded any more.

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EPtalk by Dr. Jayne 3/9/17

March 9, 2017 Dr. Jayne 3 Comments

I’m still getting back into the swing of things following my recent adventure in healthcare. I’ve enjoyed the relative downtime, although I’m getting a little stir crazy. Hopefully I’ll be cleared for travel early next week so I can keep the good stories coming from the trenches.

In the mean time, I’ve been going through my post-HIMSS and post-hospital mail. A couple of vendors need to get some money back on their marketing efforts: the postcard from eClinicalWorks arrived on Monday after HIMSS had already started, with an invitation to “The Way of Tea” at the Vital Images booth arriving on Tuesday. The grade schooler who picks up my mail when I’m gone does an excellent job sorting and bundling so that I know what mail is the oldest. I can’t wait until he grows up – I see some serious potential as a process improvement specialist.

I’ve been working my way through loads of email. A special thank you to all of you who sent well wishes and good vibes for a speedy recovery. It was nice to have those little rays of sunshine popping into my inbox.

I was glad to have been on sick leave from my clinical position because I was supposed to be working the day the big Amazon Web Services outage hit. Our vendor sent quite a few emails apprising users of the status. They were apparently having a partial outage, where users could document visits but could not see images, forms, and letters. You can have a really great downtime strategy in the office, but you never know how things are going to unfold when an outage hits.

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CMS has finally updated its website with Clinical Quality Measures information for the 2017 performance period. The Meaningful Use domains have been removed and now the measures align with the Quality Payment Program and its Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) tracks. CMS invites people to submit questions about the documentation, but I wouldn’t hold my breath waiting for a response. I’m still waiting for clarification on some Chronic Care Management questions from earlier in the year.

I’ve also had a ringside (couchside?) seat for the release of the American Health Care Act, with plenty of time to digest the back-and-forth commentary from politicians and healthcare leaders. I finally had to step back after a while because it’s going to go on for months as everyone tries to get their piece of the action with the usual wheeling and dealing, negotiations, and amendments.

The so-called “repeal and replace” legislation is only 4 percent the size of the Affordable Care Act (120-odd pages vs. 2,700) so the devil will truly be in the details. I’ve talked to a couple of friends who are OB/GYN physicians and their patients are still terrified about losing coverage for contraception and preventive services. One physician has a patient who is trying to import black market IUD devices from Canada. Apparently they’re made by the same manufacturer that makes them for the US market, but the cost is less than 25 percent of what they go for in the States. That’s a sad commentary on the state of healthcare in the US.

After the Affordable Care Act went into effect, my personal insurance plan was still grandfathered and didn’t have to offer all the mandatory coverage. Late last year, the trustees of the plan voted to un-grandfather and began to offer coverage for things that were previously not covered.

I finally began to pursue a genetic consultation to address some lingering family history concerns. After months of waiting and submitting genograms, results of relatives’ testing, and more, I finally have my appointment with the geneticist next week. Of course, it’s going to be better to know one way or another, but I hope my decision to get tested doesn’t come back to haunt me if there are changes to the protections and coverage for people who know they are at higher risk for serious health issues. (At least I know I’m at zero risk for gallstones or cholecystitis now, so that’s a plus.)

I had a strange experience as a physician this week. I received an email in my consulting business account containing a link to access a summary of care record. It was from a hospital where I haven’t been on staff since before I bought this domain, so I’m not entirely sure how my address came to be linked up to their system. Sure enough, it was a patient discharge record.

I cross-referenced it against my patient panel from the last year I was in a traditional primary care practice and found the patient. I’m not sure if it was a computer glitch or whether she really still considers me to be her primary care physician after all this time, but it was a nice memory. I called the hospital and they weren’t terribly helpful in trying to figure out how it got routed to me as it did, but instructed me to simply discard the message.

Physician readers familiar with “The Match” will cringe at this news story. The cardiothoracic surgery program at New York-Presbyterian / Columbia University failed to submit its resident ranking list, meaning it will not be able to offer residency slots as part of the traditional Match Day next week. Columbia can still fill its program through the Supplemental Offer and Acceptance Program, which makes unfilled slots available for residents who did not match. This could be a boon for students who didn’t get a spot via the actual Match process, but it means that the program will most likely not have access to its top-ranked candidates.

I still remember my own Match Day, and not entirely fondly. Although my placement was a sure thing, I was on the edge of my seat waiting for my turn to open my envelope in front of my entire class. For some, it was a barbaric way to do things as we watched people’s dreams get crushed in between happy Matchers jumping up and down. Schools still have formal Match Day ceremonies where this continues to happen, although applicants can now skip the envelope and find out an hour later via email.

What’s your Match Day memory? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/6/17

March 6, 2017 Dr. Jayne 2 Comments

Jayne Goes to the Hospital

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You may have surmised if you follow my Twitter postings that I recently spent some time in the hospital, but not in a patient care capacity. It was one of those unplanned, middle-of-the-night type of events that no one ever wants to happen to them.

Of course, the chain of events might be different when you’re a physician. You sit at home wondering if you are over-reacting and generally second-guessing yourself. At one point, I found myself in severe pain, wondering if I could hang in there until my urgent care opened at  6 a.m. rather than risking the emergency department during flu season. When those thoughts start to cross your mind, it’s definitely time to go.

Based on my symptoms (including the fact that the pain was so bad I couldn’t bend over to put my own socks on), I had a sneaking suspicion that I was going to end up with surgery, so I grabbed my travel necessity bag and threw it in the back seat of the car. That’s the advantage of being a frequent traveler, but you never want to be that patient who rolls into the triage area with an overnight bag, so I left it in the parking lot, perhaps as wishful thinking.

My worries about being in the ED during flu season were unfounded and I wound up being the only person in the waiting room. Registration was a snap since I had my insurance card and photo ID at the ready, wanting no barriers between myself and some serious pain medication. I had to endure five minutes of bad late-night TV (some dating show involving “baggage” that was truly, truly horrid) and was called back.

There are times when you are sick, especially when you are a healthcare provider, when you wonder if you’re over-reacting to what you fear might be going on. I knew when my blood pressure was in the 160s/100s range with an elevated heart rate that whether or not my brain was over-reacting, my body most certainly had an issue with what was going on.

The ED physician ended up being the spouse of one of my urgent care colleagues, who fully appreciated what it means when a physician rolls into the ED in the middle of the night when they’re supposed to be working that morning.

Tests were ordered and an IV was started. After receiving some pain medication, I very quickly understood why people abuse it. The phrase “magic carpet ride” doesn’t begin to describe what it feels like when you see the privacy curtain flowing to the left and the door jamb scintillating off to the right side of the room.

I was pleased that my pain immediately went from 10 to 2, but even more grateful that my blood pressure and heart rate started moving more towards normal as I rolled off to get my CT scan. Once those results were back, the physician returned to complete a more thorough history and physical to prepare my admission documentation.

This time he had a scribe, or at least who I thought might be a scribe since we weren’t properly introduced. Normally I’d make a point of saying something, but I was still surfing on my cloud of Dilaudid and just wanted to know what the plan was and call my COO so he could find someone to cover my shift that was supposed to start in four hours. I was totally ruminating on that detail because I didn’t want to be “that doctor” who just doesn’t show up.

There was a parade of different nurses through the room. I received some antibiotics and some different pain medication. Then it was off to the inpatient unit to wait for the surgeon to meet me before I was whisked off to the operating room.

I received a room assignment on a brand new wing (confirmed by the new paint smell) and arrived right before shift change. Both the outgoing and incoming nurses were wonderful, explaining everything that was going on and letting me know when my next doses of antibiotics and pain medication were due. The outgoing nurse got a chuckle out of administering my intake questionnaire since I knew the answers to all the race, ethnicity, blood product acceptance, and cultural pain practices questions before she was even done asking them.

I was trussed up with DVT-preventing sequential compression leggings so I didn’t get a blood clot. Thankfully, she showed me how to disconnect myself so I could get to the restroom without having to call for help. I guess there are some benefits to being a physician.

The surgeon came by promptly and said he wanted additional confirmation of the diagnosis in the form of an ultrasound, which was performed immediately at the bedside. You know when you’re in trouble when the ultrasound tech takes a bunch of extra pictures even if you can’t see the screen.

Not more than 20 minutes after the test was done, the nurse came in to announce that they would be coming to take me to the operating room sooner than later. She was followed by a patient care tech bearing a couple of packets of pre-op scrub wipes, who dropped them off with instructions on what to do.

By this time, I had non-medical family at the bedside. They were shocked that the staff would expect the patient to do their own pre-operative prep. I’m no expert on pre-surgical care, but I’m hoping if the patient wasn’t a relatively healthy and mobile person that they would assist a bit.

I went quickly to the operating room after that, rolling out the door while reminding my family where to find the healthcare power of attorney and living will if something went wrong. I didn’t have time to get a copy before then, but you can bet that it’s in my Dropbox now. I had my noon dose of antibiotics in my lap since it would be due while I was downstairs and my nurse didn’t want them to be late.

The weekend operating room staff was excellent. I woke up feeling like no time had passed and with all my teeth still where they belonged. I’ve always been afraid of general anesthesia and having my teeth messed up during the intubation, so it was the first thing I thought of. In hindsight it’s pretty weird, but healthcare people think of all kinds of weird things based on what we’ve seen. I had a happy little pillow from the hospital auxiliary tucked under my blanket to brace myself with in case I had to cough and was back in my room in a flash.

The next shift change signaled a change in the level of care I received. As the nurses rounded together, the incoming nurse commented about me deciding to “self-discontinue” the DVT-prevention leggings. Since I had just come up from the operating room and hadn’t left the bed yet, I had no idea what she was talking about. I still had the leggings on, but it turns out someone removed the controller and inflation tubing from my bed when they took me to the operating area. It didn’t occur to me in my post-anesthesia haze that they weren’t connected to anything. Blaming the patient for a process issue isn’t a good way to start a patient care relationship.

From there, things trended downhill. What I did have was a lovely private room with a (no kidding) 60-inch flat screen television and dietary staffer who personally went through the menu options with me for dinner and breakfast. What I did not have was timely antibiotics and pain medication or consistently visible handwashing or foaming. I also did not have a functional IV access site and had to argue to have it moved when it was oozing enough blood that it was leaking out of the dressing and onto my hospital gown.

It turns out that due to staffing and census issues, my nurse was split between two hallways. What that translated to was feeling like I wasn’t getting good care and that I was last on the list. I know hospitals are busy places and there probably were patients sicker than me, but when I’m on scheduled medications, I’m not giving you more than 15 minutes grace before I ring the call button. I was close enough to the nursing station that I could hear the call signal sounding at the desk when I rang it. I could also hear when it went into “alert mode” because it hadn’t been answered by the first-tier response time. Eventually a patient care tech answered and said she would contact my nurse, who didn’t come in.

This cycle repeated every 15 minutes until my antibiotics finally arrived. The nursing staff was equipped with Vocera two-way communications lavalieres, so there was really no excuse for lack of communications while I waited for my antibiotics to arrive over an hour and 15 minutes late.

Although she was apologetic and said she’d return in 30 minutes as soon as the infusion was over, she did not. That led to another 30 minutes of call light and alarming IV pump nonsense until someone came to the rescue.

By now it was 11 p.m. I was due for scheduled pain medication at midnight, but I was honestly afraid to go to sleep because I knew I couldn’t count on getting medications when they were due without being a call-light stalker. By this point, I wasn’t taking any narcotic pain medications, just scheduled NSAIDs, and I wanted to keep it that way. It’s a terrible thing for a patient to be afraid to sleep for fear they won’t get their meds.

As predicted, they didn’t arrive on time, leading to another 30 minutes of call-light tag before they arrived. She was happy to offer narcotics for breakthrough pain, but if a patient is doing well on scheduled meds and gets them on time, there shouldn’t be any need for breakthrough treatment. Needless to say, we had a few words about the timing of the medications.

I was finally able to sleep for about four hours, although it was restless sleep with the anti-DVT leggings pumping up every 30 seconds despite the fact that I had also received heparin shots for clot prevention and was ambulatory. The phlebotomy started at 5 a.m. I dozed a bit until vitals at 5:30. Surprise, after the last “conversation” with my nurse, my medications arrived promptly at 6 a.m.

I knew there was a good chance I’d be discharged that day, so I decided to wash up, throw on some mascara to look less pathetic, and make arrangements for a getaway car. Many surgeons round early and I was crossing my fingers for that kind of schedule. I was feeling really good, and after my Garmin registered 500 steps in the room and the administration of a second heparin shot, I decided the annoying DVT leggings really could come off.

Back when I was still delivering inpatient care at this hospital, we made a big deal about the discharge day and discharge planning and making sure the patient understood the planned schedule and would be ready to depart at the appropriate time. The primary care physicians were scolded if we rounded after 9 a.m. because that interfered with the 11 a.m. discharges.

Things must have changed because the discharge plan was significantly fluid despite my wishful thinking, lovely eyelashes, and fully dressed status. The dietary team came up to go over the lunch menu around 11 a.m. and I waved them off, saying I didn’t plan to be there for lunch. I was finally released from captivity a little after noon. I went home and immediately went to sleep, waking only when my alarm told me it was time for pain medication.

I’ve been recovering nicely with a steady diet of ibuprofen, Tylenol, and Pepcid. I’d kill for the martini that isn’t on the list of prohibited dietary items, but I’d rather wait until I can really enjoy it. Everything tastes strange, even a week out, and despite the lovely covered dishes that have showed up on my doorstep.

Urgent surgery is a heck of a way to get out of working your scheduled urgent care shift, so I wouldn’t recommend it to anyone. I’m just glad this little adventure in healthcare didn’t happen at HIMSS or on any one of my frequent trips across the country. I’m happy to be doing a little more activity every day, even though the score still stands at Gallbladder 1, Jayne 0.

I’ve mentioned my experience to friends who work in the process excellence realm at the hospital in question, so hopefully some change may come of it. I had to chuckle, though, on Wednesday, when I received a thank you card from the hospital: “It was our pleasure to provide your care throughout your stay with us. Our goal is to always provide you with quality care and excellent service.” Of all the people I interacted with, it was signed by the overnight staff who gave me the most concern about quality.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/16/17

February 16, 2017 Dr. Jayne No Comments

One of my clients is going through some cultural change efforts and invited me to attend some of their management training sessions earlier this week. The first warning sign that things might not be as effective as anticipated was when I walked into the room and found the instructor arguing with some attendees, accusing them of being late. I thought it was odd because I was 20 minutes early. It turns out the calendar appointment was sent for the wrong time and the instructor was unaware. Once people showed her their calendars, she backed off, but that’s never a good way to start.

We had been told that we were expected to be “fully present” during the training sessions, to wear comfortable loose clothing for team-building exercises, and that we wouldn’t be able to use our laptops during the session, but that we’d be given frequent breaks to check in. What they didn’t tell us was that one of the facilitators would actually confiscate not only our laptops, but also our cell phones. Although I understood what they were trying to do, taking phones from a room full of physicians, some of whom were on call, isn’t a great plan. It also didn’t give a positive message about treating us like adults and trusting that we could avoid non-urgent texts and emails. What they didn’t realize is that half of the class was wearing smart watches, which still worked during the course. That was a good thing for a couple of the physicians, one of whom was called to surgery.

For the rest of us, though, we had to wait nearly three hours for a break, which I’d hardly call “frequent breaks.” Oddly enough, at the break I had a message from the CEO, who had forgotten my plan for the day and had been looking for me. He was extremely displeased at being unable to reach two of us that were in the training session. There must have been a phone call to the corporate training department after I checked in with him, because the “no devices” policy was relaxed after lunch. Guess what? Everyone acted like adults and there weren’t any more interruptions than there had been in the morning. We didn’t get out of our chairs the entire session, so I’m not sure what the request for loose clothing was all about, but I guess we’ll never know.

I’m a keen student of language, so enjoyed this Merriam-Webster announcement about the new words they’ve recently added to the dictionary. Healthcare and technology were well represented with additions such as: net neutrality; abandonware; EpiPen; and urgent care. The dictionary experts also remediated some items that I’d have thought were added long ago: ride shotgun, town hall, ping, and Seussian.

I’ve started getting some HIMSS-related marketing phone calls. Of course, they quickly turn into HIMSS-related voice mails because I don’t answer calls from weird area codes or people I don’t know. A couple of them have had people speaking so quickly I couldn’t figure out what they were saying or who they were working for without listening a couple of times – which is crazy, since I’m from a fast-talking part of the country and can usually keep up. I know exhibitors have access to our profiles, so it might be nice if you remotely coordinated your pitches with the interests of your target as well as making sure your callers can articulate so they are understandable.

The HIMSS-related mailing volume is down significantly this year. I’m sad to say I haven’t received anything truly eye-catching or even worth talking about. No poker chips, no oddly-shaped mailers to get my attention, no Orlando-themed marketing hooks. I suppose Las Vegas is an easier sell, but it would be easy to do a fun-in-the-sun theme. I’ve probably received less than a dozen pieces of mail total, but of course that doesn’t count the mailings that will arrive after I depart. It happens every year and you’d think they’d have figured out how to solve that problem by now.

HIMSS did send me an email with my “Corporate Member Focus Group Confirmation,” which was funny because I didn’t sign up for any focus groups. It just seemed like too much work this year, especially with their new policy around only allowing the first 12 arrivals to attend even though they may have extended more invitations than that. Planning to attend one takes a chunk of time out of your day. Although attendees receive a gift card for their participation, the invites I received weren’t compelling enough to make it worth the hassle.

I’ve also received some downright creepy emails from other HIMSS attendees, looking to build their networks or hawk their services. I don’t know what the exact agreements with HIMSS sharing data are, but one I received felt like an invasion of privacy. The sender must have had access to my mailing address as well as my email address because he made specific references to the part of the city I live in and how he would like to get together in town if I can’t meet with him at HIMSS. You can bet I’ll be paying better attention to any opt-out settings when I sign up for HIMSS next year.

What’s the creepiest marketing effort you’ve seen or experienced? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/13/17

February 13, 2017 Dr. Jayne No Comments

I spent a couple of hours today getting ready for HIMSS. Priority one was outlining my agenda for continuing medical education sessions, which was tricky since it always turns out that there are multiple sessions I want to attend at the same time. The conference offers 22 hours of the specialized credit that informaticists certified by the American Board of Preventive Medicine need.

HIMSS delivers the sessions on demand as part of your HIMSS registration, but my experience last year was that some of the audio recordings were poor quality. There is also no substitute for attending a session in person and being able to participate in the discussion or connect with colleagues. I chose a primary and alternate session for each available time slot, but we’ll see what happens when I get to Orlando and the exhibit hall is beckoning.

I also worked on planning my social schedule, which also had too many overlapping offerings. I’ll be doing the exhibit hall booth crawl with at least four good friends. It’s always enjoyable to get other people’s opinions on new technologies and solutions. Of course it’s always a bonus to have someone help you scout out interesting shoes or create a diversion so you can photograph footwear or badly-behaved booth personnel without being too obvious.

Speaking of shoes, I spent some time looking for the perfect solution to get me through five days of nonstop walking. Last year I had some awesome pink running shoes from Edifecs as part of their #WhatIRun campaign. I’ve pretty much run those into the ground since then, but enjoyed being part of their campaign. I didn’t have much luck shopping, so I might have to pull out some sparkly running shoes to get through the week after all.

HIMSS is the virtual Super Bowl of conferences, so making sure I have a solid packing list was also part of today’s prep. I have a growing number of devices and various pieces of wearable tech that unfortunately involves a growing number of chargers. I have a universal adapter that takes care of the Android vs. iPad problem, but my Garmin watch has its own charger, as does my new favorite piece of wearable tech, my Ringly bracelet.

I had heard about Ringly more than a year ago, but am not big on wearing rings and was worried about the size of the stone being too much for me. I joked that if they ever came out with a silver bracelet, I’d be the first to order. Shortly after that, they came out with a stainless steel version, so I went on the waiting list last spring. I had to wait until the fall for it to arrive and have been putting it through its paces over the last several months. I’m pleased to say it’s HIMSS-worthy.

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I’ve never ordered a piece of jewelry sight unseen, so I was a little nervous about it. It arrived in a big chunky cube of a box with the bracelet front and center. Sliding off the outer sleeve revealed the charging box nested underneath. The charger connects via USB to your laptop or USB transformer of choice. Not a problem for me since I usually end up charging things off my docking station anyway.

Advertising on the website at the time I ordered it said that the charging box had its own battery and would hold an 8-10 day charge depending on use. I was disappointed to learn that only applies to the ring version. For the bracelet, I’ll have to tote the charging box when I travel more than 2-3 days, which is what seems to be its maximum lifespan. I can forgive the lack of clarity on the website since they’re a startup and when I ordered they weren’t even shipping product yet. Still, having a battery in the box would be an improvement for those of us who travel.

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Having to pack the charger, however, is a small price to pay for what the Ringly does. I don’t like carrying my phone in a pocket. It’s way too bulky even if I take it out of its protective case. If I put it in a purse, I have to turn the ringer on, which isn’t a great idea most of the time. I don’t like to carry my phone in my hands or leave it on the table when I’m out, which a lot of people do, but just isn’t my thing. The Ringly solves that problem – not only by providing discreet vibratory notifications, but best of all, it allows me to screen my calls and texts by configuring contacts in the Ringly app.

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The Ringly app connects with dozens of other apps to provide notifications through a combination of vibrations and LED flashes. You can set it up dozens of ways, depending on how many buzzes and what color blink you associate with each app. For phone calls and texting, it links to your contacts and you can set it to either flash an additional color for certain people, or you can set it to only receive calls and texts from certain contacts. The LED is pretty subtle but helpful for giving you information on whether you need to dig out your phone or take other action.

I wanted to test drive it extensively before I decided to trust it. As a physician who is sometimes on call, I needed to know it was reliable, and it is. The connection screen in the app also shows charging and battery status.

There are a couple of quirky things about the Ringly. It likes your location to be turned on when it connects for the first time (or sometimes when it reconnects after a period of non-use). Every once in a while it doesn’t get along with my phone – usually first thing in the morning – and you have to “forget” it in your Bluetooth settings and then rediscover it. Sometimes it wants to be on the charger in order to connect.

Issues are uncommon, but you need to know the tricks in case it acts up on you. They’re also putting out app updates pretty frequently, and if it really doesn’t want to connect, usually it’s because there is an app update available. Another quirk is that Ringly does all their support through email and Facebook chats, so forget it if you like to talk to an actual person.

The other bonus of the Ringly is that it is an activity tracker. Based on how my phone identified it before I had the Ringly app installed, I suspect that it has Garmin innards. I tested it against my trusty Garmin Forerunner and found that it under-calculates by about 30 percent, however. That’s a pretty big margin of error if you’re into accurate distance traveled, but if you just want something as a relative indicator of activity, it gets the job done. The “silver” bracelet is actually stainless steel, so I’ve worn it running and to the gym with no worries. Not sure I’d do that with the plated gold-tone version.

We’ll have to see how it does on the exhibit hall floor. I’m counting on it to remind me of my appointments and to notify me when people are trying to track me down. It’s also pretty snazzy as a bracelet, so I can’t complain about that. The stone is smaller than I anticipated. If only they’d come out with a stainless version of the ring, I’ll be first in line.

What’s your favorite piece of wearable tech? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/9/17

February 9, 2017 Dr. Jayne No Comments

Several readers asked whether I saw this article about Obamacare vs. the Affordable Care Act, so I feel compelled to respond. I don’t know about the exact statistics, but we’re having lots of conversations with patients in the office about their coverage and their concerns about what will be changing. Usually it’s in the context of their being grateful for our transparent pricing and low costs, but a lot of people are genuinely worried about pre-existing conditions and whether their insurance will still cover preventive services.

When patients complain about rising premiums or changes to insurance plan offerings, I typically mention that while the laws regulate doctors and hospitals, there hasn’t been much done in the way of insurance regulation. Whether or not you think enormous bonuses for insurance company CEOs are warranted, the sheer economics dictate that the money has to come from somewhere.

On the payer front, Centene’s recent report showed quarterly revenue and profit ahead of expectations, helped by growth in the individual coverage market and by Medicaid expansion. Net earnings for Centene were $261 million for the fourth quarter of 2016. Based on 11.4 million patients covered, it’s a small margin, but when you couple it with the administrative costs of running a health plan, it represents a tremendous amount of premium and tax dollars that are not being spent on patient care.

I’ve been inundated by requests from HIMSS for their corporate member focus groups. Some of the sessions are pretty drab sounding and others don’t work with my schedule, so I probably won’t make it to any this year. I was a little aggravated, though, that they can’t figure out how to blind copy the invitation – seems like a basic email skill.

Some of the sessions are vendor-specific and it’s obvious who you will be talking to or about, but others are a bit more vague. I was tempted by one that advertised discussion of precision medicine solutions, but I figured it would just irritate me. As a preventive and public health curmudgeon, I have a hard time talking about spending millions of dollars on focused gene-based therapy when we can’t fund the basics of health promotion and disease prevention.

I attended a service launch webinar for another consulting company this week. They’re not in the same space as me, but they’re a fun bunch of people, so I wanted to see what they’re up to. They’ve partnered with a third-party vendor for the tool, although they didn’t say it. If it’s not totally white labeled, I think it’s better to say you’re at least “powered by X vendor” rather than having prospects or vendors see “copyright X vendor” at the bottom of the screen and wonder what’s going on. The presenter also seemed nervous. Even if you’re a presentation pro, I’d definitely recommend a dry run when you’re launching something new or presenting in a new format.

For weird news fans: I stumbled across an article about a patient who lived for six days without lungs. She had been waiting for a transplant but developed influenza and sepsis along with organ therapy. After concluding that death was likely imminent unless there was intervention, physicians removed the source of infection – her lungs. She was placed on an external oxygenation device (Novalung) with rapid improvement and received donor lungs several days later. Four months later, she’s breathing normally on room air, although she does still have to have dialysis following kidney failure. Hearing about physicians pushing the boundaries and having success reminds me of the excitement of medical school, when it seemed like our faculty was making history on a weekly basis.

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CMS has extended the submission deadline for 2016 clinical quality measure reporting required by eligible hospitals and critical access hospitals participating in the Medicare EHR Incentive Program or the Hospital Inpatient Quality Reporting program. Electronic clinical quality measures are now due March 13 rather than February 28. For 2017 reporting, CMS plans to start a rule-making process looking at modifications to the final rule. It’s always fun to wait for the rules to be finalized after you’re already playing the game.

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The AMIA Mentor Match program is looking for informaticists willing to spend an hour a month for the next 11 months working with mentees. I’m thinking about signing up, but struggle with how to describe my experience and areas of expertise. Somehow I don’t think “Sassy former CMIO turned consultant seeks idealistic mentee to remind me how idealistic I used to be, before corporate healthcare and chaotic vendors drove me over the edge” is what they’re looking for. Some days I wish I had a mentor of my own to give me perspective on the bizarre work situations in which I often find myself.

I’m spending some extended time in the patient care trenches due to a colleague’s medical leave. We’ve started seeing some EHR performance issues during the times of peak patient volume. It’s bad enough when you’re overwhelmed with patients, but having your system fail you makes it intolerable. At times, the system is at a crawl.

I was spoiled when I was a CMIO because our EHR vendor had a SWAT team they would send out for issues like this. Even if you had strong resources in house, you could leverage the team to review performance and monitoring tools and make recommendations. My current vendor is on the smaller side and not terribly helpful when it comes to helping us manage the issues.

We use a third party to manage desktop and wireless solutions, so as you can imagine, there is a bit of finger-pointing between the access crowd and the application support folks. It always unnerves the IT team when you have a physician who starts asking about latency and Citrix load balancing, but I’m happy to give everyone a nudge to stop the blame game and get about the business of finding solutions.

The HIMSS mailings have started rolling in. Every year it seems like the marketing themes and giveaways get a little goofier. Physicians have long been scrutinized for regarding gifts from industry, but there’s no reporting for the majority of healthcare IT professionals. I hope the Open Payments system has fields available for tracking giveaways such as virtual reality goggles, scooters, art pieces, and more.

What’s the best trade show giveaway you’ve ever seen? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/6/17

February 6, 2017 Dr. Jayne No Comments

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I’m playing cleanup for one of my clients this week. They’re dealing with one of the most common management challenges I see – lack of redundancy for key positions or functions.

Due to some leadership personality issues, individual contributors were allowed to become “experts” on a variety of topics without any thought to backup, collaboration, or shared responsibility. When issues came up, it placed the experts in a position of being able to swoop in and solve the problem using their sacred knowledge, further solidifying the idea that only the rescuer had full command of the information. Instead of raising appropriate red flags about why only one person could solve a problem, previous leadership continued to groom these expert resources.

In reality, what some of the experts were doing was front line customer support, but because no one else had visibility into what they were doing, it appeared that they were doing a lot more than was actually going on. Now that a couple of them have left the organization, it has become apparent that some of them were doing very little, and others were doing work that could have been handled by appropriately training the practice call center employees who interact with the internal customers on a daily basis.

When I came into the situation, the organization was in a tailspin trying to figure out how they could possibly replace these people. The reality was that we were able to outsource it pretty quickly, along with selling them some consulting services to document the process, educate others, and prevent this from happening in the future.

In looking at the broader structure of the organization, however, there are much larger cultural factors at play that allowed this behavior to continue. There is a history of promoting individual contributors to management positions because there was no other career path for them. When you take people with no management experience and plop them into a management role, it often feels very uncomfortable. That can lead to the new manager withdrawing from those responsibilities and instead to try to create new individual responsibilities that are more in their comfort zones. Couple that with upper management that is too crisis-oriented and doesn’t budget adequate time to develop these new managers and you have a recipe for a mess.

My task with these folks now is to evaluate the depth and breadth of the experts and figure out what they were actually doing. Some of them have been doing obscenely little given their titles and pay grade. Others were trying to do more than anyone could possibly do well because of wheel-spinning and inefficiency. Once we identify the core body of knowledge and the tasks that need to be completed, I assign an external resource to first cover the acute needs, but second, to document everything and create a training plan to build out multiple resources to cover the needs moving forward. I’m unfortunately seeing a lot of resistance as members of the organization figure out that the emperor has no clothes and begin to worry that they might be next in being exposed.

This fear of being exposed leads to all kinds of bad behavior: information hoarding, siloing, manipulation, maneuvering, and more. People feel threatened when they’re worried others will figure out they have been operating outside accepted boundaries and will do anything to protect themselves.

My favorite strategy is blaming the consultant, who has clearly been brought in by the leadership to fix something that has been identified as a problem. There’s a certain level of trust (and money on the line) when you bring in an outsider and give them carte blanche to realign resources and shift roles and responsibilities. Complaining about it or pitching a fit only makes you look bad and potentially tees you up to be “realigned” outside the company if you are uncooperative enough. Couple that with the fact that the consultant was able to replicate your job duties at a fraction of your cost, and it might just be better to keep your head down and cooperate.

I’m on site this week doing stakeholder interviews, trying to sort out what people think about their role in the project and how the project is going overall, vs. what others have to say and what the leadership thinks is going on. It’s not looking good for some members of the management team who are behaving like cornered animals. Although downsizing was not an original goal of this consulting engagement, how they’re handling it is making it seem like losing a few people might be a good idea.

I enjoy doing stakeholder interviews and organizational assessments. Sometimes they can be enlightening, but often they’re fascinating journeys into the underlying psychological baggage that people carry around with them. Some of my standard interview questions involve the team, its goals, what people think about their participation, the overall health of the project, and how they think they’re contributing.

I conducted one interview this morning where the participant raved on and on about a colleague and how helpful she is, how much of an asset to the team, how she enjoyed working with her, etc. A few hours later, I met with the subject of the glowing commentary, who went on and on about how she thinks my previous interview subject hates her and is trying to undermine her within the company. This client has a fair number of “you can’t make this up” scenarios that I have to figure out how to deal with. I’m thinking I need to bring in a therapist in addition to subject matter expert consultants.

The leadership is not without blame here. Although they’re relatively new and inherited the bulk of the mess, they’ve been complicit in allowing some of the craziness to continue without stepping in earlier. They’ve allowed the process of making people managers because there’s no way to promote people in various job classes, which has compromised people’s effectiveness and weakened the organization.

Members of the leadership also project the air of being too busy to help the little people sort it out, which is going to be a long-term issue. They’d be much better served by at least appearing that they’re willing to roll up their sleeves and dig in to build the organization rather than making it clear that their main goal is to continue acquiring physician practices and everything else is secondary. Adding more practices (many of which are distressed when they’re acquired) when they’re struggling to support their existing practices doesn’t seem like the best strategy, so I’ll continue to work on that piece as well.

What’s your current project? Does it make you want to crawl back in bed every morning? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/2/17

February 2, 2017 Dr. Jayne No Comments

It’s increasingly difficult to keep up with the literature when there is so much coming out and the pace of change is so rapid. This article in PLOS One regarding influenza vaccination for healthcare workers caught my eye. It looked at vaccination statistics in long-term care facilities and whether the “number needed to vaccinate” in order to prevent patient death was in alignment with what had been predicted based on previous data. Rather than the previously predicted number of eight vaccinations needed to prevent a single patient death, the number was calculated at somewhere between 6,000 and 32,000. Authors concluded that the four studies supporting enforced vaccination for healthcare workers “attribute implausibly large reductions in patient risk to healthcare worker vaccination, casting serious doubts on their validity.”

This is a great lesson in small data vs. big data and the need to keep questioning and keep researching as the healthcare knowledge base continues to expand. Through the magic of eBay, I once purchased a set of medical student notebooks from the 1920s. They’re half-legal sized bound notebooks that flip at the top, and it’s amazing to see what is written and what we knew then. My favorite page starts with the statement, “There is so much we still do not know about the thyroid.” I wonder what that medical student would think of our current knowledge base? Those notebooks also make me wonder what physicians will think of us 80 years in the future, especially given the current wrangling over whether we as a nation are committed to ensuring medical care for all.

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I recently posed the question to my readers about what would their ideal jobs would look like.

From Sunshine State: “An optimal role would be leading several business units from a COO or similar position, with a focus on solving problems in our industry in a fast-paced and dynamic environment. A level of risk is attractive — as John Paul Jones stated, he who will not risk cannot win. How do we shrink an industry and not put people out of work while advancing care? With a generalist background, a greater contribution is possible with coordinating resources and goals across groups rather than leading a specific business unit or department requiring specialized skills.” I agree that the idea of having more than one business unit at your disposal might make it easier to solve problems creatively without the distraction or bottlenecks that occurs with more siloed organizations. There’s a temptation for leaders to protect their own rather than stepping out of their comfort zones in an effort to solve the bigger problem. Certainly figuring out how to reduce cost, increase quality, and maintain jobs is a challenge, even more so when you have limited financial or personnel resources.

From At Bat: “Funny you should ask about the perfect job because I happened into it several years ago. I worked at a large hospital for 30+ years in direct patient care, managed care, the physician organization, the health plan, patient safety, and at the last part of my career in evidence-based medicine. I’m not technical, but was involved system-wide in various projects. I was contacted by the executive for our data warehouse asking if I would speak at a conference on a particular topic. I replied, ‘No problem, any opportunities?’ and after a whirlwind of phone interviews and a quick meet-up at HIMSS, I was offered my dream job helping health systems with analytics initiatives. I have to honestly say that if you gave me a pencil and paper and said to write down the perfect job, this would have been the result. I work from home when I am not traveling, and while I do get a tad lonely, it is the most rewarding job I have ever held. I am slowly getting used to working in the for-profit vs. non-profit world.” The ability to wear fuzzy bunny slippers to work cannot be underestimated. It can be a drag, though, when you realize you’ve been wearing pajamas all day and have been so busy working that you’re not even sure you brushed your teeth today. I’m always happy to hear when people find something that really clicks and hope that it lasts for them.

From What The?: “I wrote you a couple years ago about the perfect job and thought you might appreciate an update. I had decided after being a healthcare IT consultant that I knew without a doubt that I wanted to be a doctor. I have a liberal arts degree and zero science background, but seeing how people like you approach healthcare convinced me that this was something I needed to do. I was accepted to my medical school of choice last fall and am doing contract HIT consulting work to save up money until I start classes. I just got an email about my white coat ceremony in July and could not be more excited about the opportunities ahead.” This put a big smile on my face. Although sometimes those of us in the profession knock it due to the hours, the stress, the external pressures, and more, being a physician is still one of the greatest privileges any of us can have. For patients to trust us in their times of vulnerability and weakness is truly something special. Even though there are tens of thousands of “healthcare IT people” who never go anywhere near a patient, we need to continue to remember why we are doing this. It’s about our grandmothers, brothers, sisters, and everyone else who relies on the systems we use to make decisions and deliver care.

Email Dr. Jayne.

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