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Dr. Jayne from HIMSS 2/29/16

February 29, 2016 Dr. Jayne 1 Comment

Usually the travel day to HIMSS is uneventful and this year didn’t start any different. I boarded my flight at O Dark Thirty and settled in to watch some software training videos that my client had created, since I knew there was a good chance they’d put me right to sleep. After a nice nap, it was time for email clean up.

I must have missed this before, but CMS has extended the Medicare EHR Incentive Program hardship deadline until July 1, 2016. If you haven’t submitted your application yet and want to avoid adjustments to your 2017 Medicare payments, you have plenty of time.

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I touched down in Las Vegas right around the start time of the Hot Chocolate 15k run, which had multiple roads closed. Fortunately I had a taxi driver with a great personality, which made the delay tolerable. Although the roads were closed, I never saw any actual runners.

Speaking of runners, I mentioned previously that Edifecs has their #WhatIRun campaign live. I’m flattered to have my profile posted under the healthcare leaders section and appreciate their willingness to keep me anonymous.

For those of you who pop over to take a peek, yes, the comment about the refrigerator is true. Once I arrived at my hotel, I found out that my promised (and paid for) early check-in had been pushed back an hour. It was difficult to find somewhere to hang out that wasn’t completely smoke filled, which reminded me why I am not a huge fan of Las Vegas.

Once I finally received my room keys, I was quite surprised (as was he!) to find a naked guy who had apparently just stepped out of the shower. The front desk was apologetic and reversed my early check-in fee and also upgraded my room. It wasn’t their fault, though – the guest had checked out before he was actually ready to depart, so let that be a good lesson to only check out when you’re ready and also to use the privacy lock.

Once I was settled, I enjoyed the opportunity to get outside and actually see the sun since there is still snow on the ground in my world. I’m always saddened to see the panhandlers on the elevated walkways. Although it’s a complex problem, one man today was clearly having a psychotic episode outside the Palazzo. Hotel security were keeping an eye on things since he was accosting pedestrians. I hope he gets the help he needs.

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The fountain at the Wynn was getting some maintenance and I imagine electricians who own dry suits are in demand across down. Registration was smooth, although there was a snafu with picking up bags and materials. At the registration area, they were telling people to come back in three hours to get everything. I decided to wander around the meeting areas and found the bag desk a few dozen yards away, fully stocked and ready to distribute. There were several people headed to the CHIME golf outing toting their clubs.

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I stumbled across this Sunday session, featuring AMA president Steven Stack as well as Nancy Gagliano from CVS Minute Clinic and some others. From the time I saw it to when I returned to snap a photo, they had added the “free” to the signage. I registered and chatted with some of the staffers, who were very enthusiastic about their mission. I popped in for a bit and didn’t learn anything new, so headed back out for some more sun.

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I connected later in the day with Dr. Lyle and some of his Healthfinch colleagues, who were on their way to a get-together at the Palazzo. My favorite part of HIMSS is catching up with people that I may only see once or twice a year. The rest of the evening was spent with friends old and new, as we christened the Southbound Greyhound as Dr. Jayne’s Official Drink of HIMSS16. (I personally like to muddle in a few blueberries, but there were none to be had.) Note to the bartenders at Treasure Island: you might want to stock in a few more bottles of Deep Eddy Ruby Red. You’re going to need them.

I was trying to unwind this morning in preparation for this evening’s big events, but despite the privacy sign on the door, the housekeeper opened the door without knocking. I always use the privacy lock, so she wasn’t able to get in, but it was annoying, especially since it was barely past 8 a.m. I know they’re in a hurry to turn over rooms, but I’m not checking out today and I did have the sign on the door.

I’m going to meet up with a good friend for lunch and lay out the battle plan for the week. Unfortunately I’ll miss the opening keynotes due to HIStalkapalooza prep, but I don’t think I’ll be missing anything earth-shaking.

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For the rest of you prepping for the big night, may I suggest the liquor section at Walgreens, which has the Pedialyte thoughtfully displayed with the Ketel and Tito’s. I’m looking forward to the dance-floor stylings of Matthew Holt as we Party on the Moon. See you there!

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/25/16

February 25, 2016 Dr. Jayne 1 Comment

This week has been completely off the rails, with all my best-laid HIMSS preparation plans left undone. There’s nothing like five inches of mucky wet snow, flight delays, and a case of pinkeye to throw a girl off her game. Luckily I made it home, saw one of my partners for some eye drops, and am now playing a frantic game of catch up.

The pre-HIMSS news cycle is pretty slow. There was a flurry of mailings earlier in the week, most of which were nondescript post cards that wouldn’t lure me to a booth. Today there was nothing, but there will always be those post-HIMSS straggler mailings to look forward to.

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Several readers have been sending me their shoe pics, wondering if they’ll give them a proverbial leg-up on the competition. There’s even a HIMSS Style 2016 board  on Pinterest, with suggestions for both ladies and gents. I do like the pink socks and fetching wing tips pinned from www.dapperclassics.com.

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Another sent me a pic of this two-heeled number from Christopher Dixon, which are supposed to be extremely comfortable. They’re also tech savvy, using Silicon Valley partner Chronicled to ensure authenticity. Shoes are tagged using a microchip and registered from a mobile app, allowing a future secondary market for non-knockoffs. Accessing the shoe’s chip via the app also displays a story about the inspiration behind the shoe and the sourcing of its materials. I doubt we’ll see any on the show floor, but a girl can dream.

I’m putting together my final social schedule for next week. Unfortunately, there are way too many events on Wednesday night and too few on Tuesday night. Most of the vendors who are hosting events are either gracious enough to allow public registration or are swayed by the MD accompanying my generic-sounding practice name.

I did have one of them question exactly how I received their invitation since it didn’t match their list. I had to just ignore it because I couldn’t exactly say, “Well, someone on your marketing team thought it was worth inviting Dr. Jayne.” One vendor offered to add me to its attendee list if I would send my real name – nope, not happening.

If you have an event on Tuesday that’s open to all readers, let us know. We’d be happy to have a member of the HIStalk team cruise by if time permits.

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I tried to attend a Google Hangout this week, where NCQA was going to talk about the pilots for their redesigned Patient-Centered Medical Home program. The audio from the moderator’s PC was so bad that people couldn’t hear, which turned some attendees away. There were also a lot of people who weren’t muting their own microphones, adding to the problem.

Once the featured speakers started their talks, things got better, but it goes to show that Web conferences still can be tricky for a lot of people. At least the comments were fun to read.

I followed up after with one of my friends who does a lot of PCMH consulting work. She’s personally steering people away from NCQA, not only due to the complexity of their process, but also the growing fees. I haven’t had a chance to look at their new measures in depth, but she has seen them and thinks there are a few in there that are nonsensical. Looks like I have some reading to do.

CMS shut down the Medicare/Medicaid EHR Incentive Program attestation website over the weekend to correct an error preventing Eligible Professionals from claiming an exclusion for one of the measures in the Patient Electronic Access Objective. Those whose attestations were rejected previously must resubmit their information.

ONC has released a new Health IT Buzz post about “The Real HIPAA,” giving examples from care coordination and case management. This should be required reading for all the people who continually try to use HIPAA as an excuse not to share patient information when it is clearly permissible. The next installment is slated to cover Quality and Population-Based Activities and I’m looking forward to seeing what they have to say.

If you’ll be in Las Vegas next week and are interested in giving feedback to CMS, they will be hosting three Design Lean Planning Sessions during HIMSS. The goal is to receive feedback on the Merit-Based Incentive Payment System (MIPS). Sessions are one hour long and will be held March 1 at 2:30, March 2 at 2:30, and March 3 at 11:30 in the CMS Meeting Room, Venetian Level 4, Zeno 4603. Space is limited and you must email  with your session choice, name, title, role, and organization to register.

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Another reader recommended I not spend too much time at HIMSS job hunting, suggesting that I consider a position in New Zealand. They’ve been trying to recruit a primary care physician for more than two years with no takers. The position has good compensation, no nights or weekends, and 12 weeks of holidays. I’m not ready to live in the southern hemisphere, but a nice locum tenens gig might hit the spot. Unfortunately, he’s been inundated with applications of dubious merit, so he probably won’t see mine.

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My week also went askew thanks to the usability efforts (or non-efforts) of Microsoft, who decided in their infinite wisdom to “update” Office 365 with a feature that completely broke my workflow. I have been enjoying my Surface tablet, especially the Surface Pen, which I use in lieu of a mouse or the touchpad on the keyboard. I have been working on a huge editing project (textbook chapter, anyone?) and two days ago the pen stopped working as a selection device and only worked for annotation. Using classic user psychology, I assumed I had done something wrong or activated something unknowingly. I immediately knew better when I did a Google search and typed “Microsoft Surface Pen” and it automatically suggested adding “stopped working” to the search.

Apparently Microsoft engineers decided we no longer want to use a pen or stylus for anything but annotation — the pen is now locked in Ink mode while using Office products. Although there appears to be a button to return it to selection mode, it doesn’t work. Multiple users have already weighed in on a Word suggestion forum that there needs to be an option to go back, with several comments from people who used the pen as an accessibility and adaptation tool to help with physical limitations. I use mine with the keyboard, so I can use the touchpad even though I don’t like it, but I truly feel for those actually using it as a tablet. Having to use the touchpad reduced my editing productivity by more than 50 percent.

Even worse, the on-board Microsoft Help seems to brag that the “select objects” button (which should turn inking off) no longer works. The Microsoft Answer Tech gave me an escalation link that wasn’t customer facing and the escalation site shows they don’t know the difference between a country and a language (featured above).

Help a girl out by sharing the link and helping us tell Microsoft they’re offending their users. If I scurry home from HIMSS, I’ll still have two days left in my return window to offload it.

I won’t post again until I get to HIMSS, If I have to ditch the Surface, what’s your advice on a tablet? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/22/15

February 22, 2016 Dr. Jayne 3 Comments

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I’ve mentioned a couple of times about having issues in the office recently, where our cloud-based EHR is down. A reader asks: “Please explain to me as an IT physician expert why your cloud EMR was ‘down again.’ Mission-critical systems should have backups. I also believed that bigger organizations should have more resources (like you) to prevent/remediate these events. Please tell your readers why this is happening and what procedures your organization has in place to prevent this?”

We actually went down again while I was seeing patients last week, although it only lasted for a few minutes. I’m happy to tell my story.

In my current clinical situation, I’m more representative of the “average Joe” (or Jayne) physician than an IT physician expert. Like many other physicians in practice, I am employed. Although I used to own my own practice, that was more than a decade ago and the demands of running the business took all the joy out of medicine, sending me into employed practice in the first place.

That was the position I was in when I became a CMIO – homegrown by my hospital/health system to take the reins as we moved into the EHR world, long before Meaningful Use was even thought of.

From a physician informatics consultant perspective, I live and breathe downtime strategy. Clients hire me to engineer their downtime strategies and ensure that being down is something they never have to encounter. Whether it’s the threat of utility providers with backhoes or a natural disaster, I’m all over it.

The downtime solutions I helped engineer when I was a CMIO were initially ridiculed by the IT department as overkill, but they proved themselves time and again as we encountered a variety of unstable situations. Car crash into the data center, knocking out power? Check. Flood in the backup data center? Check. IT guy pulls the Halon fire suppression system on accident, shutting down the building for half a day? Check. Network switch down? Check. Vendor fries your database with a bad upgrade? Check. We had it covered and I learned a great deal along the way.

However, when I go into the office now, I put on my physician hat. My employer knows full well what I do the rest of the time, and although we are a good-sized independent physician group, we don’t have the level of dedicated informatics or IT resources that a hospital-owned group or academic medical center might have. We sometimes run on paper-thin margins as we deal with shifting reimbursement schemes and a rising balance of patient pay accounts.

The bottom line is that that our management (like many other private practices) are not able (or perhaps willing) to pony up to have a full-time or even part-time expert deal with the situation.

That scenario is exactly why I went into consulting in the first place. I started my consulting practice on the side while I was still a CMIO, working with practices that might be on the smallish (or cheapish) side but that still wanted expert advice. Practices who may not feel like they can afford ongoing expert assistance, but might be willing to hire someone to come in, do an evaluation, and give them advice. But despite dire warnings and imperatives, clients don’t always take my advice and sometimes simply cannot afford to do so.

Eventually my consulting practice grew to where I also handle large hospitals and health systems, especially ones with more than their share of challenges. I left the hospital-based world some time ago and hung out my consulting shingle full time.

I had several locum tenens and urgent care-type assignments before settling in at my current practice. In my employment as “staff physician,” I am somewhat blinded to what our owners are doing with regard to the EHR vendor and the ongoing issues. I do receive direct emails from the vendor when the system goes down, and they’re “all customer” type bulletins, so I know that our outages aren’t due to local connectivity issues.

The level of redundancy our vendor may have is a black box to me as an end user. Although I have made suggestions about improving the downtime documentation tools and having regular drills, as an end user employee, dealing with the vendor is not my responsibility. (As a CMIO, I’d have had a vendor exec on a plane and hundreds of thousands of dollars of maintenance credits by now, had we had these issues.)

I’m not excusing the actions of my employer, but just sharing how it is in my world as an employed physician. They know what I do. They know I’m available if they want my opinion. Otherwise, my role is to care for patients and let management do the managing.

I will be visiting the vendor’s booth at HIMSS and asking a lot of pointed questions, but I won’t be doing anything to jeopardize my employment. A practice that lets me work a relatively limited schedule and is flexible with the demands of my consulting practice is rare. One that actually performs (from a clinical standpoint) at the level of my current employer is even more so. Despite the recent failures of our EHR, it does generate mounds of quality data that put us in the top decile for many benchmarks. Patients are voting with their feet as well, allowing the group to continue to grow.

You can bet that things would be different if I held a leadership or ownership position. But much like many other physicians across the country, I don’t. I am subject to the decisions of my employer. Maybe someday they’ll reach a place where they have dedicated informatics resources, but until then, I’m going to put my stethoscope around my neck and see patients.

How do you feel about being an employed physician? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/18/16

February 18, 2016 Dr. Jayne 1 Comment

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Although health IT news is a bit slow in the run-up to HIMSS, I’m pleased to see that things are starting to pick up. I’m back on Twitter after a long hiatus and enjoying some of the conversations around HIMSS shoes. In looking for comfortable yet fun alternatives, I realized there is an entire market dedicated to alternative prom footwear of the sneaker variety. Although I’ve been to a wedding where the bride wore vintage Chuck Taylors, she was a PE teacher and it was part of a running joke. I’m going to have to completely rethink my plans for HIStalkapalooza.

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I’m putting together my list of vendors to visit as well as my list of spectacles to try to photograph. As usual, several booths are planning a Las Vegas theme with blackjack or games of chance. Others such as FormFast are bringing exotic supercars or other “cool factor” displays. I always enjoyed the Indiana Jones-style guy they had in their booth that would throw hats to the audience. At least they’re tying in the car with their name and their business line through their “Fast Matters” campaign.

I’m also seeing an uptick in pre-HIMSS webinars as well as a couple of vendor campaigns encouraging practices to seek out replacement systems. I don’t know if it’s tied to HIMSS or not, but it was noticeable. My favorite communication from an EHR vendor this week was from Kareo, who asked me to take a survey about my practice’s success with their system. They should know that I haven’t logged on to their system in more than six months, which should be telling enough.

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Edifecs has launched the #WhatIRun campaign supporting women in technology. They are donating a dollar to brightpink.org for every share or tweet of the #WhatIRun hashtag. Visit them at booth #8107 and they will also donate $5 to Miracle Flights for Kids.

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NCQA has proposed an “ambitious redesign” of their Patient-Centered Medical Home recognition program. They’ll be hosting a Google Hangout on February 24 where practices can get an update on the redesign progress and hear from practices that participated in a redesign pilot program. I’m interested to hear about the changes, which will not only impact practices but also EHR vendors who support clients in achieving recognition. The Patient-Centered Medical Home movement is turning nine this month and the American Academy of Family Physicians put together a nice blog post summarizing a recent review of studies around the impact of PCMH on cost and quality.

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Telemedicine is a hot topic and I was intrigued to hear about Nurx, which allows women in California and New York to receive prescription and delivery of FDA-approved contraceptives within 48 hours of accessing the app. They have plans to expand to HIV PrEP (pre-exposure prophylaxis) as well. Some are referring to Nurx as “the Uber of birth control” and I’ll be interested to see how it goes. I recently had the opportunity to speak at my local school board about proposed changes to their human sexuality curriculum, so I can imagine feelings about such a service will run the spectrum. Nurx waives its consultation fee for uninsured patients and in some markets patients can receive their medications the same day. Plans for expansion into markets in Illinois, Washington, and the District of Columbia are in progress.

For those of you who have been following my ongoing saga about Maintenance of Certification requirements for the Clinical Informatics subspecialty, I have some good news to report. Several Institute for Health Improvement Open School courses have been approved for ABPM LLSA credit. If you’re a member of an ABMS specialty board, you are eligible for a 10 percent discount by entering the code MOCABMS at check-out. Approved courses cover quality improvement, graduate medical education, and patient safety.

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Packing for HIMSS is always a challenge and a reader shared a link to Heelusions as a way to make things easier. Invented by the reader’s wife and her mother, it allows you to accessorize a single pair of shoes for multiple looks. I’m all about supporting small businesses, so I’m happy to share. It’s a cool idea, but sadly my stiletto days are numbered.

Seeing patients this week has been a bit bumpy, with our cloud-based EHR being down intermittently for the last few days. Luckily our downtime procedures went more smoothly than the last time we had an outage, but it’s never fun when you don’t have all the regular tools at your disposal. I’m back in the office tomorrow so cross your fingers for me.

What’s the most annoying thing about the EHR being down? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/15/16

February 15, 2016 Dr. Jayne 2 Comments

Although I do the majority of my work independently, I have other resources that I lean on from time to time. This weekend, I had the rare pleasure of traveling with one of them as we headed to a job. I enjoyed having another person to talk to while we traveled as well as being able to use the time to plan some upcoming work.

Although he’s more of an infrastructure expert, we share a lot of the same battles: dealing with corporate doublespeak, figuring out how to deal with other people’s emergencies, and having to explain to people why we can’t deliver solutions until we know what the business requirements are.

Both of us have recently had some interesting experiences with collaboration. A recent article in The Economist covers some of the ways in which collaboration goes too far.

I’ve experienced the collaboration curse several times. The IT department at my hospital was notorious for embracing collaboration tools at the expense of actually getting work done. We were so busy with Google Hangouts and HipChat and being collaborative that no one bothered to document requirements, decisions, and outcomes. We had a mix of workers at various career stages, some of whom weren’t terribly skilled with collaboration tools.

Our leadership didn’t want us to spend the time getting everyone on the same page. Add to that an inability to manage logins and permissions adequately (it’s hard to collaborate on documents you can’t edit) and it nearly destroyed some of the teams.

My travel partner experienced it on one of his contract assignments, where management responded to a lack of in-person meeting attendance by instituting compulsory collaboration. Teams of largely remote workers were forced to come into the office one day a week, where they sat on conference calls with other teammates that were working from home on those days. After that, management forced everyone to come in on a single day of the week, where many of the workers ended up sitting in cubicles all day and talking to no one.

I don’t disagree that collaboration can be a good thing. There’s no substitute for being able to work as a team and use diverse skill sets to move a project forward. Nor is there a substitute for getting to know one another as more than just a disembodied voice on the phone or a choppy image on a video conference.

But simply putting people in physical proximity isn’t necessarily going to achieve that outcome. Teams have to be able to work together productively and have to be freed to focus their efforts in the right direction in order to be most effective.

I once worked with an IT support team that estimated their non-productive overhead at 40 percent. That seemed high until I took them through the exercise of documenting all the non-value-added work they were performing on a daily basis. Inefficient corporate requirements sucked away valuable time. Just looking at the cost of highly-paid engineers who had to battle inefficient timekeeping and project tracking systems, we could have paid for a part-time administrative assistant and allowed the team to focus on their work.

When I perform consulting engagements where I look at IT team processes, I usually see at least 20 percent of the time spent on non-productive activities – scheduling, timekeeping, logistics, waiting for people to arrive at meetings, and rescheduling due to lack of key participants. That doesn’t take into account the productivity loss when people have constant interruptions due to misused collaboration tools – the productivity cost of instant messenger and email notifications has been significant for many of my clients.

Some of my favorite consulting work is helping clients fix this problem – developing communication plans, helping teams set boundaries, and assisting them in figuring out how to collaborate but still allow time for productive individual work.

I’ve written previously about the challenges of open office design, and have seen a couple of companies that are moving back towards more traditional workplace arrangements. Others are allowing employees to work at home more regularly in order to increase individual productive time.

One of my clients recently hired scheduling assistants to deal with competing meeting requests. The effort is part of a larger initiative to increase meeting productivity and it seems to be working. Rather than having dozens of workers trying to schedule around conflicts, time off, and available rooms, team members have to send a meeting request to the central scheduler. In addition to the participants and desired time frame, the request has to include an agenda with the purpose of the meeting and expected outcomes. They’ve actually seen the number of meetings start to decline.

It’s hard to sort out all the causative factors, but staffers cite fewer meetings where key people are double booked or unavailable, which lets them actually get decisions made the first time so they can move forward. The need to have an agenda and outcomes formulated before requesting the meetings has also reduced the number of meetings that didn’t need to happen in the first place.

It was a difficult transition, though, as people had to give up a little bit of calendar autonomy while adding scheduling discipline. Individuals had to clearly identify which appointments on their calendar could not be moved or modified while trusting the schedulers to make things happen for the greater good.

The concept isn’t that different than that of using centralized scheduling for radiology, diagnostic testing, or medical consultations. The schedulers can see all the available resources as well as the queue of requests and look for creative ways to work through constraints. It’s not something I’ve seen in the corporate environment though more than a handful of times. There has to be a balance between collaboration and focused work time as well as between tasks that have to be done personally vs. those that can be centralized.

How does your employer make the most of collaboration? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/11/16

February 11, 2016 Dr. Jayne No Comments

It’s been a great week here. First, my trusty IT guy was able to resurrect my PC and we bartered for its safe return. I got off fairly cheap, but I’m sure he’ll need a supplemental favor down the line. I was also able to catch up with a good friend of mine, although I was sad that he was lounging at Pebble Beach while I was watching the snow fall. And finally, I finished an enormous consulting engagement, so it’s officially time to celebrate with a glass of wine and some invoice generation.

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Now that the big project is off my plate, my HIMSS planning is officially in high gear. I looked at the options for focus groups and can validate what Mr. H said previously about the HIMSS websites still displaying HIMSS14 or HIMSS15 labels. Certainly there is an intern who can take care of that for you? I declared my interest in several different options and hope I’ll get to attend at least one of them.

Some of the options were thinly-veiled marketing opportunities, but several looked to be educational as well as a way to share experiences with other CMIOs. Although some focus group sponsors are transparent, others aren’t quite so obvious and it was fun trying to read between the lines and figure out who was paying for breakfast.

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I’ve also started receiving an uptick in HIMSS-related mailings. Some are engaging and others are pretty dry. My favorite this week is from PC Connection. They’re mailing playing cards for you to bring to their booth and use to play blackjack. Mine was an ace, so we’ll have to see how it goes.

HIStalk sponsor Imprivata is encouraging attendees to “Get Charged Up for HIMSS” by sending Starbucks gift cards along with an offer to receive an engraved portable charger by scheduling a meeting in the booth. Too bad I’m registered for HIMSS as my real self, because having one that says “Dr. Jayne” would be too funny. One of my dear friends, Bianca Biller, gave me an engraved box for storing my pearls. Fortunately, she warned me to open it under the table at my hospital “send-off” party.

I’m also happy to announce that I’ve selected my first two “Team HIMSS” contestants to play with me on Tuesday at 11 in the Medicomp Quipstar game show. One is a true competitor whose leadership mantra of “get on board or get out of my way” inspired me. If nothing else, she’ll be able to wrangle the rest of the team while I’m donning my disguise. The other won me over by not only supplying me with a brilliant “Top Ten Reasons to Pick Me” list that included a full 37 reasons. Many of them mentioned various HIStalk moments over the last five years, confirming he is a true reader and fan. Some highlights:

  • I have a photo of Jonathan Bush and Judy Faulkner talking to John Glaser at HIStalkapalooza.
  • I won a giant three-foot-tall chocolate bunny from Medicomp, and yes, even though we needed to freeze a majority of it, had an unsuccessful fondue night with some of it, and tried to give it away, we finished the giant bunny.
  • I once conspired to take over an empty HIMSS booth and re-brand the company when their booth sat empty.
  • Matt Holt doesn’t know if I am friend or foe. I like it that way. I think he does, too.

Incidentally, the reader sent me real-time photos of the giant bunny when he decapitated it with a large kitchen knife, so I know he’s a contender.

I’m not sure who we’ll be competing against yet. We still need two more team members. A couple of potential candidates weren’t willing to commit to the time slot (Tuesday at 11), so I’ll have to put them in alternate status. You still have time to send me your top reasons for why you want to be on Team HIStalk.

Several readers have already started sending me pictures of their #HIMSShoes and this will be a great opportunity to show them off. If you can’t make that time slot but want to play Quipstar, you can register for other show times.

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In other news, CMS is extending the submission window for 2015 QRDA data submission for the EHR reporting mechanism. Eligible professionals, PQRS group practices, qualified data registries, and data submission vendors now have until March 11, 2016 to submit 2015 EHR data. A complete list of time frames is below and all times end at 8 p.m. ET, so mark your calendars now:

  • EHR Direct or Data Submission Vendor (QRDA I or III) – 1/1/16 – 3/11/16
  • Qualified Clinical Data Registries (QRDA III) – 1/1/16 – 3/11/16
  • Group Practice Reporting Option (GPRO) Web Interface – 1/18/16 – 3/11/16
  • Qualified Registries (Registry XML)  – 1/1/16 – 3/31/16
  • QCDRs (QCDR XML) – 1/1/16 – 3/31/16

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ONC launched a new blog series about permitted uses of Health Information under HIPAA. The first one is titled “The Real HIPAA Supports Interoperability” and should be required reading for all the hospitals blocking release of information where it is clearly permitted. The series runs every Thursday through February 25.

Are you getting ready for HIMSS? What are you most looking forward to? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/8/16

February 8, 2016 Dr. Jayne 3 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Where do we go from here? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/4/16

February 4, 2016 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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

Third, close your Outlook or hide your alerts.

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/1/16

February 1, 2016 Dr. Jayne 6 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What do you think about free EHRs? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/28/16

January 28, 2016 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/25/16

January 25, 2016 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Are you a sucker for hopeless causes? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/21/16

January 21, 2016 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/18/16

January 18, 2016 Dr. Jayne 3 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/14/16

January 14, 2016 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/11/16

January 11, 2016 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/7/16

January 7, 2016 Dr. Jayne 2 Comments

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/4/16

January 4, 2016 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

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