Curbside Consult with Dr. Jayne 9/23/13

I spent most of this week conducting a site visit at a primary care practice that subscribed to our affiliated physician EHR offering last year. When they decided to take the bait on my hospital’s hook (as well as the accompanying subsidy) they were on an ambulatory system from another vendor. They had a contractor perform a partial conversion of their clinical data (“partial” due to cost) but my team was told to officially stay out of the conversion due to concerns with the subsidy agreement, data ownership, liability, and other contract-related issues. It was instead approved by the practice’s clinical champion. Since they are on their own instance of the application and their data doesn’t commingle with mine, I had no reason to push back or demand involvement.

When they migrated to our platform, our team conducted their training in the same manner with which we have trained hundreds of other physicians. Since they are affiliated and not employed (and also because they are located several hundred miles from our corporate mother ship) I hadn’t been out to visit them. Their leadership complained to our CIO that they were struggling with the system and requested that we send someone out to “fix it.” The practice is in a prime location for some fun outdoor activities, so I decided to conduct the site visit myself. After some preliminary discussion with practice leadership to obtain some background information and specifics on their concerns, I was on my way.

Performing a site visit like this is not for the faint of heart. As part of an employed medical group, we have people who are constantly after us to make sure we are compliant with OSHA, CLIA, HIPAA, and a host of other acronyms. Many small practices struggle in keeping up with these basics, not to mention with the multiple regulatory requirements that keep popping up like dandelions in spring. I always remind our process improvement team that it is important to clearly define the areas of observation and the questions to be answered before you start the site visit. Otherwise, it is possible to be overwhelmed with findings that may be outside the project parameters. Many of us have been confronted with findings that although out of scope, are so critical that they must be immediately addressed and sometimes the site visit comes to a screeching halt because of it.

I’ve had providers scream at me about unrelated issues, have had providers cry while I try to interview them, and have had them complain about their spouses making them late to the office which interferes with the schedule. There have been those that argued, others that pleaded, and some that stood up and walked away when we presented our findings. We try to stay objective and professional even when we see things that make our skin crawl.

With those experiences under our belt, sometimes we numb ourselves to the things we see because we’re there to assess people, process, and technology, not how providers are practicing or how diligent the housekeeping staff might be. In my role, I’m not there to address the fact that you just performed what you thought was a diabetic foot exam but what I thought would have earned one of my interns a trip to physical diagnosis remediation class. However, if I see you wearing a dirty lab coat with a Santa Claus pin on it in August, I’m probably going to say something whether it’s in scope or not. Luckily I didn’t run across anything like that on this visit, but what I did find was a group that is trying to perform the practice equivalent of running a marathon in high heels.

The practice has a great layout and plenty of space – it was built for six physicians but currently holds only four and all of them feel that they are equally busy. Their levels of productivity are similar except for a senior physician who no longer takes call but makes up for it with lower compensation. It’s nice to have that kind of a level playing field when you’re observing practice dynamics because when some partners are busier (or feel they are doing more of their share of the work) it’s usually a marker for dysfunctional team dynamics. They’ve had some staff turnover but not an unusual amount, and currently have two clinical support staff for each physician. Another good sign.

As part of our Meaningful Use preparation, we recently upgraded their EHR to the most current version available from our vendor and they received the same training our own physicians received. Unfortunately, the positive signs stopped there. Some of the first questions I ask when shadowing physicians involve how they feel the use of the EHR is going for them, and what their personal priorities are for use of the system. I also ask what they feel are the practice or health system’s priorities. Not only did all five of them have very different personal priorities, none of them could accurately identify the practice’s priorities. They could not identify a mission statement or a vision for how care is to be conducted in the office.

I wanted to assess how the recent upgrade impacted them and they admitted that they were not using many of the new features including some that streamlined workflow, reduced manual data entry, and others that provided clinical decision support. I felt bad that despite our educational efforts, they either failed to understand the clinical utility of the content or didn’t know how to incorporate the features into their existing work flow. In digging deeper though I found the root cause. The providers had made a deliberate choice not to use the new features. Instead, they decided that they needed to focus all their efforts on the many incentive programs available to them.

In addition to Meaningful Use, they are trying to obtain recognition as a Patient Centered Medical Home and are participating in a diabetes care collaborative. They are also participating in four different pay for performance plans that each have different metrics. Due to the disparity, they’re trying to focus on the key elements for each patient based on insurance rather than taking a population-based approach. In regards to Meaningful Use, they were not able to articulate which clinical quality measures they would be reporting or how they were performing on the MU measures overall. They haven’t run any preliminary Meaningful Use reports despite planning to attest soon. They have no idea where they stand.

Over the lunch hour, I decided to queue up some of their reports and I had some not so pleasant surprises. The first things I found were some pretty serious artifacts from their conversion. There were diagnoses such as “Verify: Gout” and “Verify: Diabetes” and “CONVERSION: DO NOT USE.” All of them had ICD-9 codes of 000.00 associated with them. I drilled down to a handful of patient charts and found that they also had multiple versions of similar diagnoses (250.00, 250.02 for example) that had not been reconciled. In addition to causing havoc with the reports, the patient diagnosis lists were messy and difficult to read with the conflicting codes present. It seems that they were supposed to clean up the diagnosis lists the first time the patient had a visit on the new EHR, but it didn’t get done. Unfortunately the providers have continued to select diagnoses of 000.00 from the patient diagnosis list which carries it forward and the coders have been fixing them on the practice management side, but no one closed the loop in the EHR.

Additionally, after a couple of months on the HER, they had stopped reconciling altogether. I had been thinking about how to create some payer-specific alerts for them for their pay for performance programs (assuming I couldn’t convince them to either care for all patients with the same standards regardless of payer or drop the incentive programs that created conflict) but without accurate codes to identify the disease states, it was going to be extremely difficult.

As much as they decided to mix it up with the pay for performance indicators, they took the opposite tack with Meaningful Use. Uncertain of the actual thresholds for some of the measures, they decided to go whole hog. Instead of reconciling medications at transitions of care, they were performing full reconciliation at each visit. Instead of summarizing tobacco use and updating any changes since the last visit, they were eliciting a complete tobacco use history even if it had already been documented. One patient actually complained about being asked the questions at every visit even though he had stopped smoking years ago. They are performing full vital signs on all patients (including infants) at every visit, regardless of the reason for visit or the time since they last presented to the office. They are trying to provide patient education for every visit, even when education may not be relevant. By the end of the first day, I was tired just watching them.

I observed each physician’s care team for several hours over a couple of days and also shadowed in the lab. Working with the billing and coding staff and the office manager, we identified additional areas for improvement. Typically at the end of a site visit I do a report-out with the providers and leadership. Most of the time I am recommending that they get moving and add MU activities to their processes. This time, though, I had to make recommendations for them to do less in some regards, which felt very strange as a recommendation. We had some good discussion and they really struggled with how to determine which things they should do for every patient and which they should do only when required.

I left them with a simple litmus test: actions should be performed at every visit only when they are clinically significant or are required by a regulatory body. We looked at the tobacco use item as an example. If the patient is not currently smoking, does it make sense to ask about their past use at every encounter? Probably not, as long as they are flagged as a never smoker or a former smoker. If the patient is currently smoking, does it make sense to ask about cessation at every visit? Yes, because all four P4P programs are looking for that element. I’ve asked them to go through their work processes and ask those kinds of questions for the various documentation elements. I’ve also asked them to start reconciling diagnoses on each visit to get those lists cleaned up before we head for ICD-10.

We’re going to set up monthly calls to check on their progress. I’ve given them some homework that is due before the first one. I’m hopeful that we can make their workflow more streamlined and less stressful while delivering quality care. They’re going to be working hard to get ready for their attestation period, but I’m cautiously optimistic. Hopefully I’ll be able to keep you posted on their progress.

For those of you who are curious about the picture, it’s Julia Plecher of Germany. She holds the Guinness World Record for the fastest 100 meters in high heels. Her time: 14.531 seconds. I wonder if Inga will be able to top that in her party hopping at MGMA? I can’t wait to find out.

E-mail Dr. Jayne.