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EPtalk by Dr. Jayne 12/29/16

December 29, 2016 Dr. Jayne 3 Comments

I’m happy to report that organizations seem to be getting the message that it’s a bad idea to wait until the end of the year to prepare for quality reporting. I’ve already had nearly a dozen clients sign contracts for assistance with quality reporting and similar initiatives in 2017. That’s a big change from last year, when many of my clients didn’t start getting serious about it until after the end of the first quarter.

One of the barriers in 2016 was lack of vendor readiness. It’s hard to get excited about working on metrics when your vendor hasn’t released their reports yet. Even though the changes are usually small and it’s possible to use the previous year’s reports as a proxy, there seems to be a psychological barrier to doing so. Regardless, most of my clients are on systems whose vendors are already prepared for 2017 reporting, so I’m grateful.

For those clients eager to wrap up 2016, CMS released its attestation worksheets for eligible professionals and eligible hospitals. The attestation system opens January 3 and will be accessible through February 28. If you haven’t started gathering your data, it’s time to start, and the worksheets allow organizations to make sure they have dotted the I’s and crossed the T’s before accessing the online registration system. It’s also a good time to test your logins as well as make sure your registration information is correct.

Even if you don’t plan to complete your attestation until the end of February, fixing issues early is definitely the way to go, although the system will be down this weekend for updates prior to the opening of the attestation period.

Still, many organizations aren’t ready to go quietly into 2017, with the American Hospital Association calling for President-elect Trump to put an end to what is still being referred to as Meaningful Use 3. The organization cites concerns over hospitals spending significant amounts of money to upgrade their systems to the point of compliance. They also requested support in avoiding anti-kickback provisions in the event that providers compensate each other as part of value-based care initiatives. Any modifications to the anti-kickback rules would require Congressional intervention.

The hospital trade association is also seeking a streamlined process for reviewing hospital mergers. The current process has different review criteria for the Federal Trade Commission and the Department of Justice to challenge mergers or acquisitions and there is hope that Trump’s past business deals will set the stage for a relaxed climate in the future.

A friend who works in the process improvement space sent me this LinkedIn article by David Feinberg, president and CEO of Geisinger Health System. It discusses his goal to eliminate waiting rooms in the next two years. It’s a fluffy piece with a lot of discussion of patient-centric care, which aids in getting people on the bandwagon. But as a practicing ED physician, I think it misstates some issues or misses them entirely.

“A waiting room means we’re provider-centered – it means the doctor is the most important person and everyone is on their time. We build up inventory for that doctor – that is, the patients sitting in the waiting room.” Sometimes having a waiting room means that many patients showed up at the same time, or that patients are too sick to be quickly dispositioned. Maybe there just aren’t enough rooms for the patient demand. But the mere status of having a waiting room doesn’t mean we’re not patient-centric.

My current practice situation is the most patient-focused organization I’ve ever been in. Nearly 95 percent of our patients are treated and released in less than an hour, including pharmacy services. Nearly 98 percent of our patients are roomed immediately on arrival. But yes, we have a waiting room, and sometimes it is full. Recent weather events prevented patient travel during a 12-hour ice storm, which led to tremendous volume once the roads became passable. You can’t necessarily design processes around mother nature, but we had some in place. We flexed staffing and worked as quickly as possible with scribes and other supports.

“For starters, treatment will start the moment patients enter the emergency room because remember, it’s an emergency.” This statement is a great emotional appeal, but it’s not the reality of what many of us are seeing in emergency facilities around the country. I would wager that nearly 80 percent of the patients I see do not represent a true medical emergency.

I understand that the nature of an emergency is somewhat in the eye of the beholder, but having the sniffles for one day is not an emergency. Nor is being sunburned while drunk in Cabo San Lucas and then coming to the ED two days later when you arrive back in the States. Also, “I can’t be sick for the holidays because I have 20 people coming over” is not an emergency, either. But it’s the reality for many of us in the trenches. And if you have five people that arrive at the same time, I’m going to treat the one with chest pain or a stroke before I treat the person who cut their finger two days ago and is just now coming for stitches because their mother told them they had to. Yes, my comments are emotional appeals also, but hopefully the point is made.

He goes on to say “our industry is ripe to be disrupted,” which jumps on the overused disruption bandwagon.

Let’s talk about what else the patient care industry needs. First, we need to sink resources into greater patient education and health literacy so patients know what is and is not an emergency. I spent some time in the UK, and they’re really great at this, running ad campaigns to educate patients. They have multiple versions of the same theme and make it clear that people who don’t need to be in Emergency are causing delays for those who do need to be there. We don’t see that in the US because we’ve swung the patient-centric bar too far in some cases as we continue to pursue patient satisfaction scores, sometimes at the expense of quality.

We need more primary care physicians who are compensated at a level where they want to stay in practice and not retire or go part-time or switch to urgent care. We need to incent them to provide after-hours care and keep their patients out of the ED. We need to help them put systems in place that protect them from burnout. We need to reduce the burden of legal-driven care interventions so that physicians can trust in multidisciplinary teams without the constant threat of lawsuits. We need to incent them to deliver low-intervention care when it’s warranted, and help them educate patients away from the “you have to do everything” mentality.

We also need streamlined data exchange so that the ED isn’t in the dark because a rival health system is engaging in information blocking. You know who is responsible for ALL the information blocking in my area? The hospitals and health systems themselves. Not the EHR vendors. Every system in town has great exchange capabilities, but the hospitals put up faux HIPAA blockades around my ability to find out whether the patient has just had labs drawn.

They’re also engaging in care blocking, as I recently learned when they refused to accept the printed labs and CT scan on a CD that I sent with my patient during his transfer, instead requiring everything to be repeated in-house for liability reasons. That is insane and needs governmental regulation more than EHR vendors do. The same hospital also removed a patient’s IV and stuck her again after transfer because they “couldn’t trust the sterility of the original vascular access.” Again, it’s insane to cause a patient discomfort and remove a perfectly viable IV because you’re afraid of the lawyers.

We definitely need change, but it’s more than hiring more doctors or building more exam rooms. We need cultural change that addresses not only patient attitudes, but the reality of resource constraints in the US healthcare system. But “don’t go to the hospital because you are afraid of being sick, but are not in fact sick” is not a sexy, attention-grabbing campaign.

It will be interesting to see where Geisinger is in two years and whether they meet their goals.

What are your organization’s goals for 2017? Email me.

Email Dr. Jayne.

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Currently there are "3 comments" on this Article:

  1. A very reasonable goal would be to survive a future of “Trump’s past business deals will set the stage for a relaxed climate in the future” Does not bode well for quality of care or anything but enhanced revenue for established large players.

  2. Sorry, but you aren’t patient-centric. Perhaps you think you are, but you aren’t.

    A patient-centric organization puts the needs and concerns of patients first. Thus, when a patients tells you “I can’t be sick for the holidays because I have 20 people coming over”, that is very likely an emergency for that person.

    There’s a saying in business. ‘The customer is always right.’ Now, I’ve been around long enough to reject the literalism of this statement. However I understand what the message there is, which is, ‘Get over yourself and your insider concerns. The customer pays the bills. You have to make every effort to please the customers, even if you don’t always agree with their point of view.’

    Oh, I know all about triaging, and clinical indicators and all that. However those are still the concerns of the clinicians, not those of the patients.

    At the end of day you may decide to part company with certain customers. Your Cabo client might be one such. However even then, the patient-centric thing to do is to leave that person thinking they are still welcome back. Let them know that while you cannot assist them today, perhaps you can tomorrow.

  3. The goal of my personal organization is to not see any doctors in 2017. Epic amounts of healthcare seems to spawn cancer treatment (“…although you don’t have cancer, we’d like to refer you to an oncologist”). And God Forbid! – a shot of morphine for a kidney stone involve anything less than that the emergency room followed by 4 referrals.

    So while I understand how providers get it into their head that they matter – it’s sad to see them so disconnected from the real world that they don’t grasp how obviously counter productive they are.

    Note that in a final rule, the government is requiring dialysis providers to report every time they pay for a new patient to join obamacare prior to signing up for medicare (the trick puts up to 200K of additional money in dialysis provider’s pockets). It’s pathetic to see that providers have to report when they funnel money through a “Charity” to pay for the new signups.

    So while I do understand, I also want to help providers – in some way – realize their self ascribed professionalism would need to be enhanced 20 fold to achieve a level of ineptitude, With another 100 to 200 fold increase, maybe professionals might appear that could handle their business with any sense of decency.

    In the meantime, we should all feel better knowing the cancer survival rate is doubling every time twice as many people get treated for cancer. (when you do the hokey pokey and your turn yourself around: “That’s!” what it’s all about.).

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