Curbside Consult with Dr. Jayne 4/27/15

CMIOs Gone Wild

One of the challenges of being anonymous is missing out on get-togethers at HIMSS. Sometimes vendors invite me to participate in events as myself, but other times the invitations come to Dr. Jayne. Even though most of them promise to either maintain my anonymity or allow me to register under whatever name I choose, attending such invitations has risk. Plus, I generally don’t attend events that I didn’t get invited to as my “real” self (or at least couldn’t tag along as someone else’s +1).

Although I trust Lorre and Mr. H to protect my identity, I had mixed feelings about attending the HIStalk CMIO lunch at HIMSS. I was excited about meeting other CMIOs outside the settings where we normally cluster in the wild – symposia, conferences, and of course the AMIA Clinical Informatics board review course. I get together with other CMIOs in my health system at least quarterly.

But it’s different when you have the opportunity to talk to people from other parts of the country that may be facing challenges that haven’t hit your market yet. It’s also different when you get a group of CMIOs who face the same pressures every day and they’re put in a relatively “safe place” where they can speak their minds.

My original plan was to cruise by, see who was at the table, and drop in if feasible. Most of the time though the table was packed and Lorre reported that they had to swipe chairs from the McKesson table because more people kept arriving. She was gracious enough to take notes on some of the discussion so that I could attend vicariously, as well as some pictures.

I thought about running the photos, but then I remembered my own hospital’s rules about vendor interactions and I certainly don’t want to get anyone in trouble by calling them out. I’ll keep the attendees anonymous, but here are the group demographics:

• University hospital or major health system – 4
• Physician group or IPA – 2
• Government or public health – 3
• Industry or vendor – 6
• Other – 2 (multiple roles, consulting, etc.)

Since women in technology leadership has been a hot topic on HIStalk lately, I’ll give the breakdown: two were women, the rest were men. There were more vendors than I had expected, but several were either notable personalities or had been CMIOs in a previous position.

Although I had given Lorre some conversation starters in case the group was quiet, from her notes, it sounded like the discussion did just fine on its own. Hot topics included:

• Patient portals. What strategies are CMIOs using to increase patient portal use? Most agreed it needs to be more valuable to the patient to get them to engage. One mentioned that at Duke the only way to pay a bill is through the portal. Others agreed that the ability to schedule appointments was key. There are different strategies to gradually add the appointment piece to the portal since physicians are sometimes reluctant to allow patients to self-schedule. Appointment cancellation is also important. The topic of no-shows came up and the general thought was that if patients are willing to go online to schedule, they’re typically willing to go online to cancel.
• Physicians opting out of MU. Several felt that MU is not useful. One commented that, “There are no opt-outs in malpractice.” Another commented that the penalties aren’t high enough to force providers to engage – some have done the math and if they can see one more patient a day and do less work, that’s more economically favorable even with the penalty.
• Board certification. CMIOs discussed fellowships vs. on-the-job training. Many would not choose to spend time in a fellowship if it was required. There was discussion about Maintenance of Certification and the fact that the American Board of Preventive Medicine has not certified enough relevant content for Clinical Informatics. One CMIO is going to take a dive medicine trip because those credits count and she gets to SCUBA dive.
• Various CMIO challenges. New problems seem to crop up daily. One physician found that lab analysts were rounding the numbers for lab values rather than displaying them as they were reported from the analyzer machines. Another cited the difficulty getting clinical photos into the EHR and the problem of physicians taking photos on their iPhones and sending them around. They also noted the problem of dealing with operational issues that are uncovered by an EHR implementation. For example, labor and delivery nurses that could no longer “preorder” for physicians before the patient was admitted. Since there weren’t any formal standing orders, the nurses were ordering on paper what they knew the physicians would want. When they couldn’t do it in EHR, it became an issue, requiring discussion of their scope of practice.
• Documentation was a hot topic. Attendees felt that what EHRs are putting out isn’t clinical documentation — rather it’s all about billing documentation. They’d like to ask CMS whether clinical documentation should be required to support clinical decisions rather than billing decisions. Evidence-based documentation is necessary and needs to be pertinent. CDS should be a major part of documentation, but it needs to be filtered to the situation and actionable. Context is key. Alerts should be standardized. Use of documentation templates and order sets is increasing. One site is using Lean Six Sigma principles and Kaizen events to create disease specific clinical note templates to help communicate information to help nurses and social workers with post-discharge care. We need to better identify what parts of the documentation need to be discrete. What is the important information? What is the minimum needed?
• Global healthcare models are being examined. One attendee recently visited hospitals in Japan. He liked their clinical pathways, where grids are used for each day of the treatment plan. Each role had guidelines on what should be documented.
• Interoperability. FHIR was discussed as was the use of SNOMED and LOINC. What will the next standard be? There are still problems between systems. We need to broaden interoperability for problems like visual diagnostics. Providers should be able to take a photo and send to dermatologists behind the scenes for decision support. Another wants to be able to take a photo and have it count for documentation and billing/coding bullet points – rather than describe the rash inadequately, put a picture in the chart. But CMS doesn’t allow providers to do that.
• Retail healthcare was mentioned. Some CMIOs are having interactions, receiving referrals, and being part of the feedback loop. One mentioned his experience with a specific retail clinic, saying that working with them was “as complex as working with the Department of Defense.”
• HIPAA Omnibus Rule requirements were discussed. If patients declare they are paying cash, the encounter data can’t be reported to payers. How are various vendors handling this? Some are suggesting providers use a “shadow chart” for the protected content. Others are just starting to discuss tagging the data. There is concern that allowing patients to choose which portions of the chart can be shared will interrupt care and cause possible misdiagnosis if physicians don’t have all the information.

Although I’ve mostly summarized from Lorre’s outstanding notes, one of the quotes caught my eye. I’m not sure who said it, but, “The CMIO is the face of dysfunction” might just be my new mantra. We (or our respective EHRs) certainly get blamed for everything. We’re also expected to figure out how to solve it without hurting anyone’s feelings while helping the operational, clinical, and technical teams play nicely together.

Based on the number and caliber of attendees who stuck around for a fairly long time during a very busy HIMSS week, it sounds like they found the event valuable. I hope Mr. H will consider doing it again in Las Vegas.

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