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Curbside Consult with Dr. Jayne 9/10/18

September 10, 2018 Dr. Jayne No Comments


There’s such a range of activities that CMIOs perform in their daily work – it’s one of the reasons I enjoy what I do when I’m outside the realm of direct patient care. I’ve been working as an interim CMIO for a mid-size provider organization, and one of my projects is to assist in standardizing patient education materials. Many healthcare organizations subscribe to commercially available patient education databases, such as Healthwise, which integrates with the EHR. This organization had previously moved from a sorting cubby full of handouts at each location to a PDF-based repository on a shared network drive. However, over time many of the handouts had become dated or overly-customized, leading to the need for a review project. The existing medical leadership was overwhelmed with the work of running the group including contract negotiation, quality management, and more, hence the need for a CMIO to tackle more informatics-oriented projects.

The practice had hired the daughter of one of the managing partners as a summer intern, and since she was pre-med she was eager to help with clinical projects. In no time, she had catalogued well over a thousand documents, tagging them with dates for origination and most recent update, as well as the names of any providers who seemed to “own” the various documents. She found numerous duplicates where providers had saved copies of documents with their own naming conventions so they could find them more quickly. There were also materials that not only lacked freshness but contained clinical information that was out of date. Without a solid policy and procedure behind the creation of the shared repository, and without someone to hold people accountable for its use, it had taken on a life of its own.

This project was the intern’s first brush with clinical informatics. I suspected that at the beginning she was a little bored, thinking it was more administrative than clinical. However, we had some great conversations around the value of public health and the role that patient information plays in successfully managing health conditions, and I could tell she was starting to understand how important the project was, especially since the providers used many of the documents regularly. She quickly became educated in the softer skills that CMIOs have to use – expectation management, consensus building, communication plans, and creation of governance. We had provider listening sessions, rapid design sessions for the new repository, and deep dives into review of the actual documents.

There was a lot of conversation around social determinants of health and the need to make sure that patient education materials meet the patients where they are – specific to language, reading level, amount of detail included, and more. Those factors were part of the genesis of the practice having its own library. They wanted their materials to be culturally appropriate to their patient population and, when it was initially created, they didn’t feel that any of the available content met their needs, so they created their own. During the standardization project, they didn’t want to lose that flavor or personal touch, but they wanted materials that were consistent across the provider base and easily maintainable.

I also identified a number of opportunities for addition to their document library. Although most of the chronic conditions were covered, as were preventive services, there were whole areas of patient education that weren’t addressed. One of these was general navigation of the healthcare system. I suggested that we work on a couple of documents that explained various processes that patients need to understand better when they seek care under our current system. This included topics such as reading an Explanation of Benefits document; understanding the differences between primary care and subspecialist providers; understanding different locations of care; and understanding the basics of healthcare financing including terms such as coinsurance, copay, deductible, maximums, etc. The providers were on board with these additions, along with information on managing complex medication regimens and modifying the home environment to support aging in place.

My intern did a fair amount of research on the topics, making recommendations on whether they should personalize an existing open-source document or whether they should write something new from scratch. I paired her up with a couple of providers to work with on new documents, along with a small committee to use as a sounding board for evaluating documents from various national organizations that we might be able to use as-is. We’ve got the library about 75-percent complete, and although she has gone back to school, she’s still helping a couple of hours each week as we work on the remaining documents. I think she has a greater appreciation for the so-called “non-medical” work that physician leaders sometimes have to do, along with an understanding of the technology needed to deliver resources to the patient in a way that is trackable and complies with payer requirements.

In working on the documents we created to help patients navigate the health system, she also gained a new understanding of health literacy in her community and what patients need to be able to successfully care for themselves at home and to receive the care they need from a variety of different provider organizations. Many premedical students don’t have any exposure to what happens outside the exam room, so I’m hoping the experience helps her form a better idea of what she hopes to be able to achieve through a career in medicine. She also learned to read governmental documents with a critical eye, appraising them for how well patients and providers might understand them. She sent me a link to this CMS blog on Health Savings Accounts with her thoughts on how she felt it didn’t meet the mark – too many acronyms, too many text blocks, etc.

She also posed some critical questions around why certain healthcare payment mechanisms work the way they do. For example, why can’t everyone open a Health Savings Account? Why shouldn’t it be available to all consumers of healthcare rather than just those with high-deductible plans? Why are Flexible Spending Accounts “use it or lose it?” It was surprising to her to learn that many of these options are linked to tax savings for individuals, and that incenting people to move towards these plans can negatively impact the federal budget. She had a lot of questions about how healthcare works in other industrialized nations and why our system is so complex. There aren’t any good answers for many of her questions, but I was able to recommend some good resources for further reading.

I’m hoping I inspired her to think about medicine in a different way, and to consider options if she doesn’t ultimately make it to medical school. I think we may just have a public health informaticist in the making. Or perhaps a policy expert or a legislator. I enjoy working with curious young people and getting them thinking about topics they didn’t even know existed.

Did you have any thought-provoking encounters with interns this summer? Leave a comment or email me.

Email Dr. Jayne.

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