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EPtalk by Dr. Jayne 3/17/16

March 17, 2016 Dr. Jayne 5 Comments

I’ve been spending a lot of time this week on strategic planning for the next wave of healthcare reform. For those of you who thought Meaningful Use being “dead” meant we would be able to catch our breath, there’s an even more challenging sequel. I’m talking about alternative payment models and yet more acronyms – specifically MACRA and MIPS. In a recent blog, John Halamka describes the future:

Providers will be responsible for the care that their parents receive throughout the community — inpatient, outpatient, urgent care, post-acute care, and home care all contribute to total medical expense and wellness. Some of the care may be delivered by people and organizations outside the control of primary care. The only way they can succeed is by aggregating data from payers, providers, and patients/families in an attempt to provider “care traffic control.”

When I first saw it, I thought it was catchy – yet another way to try to describe what primary care providers do. We’ve been gatekeepers, quarterbacks, and now care traffic controllers.

But thinking about the analogy to air traffic control, it couldn’t be farther from reality. Commercial aircraft and their owners are required to obey certain rules across the board. There is a central body making those rules — we don’t have subsidiaries across the nation coming up with their own “local coverage” determinations. The rules are governed by logic, physics, statistics, and experience.

In healthcare, it seems that sometimes we have none of those forces at play. Humans are often irrational (stroll through the intensive care unit sometime and watch the futile and sometimes cruel treatments forced on the elderly by “loved ones”) and our behaviors are determined by a complex interplay of biological, social, and other factors.

Planes in the skies are required to not only identify themselves, but to broadcast their intentions regularly. They have to file a flight plan — they’re not allowed to come up with a confidential or proprietary flight plan, then spring it on the passengers at the last minute. Planes have to be inspected regularly and certified for safety. Pilots are retired for certain medical conditions and after certain ages. Additionally, airliners are required to have onboard tools to help determine what went wrong in the case of a failure. Such failures are scrutinized and the findings broadcast for everyone’s learning. This is far from how healthcare operates.

Lastly, the air traffic controllers aren’t punished for the actions of pilots who don’t play by the rules or airlines who cut corners. They’re not punished when passengers are kept on the tarmac for hours or when flights run late or are cancelled. They’re not personally liable for “oversold situations” or forced to compensate passengers for lost or mangled luggage. Under the “care traffic control” theory of healthcare, we’re asking front-line physicians (particularly primary care providers) to assume the equivalent responsibilities.

It was in that frame of mind that I started trying to work out some strategy for how my partner and I can assist physician and practice clients in navigating yet another seemingly dysfunctional scheme that is coming their way. It was also in that frame of mind that I received word that three more of my former partners from Big Medical Group had taken or were about to take the jump to either cash-only care models or concierge models.

One has been in practice for nearly half a year and interviews all her patients, taking only those who agree to her model of care. She has very little overhead due to her non-involvement with payers and the government, so she doesn’t have to see many patients at all to make ends meet. Additionally, she’s doing a time-share out of another physician’s office and is only paying for fractional use of his staff. But most of all, she’s practicing the way she wants to and finds her work satisfying again.

Not everyone can practice this way, and if we all did, “disruption” would not be a strong enough word to describe what was happening. But it’s an interesting thought and was a nice distraction as I worked through scores of analyses and discussions of where we believe policy and legislation will take us over the next two to three years.

Among all this deep thought, I’ve still been trying to get caught up after HIMSS. Given some of the changes to my business model and our plans to expand our offerings, I’ve been following up with contacts and reading proposals. I still have over 1,000 emails to deal with, and unfortunately, they seem to be coming in as fast as I can dispatch them.

One from today was a notification from Microsoft that they’ve released a fix for the pen issue I’ve been having with Office 365 and tablets. Although it’s only available to their Microsoft Insider group at present, they estimate it will be available to the general user base in a week or two. Although I’m eager to receive it, I’m not eager enough to sign up for the Insider program, which seems like an ongoing beta program with a high potential for workflow disruption.

I was happy to receive a couple of reader emails, including one with photos of the limbo portion of HIStalkapalooza. She managed to capture several people I know in the pics and I’m debating whether to share them with the respective parties or hold them for future blackmail.

I asked last week whether interoperability is really the answer to all our problems and was happy to receive a detailed reader response:

In my mind, not until we find a way to retire faxing. MU didn’t account for the value of narrative and so it left faxing as a safety net, therefore increased faxing. It’s a 40-year-old technology that is still the backbone of communication between practices and from hospitals to providers. Healthcare is wasting millions of dollars in time, money, and hours better used elsewhere dealing with faxing. My organization sends 35,000 faxes a week. Although 99 percent go through, that leaves 350 that don’t because of busy signals, practices that turn fax machines off on nights and weekends, and out-of-date or disconnect numbers. Still 10-20 fax issues come in daily, with the most common being:

  • Provider left practice and no one told the hospital.
  • Patient isn’t mine. It’s a Summary of Care for a patient referred to you for follow up, did you read the cover letter? Or maybe registration entered the wrong referring, ordering, or PCP?
  • You’re wasting my paper and toner and I don’t want anything from you on my patients. (my favorite)

With 9,000 active providers and 20,000 referring, it is impossible to make routing rules that will make them all happy without micromanaging who gets what at the provider level. Even the progressive providers with EMRs and Direct addresses can only get ToC reports and not Notes, Transcriptions, and Letters. Why? Because it’s not in the locked down MU XML specifications. Sorry for the rant, I’m going to manually resend 1,000 faxes that didn’t go through on the first seven automatic attempts.

He bid me a good night, and so I pass it on to you. Sleep well with visions of fax machines dancing in your heads. Or perhaps you had a nightmare? Email me.

Email Dr. Jayne.

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Currently there are "5 comments" on this Article:

  1. Ugh… I could have lived the rest of this life without being reminded of the fax issues I had to deal with in my previous one. The reader also omitted a lengthy list of technical issues (such as poor phone lines) as reasons for fax failures.

  2. Air Traffic Control System = Better Health care management ??

    Really? Some facts about that wonderful ATC system we have in the US.
    1) Interoperability – do you know that the ATC system in NYC does NOT talk directly to the system in other cities (and vice versa). Human intervention is needed. ATC systems in different cities run on different platforms, data sets, languages, etc. Sound familiar?

    2)The new FAA air control system is still NOT is still not available after a decade of work and is about a half BILLION $$ over budget. Airlines are refusing to go ahead with it because of repeated failures. If after decades and billions the feds can’t develop a system to tell where two planes are in the air (given all the core tools that already exist – like satellites, GPS, etc.) then what’s the real problem?

    3) A year or so ago, the air traffic control center in Chicago got trashed by a contract employee and thousands of flights got canceled. NO offsite backup, no system redundancy. No real disaster plan. A week later the system was still down.
    But a hurricane hits a hospital in NOL – and EMR info is back up in a day, a tornado hits a hospital in Joplin MO, EMR data is back up in hours.

    So tell me again Dr. H why we want to run healthcare like the ATC system??

  3. I know…that’s why I referred to Dr. Hamalka at the end, and I thought some facts about the great ATC system could further your points. Nice to have someone agree now and then..?
    By the way I did go to his web link and I could not find the comment about the ATC. If I did I would have posted it there as well!

  4. Amen sister! Poggio… Really???? Half a billion is peanuts in the healthcare $$s we “waste”… And the problems you point out happen once or twice a decade. Not every single day…

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