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Curbside Consult with Dr. Jayne 3/2/15

March 2, 2015 Dr. Jayne 1 Comment


I received an email from ONC on Thursday that they were extending the deadline for nominations to the HIMSS Interoperability Showcase, citing “feedback that organizations needed more time to submit nominations for participation.” From the time the email arrived, that’s a whopping three business days until the deadline. It made me wonder exactly why the deadline was extended and what their current applicant pool looks like. If they were delaying because they didn’t have many applicants, then they hardly gave much of a window for organizations that weren’t already prepared. Was the announcement a way to raise awareness about the Showcase rather than being designed truly to solicit participants?

Perhaps organizations didn’t apply because they didn’t want to spend $8,000 to participate. That’s just for the kiosk at the Showcase, which includes a monitor, keyboard, mouse, power, and Internet connectivity as well as two exhibitor badges. Travel, meals, and lodging will be on top of that. We’re doing some cool things with interoperability at my health system, but they’re not about to spend upwards of $12K for developers to go show it off at HIMSS.

Whatever the reason, I can’t help but think about the ongoing list of government initiatives that have to be delayed, extended, or otherwise modified because they don’t seem to be achieving the desired results. Being a process improvement person, I’m always looking for the root cause when outcomes are not achieved or when projects run off the rails. Recently, we’ve had delays in ICD-10, Meaningful Use, and Healthcare.gov. Some of us, however, remember delays in the implementation of the 5010 claim standard and those of us deep in the weeds know about dozens of lesser-known parts of HIPAA and other omnibus legislation that are virtually unimplementable.

In medicine, we have a doctrine about ordering laboratory and diagnostic tests: don’t order it if it’s not going to change your plan for the patient. I do a lot of work with reporting from our EHR data and we have a similar dictum: don’t run the report if you’re not equipped to act on it. You’d think there would be a similar mantra about not making rules that people can’t actually follow, but that doesn’t seem to be a factor for those happily engaged in rulemaking. Only in healthcare do we come up with creatures like the “Two Midnight” rule and other similar nonsense.

My extended family is always asking about some of the wacky things that go on, such as provider-based billing, which allows hospital-owned practices to charge both a professional fee and a facility fee for outpatient visits. I’ve become as expert at explaining the Medicare Part D “donut hole” as I am at teaching patients to use a home blood glucose monitor. In trying to find some method to the madness, I stumbled on an article that attempts to explain why healthcare regulation is so complex. The first paragraph opens with a perfect summary: “Health care professionals may feel that they spend more time complying with the rules that direct their work than actually doing the work itself.”

The author contends that “regulation arises largely from a set of confrontations between opposing interests that created the system.” I agree that there are clashing agendas and learned that first hand as a young physician when the hospital’s chief of staff wanted to know why he wasn’t getting my referrals. It felt more than a little like a shakedown. He wasn’t aware that I sent nearly all of my referrals in his specialty to one of his partners, so at least his practice was seeing volume if he wasn’t personally. It didn’t matter, though, since it was apparently all about his ego. These conflicting agendas are ongoing, and “Doctored: The Disillusionment of an American Physician” talks about one physician’s struggle.

Although there are certainly turf wars at play, the regulatory soup includes rulemaking at so many levels that it’s nearly impossible to keep track of what needs to be done. I have to follow the rules of multiple hospital medical staff organizations, two state licensing boards, two specialty certification boards, one professional society, dozens of payers, the city, the county, the state, and the federal government. These rules (and non-rules that often have the force of law) sometimes conflict each other and often fail to make sense.

Several times in the last few decades, studies have looked at everything a primary care physician should be doing for his or her patients and how long that would take. An article in the Washington Post summarized the most recent data from the Annals of Family Medicine, which found that for a typical panel of 2,300 patients, the physician would have to spend nearly 22 hours a day to provide all the recommended care. That’s just delivering the care itself – it doesn’t factor in the time needed to comply with everything else a physician does such as arguing with payers, managing staff, dealing with regulations, worrying about compliance with programs, and trying to stay current with medical knowledge.

That’s what we’re dealing with in the ambulatory setting. Hospitals and health systems deal with many more rules and countless regulatory bodies. Similarly their IT departments are trying to keep the systems up and running, prevent breaches, avoid breaking something that’s required for Meaningful Use, and so on. It’s no surprise that people are not coming out of the woodwork to sign up for the Interoperability Showcase.

What regulations keep you hamster wheel spinning? Email me.

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Currently there is "1 comment" on this Article:

  1. Dr. Jayne,

    I’ve been reading your “cubside consult” the past couple weeks and have enjoyed your matter-of-fact style of writing. That you have a provider point of view is refreshing form hearing from just the pure-technologist using their talents/skills in Healthcare.

    Today, on Facebook, I once again heard the rants of those who love their Samsung phones and make their technology worship session another opportunity to bash those of us who like using the iPhone. Frankly, I don’t think either technology is perfect, but one thing I have noticed as a self-professed iPhone technocrat is that most of my non-techie colleages, friends and yes, even my wife swear by their iPhone as something that simply works. In contrast, the only time I ever hear about the Samsung is from the technologist who feels a need to be justified for their decision to not be “brainwashed” by the Apple marketing machine. Whether they are right or not about the technology, I view the purist technologist to have some of the same shortcomings the “Chief of Medicine” had about referrals not coming directly to him you mention in your post.

    A trend I have noticed in my lifetime… when we become ‘experts’ at something, we tend to want to diminish those who aren’t. For this reason, I try to remember and avoid that predisposition each time I’m able to show someone how to do something on a computer or their mobile device they didn’t know how to do before. I’m particularly sensitive to physicians or nurses who clearly know much more about my physiology than I do and can tell me things I should be doing with my body better than I know myself similarly. I noticed when I treat them with the same appropriate “bedside manner” we expect them to provide their patients, I get much further with helping them ensure the technology is working appropriately for their needs. The subsequent visits to these grateful clinician become even more effective than the last as gaining their trust I truly understand their frustration becomes implicitly understood and I can get straight to what “ails them” on their technology. A happier more productve MD/RN after such a series of consultations I describe here is amongst the greatest joys of my profession in Healthcare IT…

    Back to your question… Where regulation comes into this discussion is that at some point we conclude we can’t trust the dialogue between client (patient in this case) and expert (doctor in this case) anymore because one or the other is presumed to to not behave appropriately. Either the patient won’t openly share all their record for fear of not getting the care they want, or the doctor won’t admit their not quite sure what the problem is becuase they don’t want to be a defendant in a malpractice suite. This cascades into the need to insert all the middlemen some of whom eventually become regulators whose only job is to arbitrate all the other middlemen to do the job the client and expert can no longer be trusted to do on their own.

    So what regulation keeps my hamster wheel turning?… ALL OF THEM to some degree is my answer. I do believe some regulation is needed and desirable. I’m not so naive to believe everyone can be trusted (e.g. the testing of medical practices on human subjects is regulated by the FDA as an off-shoot of the Nuremberg trials where Nazi doctors claimed they were under orders to test things on those imprisoned in concentration camps). With exception of those type of atrocities, most other regulations have mostly become necessary to offset the conflict of interests that exist between client and expert that trust (i.e. a handshake and/or a promise) was once more than adequate to mitigate.

    In my opinion, the solution to over regulation can best be found by answering the question, “How do we restore trusting relationships between these patient and provider and remove the need for so many other ‘experts’ that primarily only serve to muddy the healthcare system today, reduced it’s effectiveness and raising its costs to society?”

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