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Curbside Consult with Dr. Jayne 9/17/18

September 17, 2018 Dr. Jayne 1 Comment

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To maintain my board certification, I have to do a variety of coursework “modules” on an ongoing basis. Sometimes they’re more academic, such as learning the latest and greatest clinical guidelines, and sometimes they’re more practical, such as a practice improvement project around handwashing by providers and staff. For those of us who aren’t in traditional practice, the choices are sometimes slim since we don’t have continuity patient panels that we can research with or look at trends in quality. One of the offerings that I completed for my upcoming board certification renewal was a module on cultural competency.

In healthcare, cultural competency means caring for patients in a way respects their health beliefs and cultural practices. Sometimes it can directly impact medical treatment, such as not making recommendations for animal-derived products when that would be contrary to a patient’s beliefs or preferences. In other situations, it might be more subtle, such as having an understanding of the communication preferences of different cultures and how decisions are made within extended family structures. It can also be having an understanding of medical treatments performed by different groups, including everything from cupping to intercessory prayer. It might also be respecting a patient’s desire to entirely reject treatment regardless of the potential for success.

Understanding different cultural beliefs of your patients can certainly help build trust and rapport with them, as well as helping to identify treatments that they will accept and complete. Letting patients know that you’re interested in learning about their values and beliefs helps them feel empowered and part of the care team. It’s great that healthcare providers are thinking about cultural competency, but learning more about it got me thinking about cultural competency in that context of the general workplace.

I recently worked with a company that placed a priority on this, creating various forums for employees to interact based on their family situations, ethnic groups, or interests outside of work. It was great to watch people who might not normally interact get together around a common characteristic and get to know each other.

I’ve also worked with companies that don’t have even a basic understanding of cultural sensitivity. In our increasingly polarized society, some people push back against the idea of political correctness, but rather than thinking about it that way, one might want to consider that it’s just a basic human kindness to respect the beliefs of others. I’ve been at a company that was hosting a development team from India (along with the host team’s existing multicultural employees) where the catered lunch that was ordered consisted entirely of barbecued beef and other items that had meat in them, including the baked beans and the potato salad. I cringed when I saw several people with plates of only corn bread and coleslaw.

I’ve been in meetings where the presenters used hunting metaphors such as, “You can’t shoot the moose from the lodge” and other gems, not noticing that it wasn’t playing well to the non-sportsman audience. Of course, the audience can exhibit cultural sensitivity and understand that the presenter is reflecting his own cultural practices as well rather than just acting horrified. Cultural sensitivity is a two-way street.

That’s the challenge in coaching people to develop a workplace demeanor that allows them to respect their own beliefs and traditions without stepping on those of their colleagues and employees. There’s certainly a continuum of behavior, ranging from insensitive to boorish with many different shades in between.

It’s important to understand the potential for difficulty here, because when someone in a leadership position doesn’t understand that balance, it can be perceived as creating a hostile workplace. Even when it’s unintentional or through sheer ignorance, a pattern of disrespectful behavior can become a serious workplace issue. Some companies have responded to this by formally implementing diversity training programs employee education, but it needs to go beyond that. Sometimes those programs are highly focused around specific groups rather than focusing on the more general concept of acting in a way that would make people comfortable regardless of their cultural background or beliefs.

Assuming that people from a specific background don’t eat or not eat specific foods can be an issue. I’ve worked with dozens of people whose practices are very different from their historical roots. Sometimes it’s easier to think about these challenges in a broader way – for example, thinking of dietary needs as not only a cultural issue, but also a medical one. Asking a more open-ended question around whether people have any dietary restrictions or requirements is more inclusive than asking whether people need a specific type of meal. I’ve been to plenty of corporate-type lunches where the question is never asked. That’s an easy pitfall to avoid and keeps the meeting planner from trying to figure out what different parameters they need to accommodate.

From a healthcare provider perspective, it’s great to learn about different traditions and practices so that you’re not surprised by the descriptions of treatments that patients may be doing at home, or that so you can have an understanding of how those therapies might complement or conflict with what you might recommend. However, a larger part of cultural competency is just learning how to talk with people about they prefer to be treated and being considerate of fellow human beings. It’s about not making assumptions and not trying to cast your own beliefs and values on the people with whom you interact.

There is a tremendous amount we can learn from each other and it just takes being open to learning about other people’s beliefs and needs and understanding how they may differ from your own. It’s about going back to the basics of hospitality and helping ensure that people feel comfortable regardless of where they come from or where you are going.

How does your organization approach cultural competency? Leave a message or email me.

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EPtalk by Dr. Jayne 9/13/18

September 13, 2018 Dr. Jayne No Comments

As we move into hurricane season, the American Academy of Family Physicians has released disaster preparedness resources for both practice and personal needs. I’m always amazed by the practices I visit that don’t have an EHR downtime strategy or business continuity plan. Even if they have plans, it’s rare that they have done drills or really discussed what would happen in a serious emergency. I’m not a serious doomsday prepper, but I do have some survival basics in my car including water, food, a first aid kit, and a survival blanket. There are plenty of organizations that end up having staff sleep at the hospital or medical office buildings in the event of major disasters, so it’s not a bad idea to keep some extra clothing and essentials like a toothbrush in your “go bag” because you never know where an emergency is going to happen.

Backup solution vendor Webair is offering complimentary offsite backups and disaster recovery services for business affected by Hurricane Florence. Clients can select backup replication sites on the West Coast or outside the continental US. I took a look at their offerings and was happy to see that they include up to 72 hours per month for disaster recovery testing. Far too few sites test their backups or disaster recovery strategy, so this is a plus.

HHS has declared a public health emergency in the Carolinas in preparation for Hurricane Florence. The public health emergency eases some restrictions for Medicare and Medicaid providers, and likely will lead to accommodations for various reporting requirements for 2018. I know all of us hope that the storm will not be as bad as predicted and are sending our prayers to the East Coast.

CMS is convening a Technical Expert Panel to look at the Merit-based Incentive Payment System, specifically the Improvement Activities (IA). This panel will give feedback and provide “direction and thoughtful input on the improvement activities during development and maintenance.” They’re looking for a dozen clinicians with expertise in the Improvement Areas, consumer/patient/family caregiving, healthcare disparities, performance measurement, and quality improvement. Nominations close at 5pm PT on September 22.

A wise man once told me to always spend a little time looking for my next career move, so I keep my eye out for interesting postings or opportunities. On Tuesday, I received a notice from ONC that they were looking for a medical professional in the Clinical Division. I have no desire to relocate to Washington, DC but was curious about the posting. Clicking the link embedded in the email took me to Indeed.com, where the header said the posting was no longer available on Indeed. It’s going to be difficult to recruit someone if you don’t keep the posting live, and the email from ONC made it sound like it would be open through September 19. It did cross-link me to a Medical Officer posting, which was interesting in that it was targeted to someone who is already employed by a governmental or academic institution that is willing to contract them out for a period of two years. Despite the requirement that the candidates be MD or DO physicians, the salary range is $114k to $164k, and there is no eligibility for federal benefits. I wonder if they will have candidates beating down the doors for this one given the cost of living in the DC area and the earnings potential for physicians in clinical practice.

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It’s that time of year to start talking about flu season preparedness. This week brought a blip in reported flu cases, and I hope it’s not a predictor of an early or more severe flu season. Vaccinations arrived at my clinical office on Tuesday, and everyone rolled up their sleeves and got it done. After seeing the number of seriously ill patients we saw last season, no one wants to experience that personally. Please consider a flu vaccination to protect patients, your family, and the community.

LOINC is holding its annual Fall Conference next month in Salt Lake City. Workshop topics include Document Ontology, the use of the RELMA mapping assistant, Clinician Perspective, and FHIR. I’ve been doing LOINC mapping for clients for nearly a decade and appreciate the logic and deliberate construction of the framework. Sometimes the specificity of some of the tests seems complicated to those who haven’t worked in the depths, but when you’re looking for granularity with lab data it’s important to be as accurate as possible.

The Pew Charitable Trusts, the AMA, and MedStar Health have released a new report detailing recommendations for improving EHR usability and safety throughout the software life cycle. It also identifies what can be considered rigorous strategy testing and how to create testing scenarios based on currently-understood EHR safety issues. The report also addresses the culture of safety along with EHR user training as ways to improve patient safety. Other topics covered include EHR design and development, EHR implementation, configuration and customization by end users, and EHR upgrades.

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This is National Suicide Prevention Week and gives us the opportunity to reflect on the lives lost each year due to suicide. I think often of my medical school classmate, the high-school student I taught, and a family member we lost to suicide. Our local high school’s Harvard-bound valedictorian went missing after graduation and committed suicide. It really is everywhere, and it can be prevented. TMF Quality Innovation Network is hosting a webinar titled “Suicide Prevention Tips for Physicians, Clinical Staff and Their Patients,” to be held September 18 at noon CT. It features Christine Moutier, MD, CMO of the American Foundation for Suicide Prevention, along with Leah Patterson, a survivor. They will offer practical tips for clinicians to address suicide risk for patients, peers, and themselves.

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Curbside Consult with Dr. Jayne 9/10/18

September 10, 2018 Dr. Jayne No Comments

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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.

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EPtalk by Dr. Jayne 9/6/18

September 6, 2018 Dr. Jayne No Comments

Part of being a clinical informaticist is understanding how to lead organizations through change, especially complex and transformative change. Culture is a big piece of that, and I’m often amazed at the disparities in culture among organizations that feel they are high-performing. I see entirely too many people who are burned out from lack of work-life balance, and who feel that they need to be constantly connected in order to stay afloat at work. It used to be that the after-hours email crew was either trying to get ahead or using remote work strategies to accommodate a flexible work schedule, but now it seems to be the status quo. I see a lot of parents missing out on their children’s activities because, although they are physically present, their thoughts (and eyes) are turned to laptops and phones. I’m sympathetic to the parent who is camped out at a four-hour track meet to watch their child run a  10-minute race, but I’ve also seen parents spend an entire event working email, not seeing their child participate.

The New York Times ran a piece that covered the idea of employees working during their commutes. According to researchers, half of workers addressed work email or documents as they commuted. One researcher commented that those studied “didn’t see it as official work time, but something to make their lives easier.” The piece goes on to detail efforts in other countries, such as France and Norway, to either limit the length of the work week or to allow employees to count their commutes as working time due to being under the relative control of their employers during those hours. A recent court case in France addressed after-hours, on-call compensation. My observations from not only the healthcare provider side but also the vendor side are that many workers are required to be “on-call” nearly 24×7 without any additional pay. Since they’re classified as “exempt” employees, there is no overtime, and no limit to the work they can be expected to do. The only protections for those workers is for them to vote with their feet.

The comments on the piece are worth a read, with some making the point that workers are forced to be available at all hours and others pointing out the amount of time that workers spend surfing the Web and doing non-work tasks during the traditional work day. One commenter noted the number of people who are expected to be on conference calls while commuting, and I’ve definitely seen an uptick in that. People are trying to take calls from the train (sometimes in the quiet car) and even on planes, using VOIP to try to connect when they’re in the air. There were several negative comments directed towards those seeking work-life balance, one trying to make the point that working email isn’t “work” and insinuating that family leave or bereavement days are an indulgence. They do paint a compelling picture that many employees feel their workplace culture is broken – and although I see companies paying lip service to the idea of work-life balance, they don’t always make good on their stated intentions.

In many situations, rendering providers aren’t paid overtime – even when we do shift-work such as in the emergency department or as a hospitalist, we’re expected to spend whatever time is needed to wrap up patient care or complete documentation after our scheduled hours end. In my hospital career, I was never paid past my scheduled shift even though I spent many hours in the ED getting patients transferred to other units, writing incident reports, or handling other tasks that couldn’t be done while I was actually seeing patients. My current organization has wrestled with this for the last several years, and recently agreed to pay physicians for the hours actually worked, even though it’s not overtime per se. Physician Assistants and Nurse Practitioners were already paid for actual hours worked, but physicians were only paid based on their scheduled shifts. It’s not a perfect solution – the physician has to work at least half an hour past his or her scheduled end time before the extra payment provision goes into effect, and we’re only paid as long as patients are physically in the building, not for any resulting documentation or follow-up. Still, it’s gone a long way towards physician satisfaction, especially when you have patients walking in the door as the staff is trying to lock it.

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When I’m wearing my clinician hat, I don’t ever have to worry about not hitting my daily step goal. As healthcare IT workers, though, we have known for a long time that our sedentary lifestyles place us at risk for unhealthy outcomes. Now the World Health Organization has issued a report showing that there has been little progress in getting people to be more active. WHO estimates that more than 25 percent of people worldwide don’t get enough activity on a daily basis. That’s approximately 1.4 billion people and the percentage hasn’t changed much in the 15 years where data was available. Not surprisingly, high-income countries were more sedentary. The UK and USA had inactivity percentages that increased from 32 to 37 percent, where low-income countries stayed steady at 16 percent. Inactivity was defined as less than 150 minutes of moderate exercise (or 75 minutes of vigorous exercise) weekly. The authors noted decreased exercise in women compared to men for most countries, which they attribute to cultural factors and family responsibilities (such as child care) that reduce the time available for exercise. Other factors impacting activity include sedentary jobs, use of motorized transportation, and sedentary hobbies.

I’ve made a conscious effort to try to be more active even when I work from home. I’ve got my printer on another floor of the house, which forces me to get up if I need to get documents, and I make a point of going to the kitchen when I need a drink rather than always keeping something on my desk. I intentionally park far from the door when I go shopping, and I’m hoping that those little factors add up. I also hit the treadmill when I’m on a listen-only conference call or attending an educational presentation, so that helps not only with cardiovascular fitness but with avoiding somnolence during certain presentations. I really logged the miles when I was listening to quarterly earnings calls and recordings of the ones I couldn’t attend in real time.

What’s your favorite strategy for increasing activity? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 9/3/18

September 3, 2018 Dr. Jayne 5 Comments

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I spent some time this week learning about the patient/family side of the changes that value-based care is bringing us. A close friend of mine had a hip replacement and got to experience the “new normal” in some dimensions of healthcare. He chose a surgeon at one of our local academic medical centers; since he is young (under 40) and otherwise healthy, he was offered the option of an outpatient procedure. As a physician who has been out of the primary care flow for a while, I wasn’t really aware that outpatient hip replacement was even an option. Of course, early ambulation is a good thing, but sending someone home the same day is relatively new.

It’s great to get people out of the hospital early – certainly not being in the hospital is a great protector against hospital-acquired infections. One can also think of the potential for higher-quality sleep at home, without having your vital signs checked or having IV pumps beeping at you. On the other hand, there may be children and pets at home, so quiet time is no guarantee. I’m sure one of the factors influencing a change to outpatient status for many procedures is the sheer cost of days in the hospital. As I learned more about my friend’s arrangements for his post-hospital care, one might begin to think twice about that cost equation. Certainly, there’s a smaller payment to the hospital, but there’s the reciprocal cost of having a spouse or family member take off work for a period of time because someone has to be home with the patient 24×7. Home health, home physical therapy, and other services may be substituted for the inpatient versions, and not having seen a bill for either of those services in a while, I’m not sure how much of a savings it truly is.

There’s also a psychological cost – for most of us used to western-style medicine, there may be comfort in knowing that if something “bad” happens, there are professionals close by. It’s easier to run laboratory tests if new symptoms or side effects develop; if the patient falls, there are trained staffers who know what to do and how to help. At home, there’s that shade of uncertainty about what might happen if things don’t go as planned, such as if the patient begins to run a fever or is having pain that isn’t controlled by the medications available at home. At an academic center there’s typically a “house officer” resident physician who can assess a patient if the nursing staff identifies a potential risk or worsening condition. At home, you have your telephone, and your own ability (or inability) to describe what is going on.

My friend is taking his recovery in stride, although figuratively rather than literally. He quickly figured out how to lash his portable, deep venous thrombosis compression pump to his walker so it didn’t strangle him when he was trying to make his way around the room, and shared his expanded knowledge of Netflix with the rest of us. Can’t Pay? We’ll Take It Away! is an interesting look at rather genteel British repo men and their work. I’m sure we’ll have some laughs when the surgery and home care bills start rolling in – we’ll see how long it takes to get everything paid and reconciled. Depending on how that goes, it might be the most frightening part of the entire procedure. Until then, he’ll have to be entertained by a parade of friends dropping by to sit with him so his family can leave the house, and endless card games playing Uno.

Labor Day Weekend is a fairly low readership environment, so I’ll keep this Curbside Consult brief. Whether you’re barbecuing, visiting with friends, packing away your white shoes, or using the long weekend to catch up, take a minute to remember what Labor Day is all about. It’s been a federal holiday in the US since 1894, and is also celebrated in Canada. Spend a few minutes thinking about the work people do and how much we all need each other to keep things going, especially the folks that are outside the C-suite. Be sure to thank the people in facilities engineering, sterile processing, dietary, custodial, and so many other departments that keep our healthcare world turning.

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EPtalk by Dr. Jayne 8/30/18

August 30, 2018 Dr. Jayne No Comments

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Thousands of health system leaders have descended on Epic’s headquarters this week for its annual Users Group Meeting. I’m even more curious about the upcoming, first-annual, Un-Users Group Meeting, slated for September and specifically inviting groups that don’t use Epic. The meeting is designed to review options for connecting with Epic-using facilities and for attendees to understand patient-driven mechanisms of data sharing. The Epic-using hospitals in my area have zero interest in connecting with anyone who isn’t part of their respective systems, so I’m not sure that hearing from the vendor would be that helpful. If you’re in an area where everyone plays nice, registration is $100 and the meeting is only one day, so you might be able to fit it into your schedule.

Speaking of vendor user group meetings, I’ve attended quite a few in my time and beyond the educational and networking components there is typically a bit of fun. As we’re in the swing of the user group season, let’s all take a moment to review an analysis of alcohol consumption and health risk recently published in The Lancet. Although mainstream media has picked this up as a warning that there is no amount of alcohol that is safe to consume, the facts of the analysis need to be considered. Researchers looked at data on alcohol use and the risk of alcohol-related conditions from people in almost 200 countries and used it to create a global risk profile for alcohol. The authors kindly note that they adjusted for tourism and “unreported” consumption, which is an interesting concept to consider.

Not surprisingly, alcohol-related harm was less where no alcohol was consumed, and the risk increased with a rising number of daily drinks from 0 to 15. Because the study used previous data rather than being a new clinical trial, researchers weren’t able to control for other health risks such as smoking or low socioeconomic status. The New York Times brings some sanity to the data in its review of the study. Author Aaron Carroll notes: “Consider that 15 desserts a day would be bad for you. I am sure that I could create a chart showing increasing risk for many diseases from 0 to 15 desserts. This could lead to assertions that “there’s no safe amount of dessert.” But it doesn’t mean you should never, ever eat dessert.” As someone who indulged in a spirit-bolstering piece of gooey butter cake this afternoon, I fully agree. Much appreciation to my Midwest client who introduced me to the delicacy.

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HIMSS19 registration is open, and they’ve upped the early bird price by $35 to a base of $825 for HIMSS members. Fees are extra for the Health 2.0 VentureConnect offering and various pre-sessions, receptions, and the SeaWorld event. I registered early so I could check one more thing off my ever-growing “to do” list, and was happy that I had booked my hotel weeks prior because my hotel of choice is already sold out.

I completed my registration while waiting on a conference line for a client who is chronically late. As a consultant, my meter starts running at the scheduled meeting start time, and the client is on the hook for any wasted time. Of course, if a client has an extenuating circumstance I will typically make an exception, but not for a client who does it all the time and has been reminded often about the time she is wasting. While I was productive, the other people waiting on the call engaged in some fairly un-professional, pre-call banter, despite being able to clearly see that an outside person was connected to the Web conference via both audio and video. I’m cool with chit-chat about weather, sports, weekend plans, kids, and what’s for lunch, but complaining about your boss probably isn’t the best thing to do on an open conference line. Especially when your boss hired the consultant who is chuckling to herself while on mute.

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A friend clued me in to Paladina Health, which delivers integrated care in a medical home model. Like other offerings, its goal is increasing value while reducing healthcare spending. However, it leads with a high-touch primary care setting –  think concierge medicine as an employee benefit. There’s plenty of technology going on with population health management, risk stratification, and outreach, but the primary physician is empowered to truly build a relationship with the patient, with appointment slots ranging upwards of 30 minutes. Physicians are paid a salary and receive bonuses based on outcomes, patient satisfaction, and cost management. Patients can be seen without paying a co-pay, with the intent of encouraging them to seek care when they need it and not having cost be a barrier. I’m not sure exactly what the physician compensation piece looks like, but it was enough to convince my colleague to leave her part-time, family-friendly position and take on being available to patients 24×7. I’ll add Paladina Health to my watch list and see how they do over the next year or so.

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For those of you in healthcare IT who don’t have to deal with the revenue cycle piece, think kindly if you encounter stressed-out colleagues who do. There are so many steps needed with appeals, resubmissions, and more, it’s enough to make someone lose their mind at times. CMS is one of the biggest offenders, although I’m currently working with a client who has several payers that are taking more than 52 weeks to pay, leaving the practice holding the bag. HHS filed a brief this week estimating that it will be able to clear the Medicare claim appeals backlog by Fiscal 2022 – but unfortunately, that’s a year longer than stipulated by a US District Court. The issue goes back to a 2014 lawsuit by the American Hospital Association against HHS, claiming that the Recovery Audit Contractor (RAC) program’s slow appeals process violates the Medicare Act’s 90-day appeals requirement. HHS has long claimed that administrative judges are overwhelmed and it doesn’t have the budget to hire more. There are over 600,000 appeals pending, and it’s expected that the number will be over 950,000 by the end of Fiscal 2021. To solve the problem, HHS plans to use over $180 million in additional funding to hire enough judges and staffers to more than double the number of appeals it can process annually. I’d love to see some provider-side data on what those appeals and delays cost those who are providing care. I’m betting there could be some serious savings if healthcare organizations didn’t have to hire staff to chase their payments.

What’s the longest delay in payment you’ve seen? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 8/27/18

August 27, 2018 Dr. Jayne No Comments

I’ve been helping a good-sized provider organization through a practice transformation project recently and it’s been a major challenge. They initially hired me to help them spin up a transformation team, which would be tasked with running various projects across the organization. Some of the change that needed to happen was financial or revenue cycle, but there were also a number of clinical projects that had been repeatedly placed on the back burner due to lack of focus or resources.

The goal was to help them identify which internal resources might be a good fit for the team and to educate those resources on not only the overall process of change management and practice transformation, but to ensure that they had a super-user level of knowledge of the EHR, practice management system, and ancillary applications. This would allow them to have the deep knowledge required to lead people through change, even in small groups where there might not be a subject matter expert readily available. They were to serve as kind of a SWAT team for transformation – go to a practice or site, lead the efforts, make suggestions, get it all documented, and supervise the rollout of the changes.

I was also tasked with helping the organization hire external resources to fill any gaps that we couldn’t fill internally. We knew that some members of the transformation team would only spend part of their time on the team – they may stay as half-time in their regular role and spend half of the time on transformation. My client felt strongly that for the transformation team to have a high degree of credibility, they needed to be in the trenches at least part of the time. I wasn’t opposed to the concept as long as we could make the scheduling and workload allocation work. The clinical employees selected for the team were particularly excited about being able to do the transformation work without having to give up the clinical experiences that they enjoy.

Where the super-user development and change leadership education went well, the hiring of external resources quickly turned into a disaster. My client subscribes to some HR functions through its parent hospital system and the hiring process is one of them. The first roadblock we ran into was getting the job descriptions created and approved.

Despite the provider organization being 100 percent on board with what I had created (drawing on samples from other major provider organizations), the hospital HR team didn’t understand what we were trying to do and insisted on trying to create the new positions around an IT-centric model that didn’t make sense for the provider organization. They wanted to classify the new transformation resources as project managers, which although it makes sense on some levels, doesn’t totally match what we expected them to do. In that IT-centric model, having the PMP certification may have been important, but not necessarily for our project. What was more important to us was having a proven track record of leading organizations through complex change, and especially experience in healthcare.

After a couple of months, we finally had the jobs posted and then were at the mercy of the hospital’s talent recruitment team to screen and vet potential candidates. I’m not sure whether it was market forces or what was going on, but nearly all of the first 10 applicants they presented to me came from the automotive industry. Their resumes were heavy on project management and not a single one had ever participated in a clinical project. That led to many phone calls between the provider organization’s leadership, the talent team, and myself trying to again explain what we were looking for.

Apparently our job postings had been handed off to a new recruiter who didn’t receive all the notes from the original HR team, and the new guy thought we wanted project managers and that’s what he was serving up. Following that clarification, we received a steady stream of candidates that were either medical assistants or office managers, but who didn’t have any background in change management. It took a little over two months to actually receive a screened applicant who seemed capable of doing practice transformation. In the mean time, I was contemplating regular appointments with Miss Clairol to cover the grey hair that I was sure this scenario would cause me.

By then, I was handed off to a third recruiter, who explained what was going on. The hospital had outsourced that particular part of HR and the recruiters were actually contractors from a third party that also provided services for a multitude of non-healthcare organizations. After some additional level-setting, we had a decent pool of applicants and were off to the races for some video interviews.

I was excited about using the video platform to do an initial interview. Particularly for activities that are technology-heavy and people-focused, understanding how they interact with their device is a good test. Our first video interview was a disaster. The candidate was logged into the Webex session twice and was trying to use both a phone session and a computer microphone / speakers session at the same time. There was a horrible echo and everything I said was played back to me as it resonated around the applicant’s desk, which was right in front of a large sunny window so that the applicant was backlit and you couldn’t even see his facial expressions.

We spent 10 minutes of the interview trying to get him to hang up one session, or at least disconnect the audio, which he finally figured out. Still, he was left with two sessions. He must have been using a laptop for the camera, but looking at us on another device, because then we always got a shot of his right-side profile as he looked away from us. At that point, I knew it wasn’t going to be a good fit because if you can’t figure out how to talk directly to your interviewer, I’m not going to want to spend a ton of time with you.

It also became apparent that he was probably doing the interview from his current place of employment, as someone walked in and just started talking to him about his work without knowing that he was busy. That’s not a good sign, either. I began to wonder whether he was doing the interview using company property or what was going on, which makes you think that a candidate is likely to pull those kind of shenanigans on you if you’re foolish enough to hire them.

By the end of the call, the HR rep was as frustrated as I was. In our debrief, it seemed that he was even more motivated to try to find the right kind of candidate for us so we can get going on these projects. I’m getting rather impatient because my client wants to power ahead with transformation efforts even though they’re short-staffed relative to what they want to do and we haven’t finished building the methodologies and training the resources that we do have. It’s hard to convince the C-suite that sometimes you have to hurry up only to wait, and that sometimes you need to go slow at the beginning so that you can go quickly in the future.

I’m doing a lot of “managing up” on this engagement and helping them understand that their impatience is what got them to the place where they needed to bring in outside assistance and to get them to trust the process and trust the team. I’ve got another stack of candidates ready for interviews once we get the scheduling sorted, so let’s hope this week is a better one.

What’s your favorite interview question? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/23/18

August 23, 2018 Dr. Jayne No Comments

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Big news for the clinical informatics community last week, as the American Board of Preventive Medicine announces that Diplomates no longer have to maintain a primary medical board certification when they apply to recertify for clinical informatics. This also applies to those certified in addiction medicine, and really is a win for those of us who don’t practice traditional clinical medicine any more but still want to remain board certified in clinical informatics. ABPM already allowed this to happen with the subspecialties of undersea / hyperbaric medicine and medical toxicology, so it’s not clear why there was a disconnect in the first place. The policy becomes effective on January 1, 2019.

I still practice and have to sit for a re-certification exam next year and am not looking forward to re-learning all the areas that will be tested that I no longer practice, such as obstetrics. It will also be my first time using a totally online prep strategy, so we’ll have to see how that goes.

From Change in My Pocket: “Re: NYU’s free medical school tuition offer. What’s your take on it?” I agree with some of the naysayers. I’m not sure it’s going to have the desired effect. I went to medical school with plenty of students who were from families that paid for their medical school expenses outright and it didn’t drive them into the ranks of primary care. Lifestyle is a major factor in choosing a medical career, as well as earnings potential. Those aren’t going to be significantly altered by free tuition, although it may reduce the number of 15-year-old Honda Accords in the physician parking lot since that seems to be the vehicle of choice for primary care physicians who are still paying off their student loans.

Being a primary care physician is extremely demanding  mentally and emotionally as well as temporally, especially if you practice full-spectrum primary care including hospital and taking your own after-hours call. Most of the PCPs I know don’t take the traditional day or half-day off each week like the proceduralists do. Yes, I know most workers don’t get a half day off each week, but that’s how it often works in the medical world (to make up for things like weekend call, after hours call, etc.) and primary care definitely feels the squeeze.

There’s also the lack of respect from colleagues who make comments about “you’re just the primary” or view us as simply gatekeepers who are there to make sure they have a referral base. Free tuition isn’t going to make being a primary care physician sexy, especially since a good chunk of the population is OK with receiving their care from nurse practitioners at retail clinics or from a revolving-door cast of primary physicians that they see over time as their insurance coverage changes.

For me, a few things would make bring a primary physician exciting again. First, salary potential. I have a number in my head that if I could make it as a primary care physician without working 80 hours a week, I would jump at it.

Second, wider networks that allow patients to actually remain with a continuity physician for 10, 20, or 40 years. I would see patients for a year or two, then they’d have to change to the other hospital in town’s network, then their insurance would change, and they’d be back again. I had a dream of seeing patients for their entire lifespan and it just wasn’t reality. But when you could keep a patient for five or more years, it was gold. I’m still friends with some of those patients even though I’m long past being their physician.

Third, fewer insurance hassles and more trust of honest physicians. In my career as a solo physician, I was never denied a treatment that I requested through pre-certification. My orders were justified 100 percent of the time, not only by medical evidence, but by the insurance reviewers. When you have a physician who meets the criteria, can’t we perhaps back off on the pre-certification nonsense? I could have slimmed down at least 0.5 FTE on my balance sheet if I didn’t have to deal with pre-certification and pre-authorization. Sure, there are bad guys out there, but find them and stamp them out — don’t punish the good guys.

I don’t even mind the CEHRT or reporting hassles as long as there are decent EHRs out there. I’d be willing to take those extra clicks if the above conditions could be met. I loved my patients and miss many of them dearly. I felt like I was doing good for my relatively underserved community. I got to do fun things like ride on a float in the Founders’ Day parade. I cried with them when it was sad, went to funerals and hugged their widows, and celebrated when their kids got married. I even caught some babies. But I also worked a lot of late nights dealing with bureaucracy and silliness until finally the siren song of healthcare IT lured me away.

I do have patients who try to have continuity with me in the urgent care environment and will call around to see if I am working at a particular location when they need care. I’m lucky that I can stay in the industry and try to work for change from another angle, but many primary care docs give up when faced with the career they have not being what they thought they signed up for.

The article brings up a couple of interesting points about NYU and their offer. Their freshman class is only 102 students, down from 120-130 previously. Its students are in the 99th percentile for both GPA and MCAT scores. These are not “average” medical students, and in my experience, students with that kind of street cred are typically bound for high-profile subspecialties like orthopedic surgery, plastic surgery, interventional cardiology, etc.

Medical school admissions are very competitive, with only 41 percent of applicants being admitted. My practice employs scribes and previously most of them were applying to med school. This year, nearly all of them applied to and were admitted to physician assistant school. It’s perceived as a way to basically do the same thing as a physician, but in less time and for less money.

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Earlier this week I attended a Medicare Shared Savings Program webinar hosted by the Partnership to Empower Physician-Led Care, which advocates for independent physicians and practices as they transition to value-based care. They put together a nice summary of the proposed Medicare rule and the changes it will bring for independent practices. Overall it should be good for physician-led Accountable Care Organizations. Comments on the proposed rule are due October 16, 2018 and we expect a final rule in early 2019. Delays in rule-making could mean that programs can’t start until mid-2019, which should make for some interesting half-year reporting. According to panelist (and not-so-secret Dr. Jayne crush) Farzad Mostashari, it will probably take 100 pages of regulations to sort out the half-year issue.

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What’s your favorite bowtie? Send a pic – email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/20/18

August 20, 2018 Dr. Jayne 1 Comment

Now that we’re in the bottom half of 2018, CMS has published the 2016 Physician Quality Reporting System (PQRS) Experience Report. The report summaries the reporting experience of eligible professionals and group practices, including historical trending data from 2007 to 2016 covering eligibility, participation, incentives, adjustment, and more. I was curious to get a look at the data because it is broken down both by specialty and by state. Here are some of the highlights:

  • Participation in the program was 69 percent in 2015 and 72 percent in 2016
  • Of the providers eligible in 2016, 31 percent were flagged for a payment adjustment in 2018. This represents over 435,000 providers

Of those receiving a penalty (I’ll call that payment adjustment what it is) almost 85 percent didn’t participate in the program. They literally did not submit any data. That means that 370,000 providers essentially said, “no thank you” and walked away from the program. My practice falls into that cohort, and I don’t think our CEO was that polite in deciding to walk away from PQRS. Other tidbits:

  • Being a provider in a small practice was a marker for receiving the penalty, with 71 percent of “adjustments” being levied on practices with fewer than 25 providers
  • Having a low volume of Medicare patients was associated with the penalty – 69 percent of those providers saw 100 or fewer Medicare patients

Having worked with dozens of practices trying to make sense of the value-based payment scheme, those numbers validate what we already knew, which was that to be successful, you need dedicated resources to help you (which small practices typically don’t) and it’s not worth the effort if the penalty is going to be relatively small due to your patient mix. Of course, 2016 was the last year for PQRS, which transitioned to the Merit-based Incentive Payment System (MIPS) which of course now has transitioned yet again. Since it’s been a couple of years since some of us have handled PQRS data (and many of us have blocked out those painful memories), remember it may use claims data, so it may not match your EHR data if you’re trying to look through the retrospectoscope.

CMS has also put together a document called the Value-Based Payment Modifier Program Experience Report, which looks at program results from 2015 to 2018 and includes the upward, downward, and neutral adjustments. In looking at the section on clinical performance rates, CMS admits that there have been numerous reporting mechanisms over the years and that it created a hierarchy that would be applied if the provider participated through multiple means so that only one performance rate for each provider would appear in the results. It’s a rigid hierarchy, so if a provider performed better through a mechanism that is lower in the list, they would retain the lower performance rate.

The report also notes that there have been numerous changes to the PQRS program over the years, with individual measures being added, removed, and redefined. Additionally, providers who shifted from individual to group reporting may be impacted by data artifact, resulting in the ultimate caveat: “It is unclear the extent to which any observed changes in measure performance were artifacts of the aforementioned changes or trends in provided care.” It goes on in true governmental fashion: “Nonetheless, this section of the report aims to describe clinical performance rates and trends.”

I have to admit, I looked at the report pretty quickly, it’s 96 pages long and there are a lot of tables. I would love to talk to someone knowledgeable to dig into why some of the measures that seem easily attained have declined so much over time. For example, measure 317 is screening for high blood pressure and documented follow-up. It dropped from 91.5 percent in 2013 to 62.9 percent in 2016. There were 4,200 providers reporting that measure across the timeframe, which seems like a reasonable sample. On the other hand, measure 310 for chlamydia screening dropped from 100 percent to 83.3 percent, but only 10 providers were reporting across the timeframe, so a change there could be due to sample size.

On the positive side, cervical cancer screening rose from 41.3 percent to 79.8 percent, but only 103 providers reported that measure. As a primary care provider, I think that’s a sad commentary on the state of preventive care in the US today. The clinical data starts on page 51, if you’re interested in taking a peek.

If you’re not on the clinical or operational side of the house, you may not have seen the decision-making process that practices go through when they try to decide what clinical measures to report. It used to be a little more straightforward, with practices wanting to report the measures where they do the best. Everyone likes to earn an A, so being able to show that you were doing something 95 percent of the time is a feel-good move.

Now that we’ve moved into an “adjustment” phase where there are winners and there are losers and the penalties essentially pay for the bonuses, it’s a different game. Providers are incented to report not on measures where they do the best, but where they do better than the next guy. If you’re doing something 50 percent of the time (which feels like a failing grade) but the rest of the population is only doing it 35 percent of the time, you win! It makes the analysis of measures much more challenging, because providers have to analyze their own performance against the performance of their peers, using a multitude of reports and benchmark data sets.

Smaller organizations may not be savvy enough to figure that out and may end up reporting on the “wrong” measures if they don’t understand how the game is played. I’ve seen a couple of EHR vendors that offer education around this, but the larger vendors seem to think their clients understand it or have enough staff to do that analysis. Even where education is offered, it’s not clear that practices are absorbing the information or that they feel they have the tools needed to make good decisions about quality reporting. Some specialties don’t have options for measures that are truly applicable to them, which puts them in the quandary of choosing measures that don’t make clinical sense just so they can get good numbers.

It might feel easier to just opt out rather than doing something that they know is just “checking the box.” I’ve worked with a couple of clients who have trouble getting the data they need to make good decisions – maybe they don’t have ready access to reporting modules in the EHR, or maybe the reports aren’t run on a frequency that allows the practice to drive change. Usually there is concern about the accuracy of the reports, with organizations having different interpretations of some of the measures than what the EHR might be pulling. That results in an unpleasant back-and-forth with the vendor, where it rarely feels like anyone wins.

I certainly don’t have the answers to this one, but would be interested to hear from readers on how their organizations are coping and whether they’re using any of the recently released data. What do you think of the new CMS reports? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/16/18

August 16, 2018 Dr. Jayne 1 Comment

CMS has posted a new presentation covering the proposed rule for the 2019 Medicare Physician Fee Schedule. For those who have not yet started to dig in for review, it’s a nice 35,000-foot summary of the E&M coding and virtual care pieces. Plus, it’s only 17 slides long, which might possibly make it the shortest document to come out of CMS in a long time.

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My fortune cookie revelations are usually pretty bland and I’ve never had my palm read. However, I wonder if my inbox is trying to predict my future. I had back-to-back emails about the best ways to onboard physicians from MGMA and the top 10 things to think about when you’re thinking of leaving your practice from AAFP’s Family Practice Management journal. It made me laugh, particularly because my current clinical situation is the best one I’ve ever worked in. The support team members are great, the owners are extremely supportive of my life in healthcare IT, and I feel energized and valued at the end of the day even when it’s been a very tough shift. I wish I had found that kind of clinical fulfillment earlier than halfway through my career, but I’m glad I found it when I did. Still, the documents were good advice, so I’ll tuck them into my consulting portfolio for the next client.

From Noteworthy: “Re: news. It’s amazing what passes for a news item in healthcare today. It’s not outcomes data, it’s not a new gamma knife offering, or even mobile mammograms — it’s vinyl flooring.”Actually, it’s both vinyl flooring and new blinds to give the practice greater “curb appeal.” The practice administrator is quoted regarding how important it is to have vinyl flooring in order to provide a clean environment for patients. Does that mean that their previous carpet provided a less than sanitary space before this week’s renovation reveal? Inquiring minds want to know. Perhaps I should pitch a new show to HGTV for renovating disastrously outdated physician offices. I’ve definitely seen more than my share.

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Earlier this week, Mr. H mentioned the phenomenon of medical students skipping classes and instead using YouTube videos and other resources to prepare for their licensing exams. There is a great comment posted by reader AndyWiesental, who details the non-content skills that physicians need to learn. The diagnostic process and how to determine the appropriate care for a given patient take time to learn, but despite the push for patient-centered care and individualized medicine, educational and quasi-regulatory bodies are still pushing us towards fact-based testing that quickly becomes obsolete. Board certification exams are a case in point, with questions such as “which of the following drugs is the most effective therapy for XYZ” where the answers are items that are 70, 72, 80, or 85 percent effective. In the world of in-the-trenches medicine, those numbers are not terribly relevant. It’s more complex than lab-based effectiveness; one needs to look at the cost vs. efficacy, tolerability and side effect profile, whether it’s on the insurance formulary, and more. And by the way, there’s a chance that a formerly-effective drug will be recalled, so all the numbers go out the window. It all depends on the patient sitting in front of you, as well as the statistics, and the way we are currently tested doesn’t take that into account.

I recently had a conversation with a physician as I was waiting for a plane, and we were lamenting the idea of recertification exams. His board is taking a more progressive approach and allowing more of an extended open-book format that demonstrates the ability to find knowledge rather than memorize factoids. That’s how we practice now, finding the best evidence through curated sources rather than trying to regurgitate what we learned to pass the exam. Although medical education is progressing, the students I work with tell me it’s not a lot different from when I was in school, just more high-tech. Where we recorded lectures on a cassette tape and had a classmate transcribe them, print them, and stuff them in our student mailboxes, today’s students view recorded videos of the lectures.

I once failed a medical microbiology exam because I actually learned the material and didn’t memorize the old test papers that my classmates circulated. When I sat for the exam, the questions were so poorly written that you often couldn’t tell what the correct answer was, with double negatives, multiple correct answers, typographical errors, and more. Yet, many of the members of the class scored 100 percent where a full third of us failed. The dean actually advised us to spend more time with the old tests and allowed us to retake it. With no studying but time spent memorizing questions, I aced it. Hopefully those days are long gone and we’re testing the ability of students to apply information rather than hoping they know the correct answer to the question about E. coli is D.

In response to Mr. H’s question: “If medical school education is vastly different from the content mastery required to pass Step exams, is either set of knowledge incorrect or are students expected to complete a self-managed, dual-track education?” In my experience the latter is correct. Students have to memorize the minutiae for certain, but it’s also often up to them to identify suitable mentors and clinicians whom they want to emulate, and try to learn how to be “that kind of doctor.” Some professors in academic settings aren’t the kind you want to copy, and it can be challenging to find opportunities to rotate with “regular” physicians in the community. There are similar issues in residency training, with some rotations being irrelevant to the trainee’s chosen career path. Statistically, only 17 percent of family physicians practice obstetrics, yet we’re all required to spend several months on rotation. I’d rather have had that time to take extra behavioral health rotations or emergency rotations since those were areas I was more likely to use in my planned future career.

Other rotations are woefully inadequate. My residency’s family medicine program ran a private practice clinic where we learned to code and bill and how to document, which are key for surviving in medicine today. We received productivity and utilization reports. By the time we were in the second half of the last year of residency, we were running full clinic days seeing a volume of patients equivalent to the faculty attending physicians, mostly in 15-minute visits. The internal medicine program ran a clinic where no one ever had to code or bill and every appointment was 30 or 60 minutes. Which trainees came out better equipped to succeed in practice? It was in those 15 minute slots that we learned how to prioritize patient issues and how to best use limited time and resources for individual patients. Of course, we’d all have preferred at the time to have the half-hour or hour slots that our peers did, but when we made it to the real world we were grateful, and our former classmates were shocked.

I’m coming up on a milestone reunion for medical school and it will be interesting to see where people have landed. Our class was an outlier, with nearly 10 percent of graduates not pursuing residency training. Some went to research, others to the pharmaceutical industry, a few to law school or business school, and a couple left medicine altogether. I’m definitely making a point to connect with some of my former classmates who are in academic settings, to see what they make of all of this.

Are you working at an educational institution? How does your employer support student learning? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/13/18

August 13, 2018 Dr. Jayne 1 Comment

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For many of us in healthcare IT, our primary arenas of work tend to fall within hospitals and health systems, ambulatory organizations, payers, and the vendor space. There are plenty of subdomains within each of those areas, such as tribal health, community health centers, post-acute care hospitals, rehabilitation facilities, and more. I had the chance this week to dig into a segment of healthcare IT that I haven’t done much work in – a university health center. This is the time of year that millions of students are making the leap from college to the university environment, and I was pleasantly surprised to see how digital health is playing out in that space.

At the university in question, students submit their health histories and physicals online via a secure patient portal, including immunization records. Given the volume of international students, the system has to be configured to accept different types of immunizations and offer enough patient-facing help features so that the incoming students understand what they are documenting and can fill out the online forms accurately. Copies of examinations and records can be submitted online, either through scans from the student or via secure email from transferring physicians. I was pleasantly surprised that there were no fax machines to be found at the facility.

Once the initial records come in, a member of the health center staff reviews them with a couple of areas of focus. Immunizations are first, because without them or a notarized waiver document, students can’t attend. Many of the students receive diphtheria and tetanus boosters prior to attending, along with meningitis vaccinations. When I began to think of the size of the entering class, plus the number of transfer students, times the number of doses administered, multiplied further by the cost of the vaccines, it was a large number representing a significant healthcare investment. If the immunizations don’t meet the requirements, a nurse reaches out directly to the student to discuss the issue, eliminating any back-and-forth related to misunderstanding of the questions or errors in documentation. Students are directed to resources to obtain needed vaccines, rather than simply being told they need to get them.

If the student’s documentation passes the immunization requirement, the file is routed electronically to a different part of the clinical team for a general review. Histories are screened for chronic conditions which may require care from the student health team beyond the routine conditions that people typically assume are cared for at a health center. I was impressed by the level of review given to some of the files – given some of the “medical miracles” we’ve seen over the last several decades, students are coming to college with fairly complex histories and specific medical needs. There is a special team to perform second-level review on these files, flagging students with conditions such as congenital heart disease (often following surgical intervention), transplants, cystic fibrosis, and more. Often the students have included their own supporting information that they wanted added to the file, whether it is a transfer of care summary from their pediatrician or a recent referral or consultation letter from a treating physician. It’s a testament to these doctors “back home” as well as to the families of these students that the necessary information is being supplied up front so that the best outcomes can be possible.

Since the patients (students) in this situation are voluntarily attending the institution, and many thousands of dollars are being spent, nearly everyone involved has a vested interest in making sure they stay healthy. Students are made aware of all the services the student health center offers – psychological counseling, preventive services, treatment for sexually transmitted infections, interventions for chemical dependency and eating disorders, screening for depression and intimate partner violence, and more. It reminded me of what many of my community health center clients are trying to do, but on a less-fragmented and better-funded platform. Of course, students are able to find a physician in the community if they choose, but with a team like this, who would want to?

The student health center is more than a walk-in clinic. It staffs a couple of beds where students can stay overnight for observation or delivery of IV fluids for fairly straightforward illness such as gastroenteritis or medications for conditions like acute migraine headaches. The physicians have referral arrangements with a group of hospitalists, which is happy to accept student patients when they have more complicated conditions like influenza, pneumonia, or the occasional appendicitis. They run a women’s health clinic and an orthopedic clinic. Given the presence of an athletic program with a notable football component, I was pleased to see they have a concussion clinic to not only follow up on symptoms and management, but to work with the patients’ academic advisors and professors to address any ongoing cognitive issues.

All of this is being managed in a state-of-the-art electronic health record, hooked up to the state HIE and also to Carequality. They’re routinely sending data to students’ home physicians of record and are electronically managing consents to make sure they can talk to parents when appropriate or to other members of the students’ support systems. The clinic is all about interoperability and coordination because they can be and want to be, not because they have to be. Since they’re not billing Medicare, Medicaid, or commercial payers, they’re not subject to a lot of the regulations and box-checking that the rest of us are. It made me think I was stepping back in time to pre-2009, back when health systems were embracing technology because it was the right thing to do, not because they were being forced to. There was a level of enthusiasm back then and in this practice now that I don’t typically see.

I’ll be working with these folks for a while and am excited about it, not only for the opportunity to see a well-oiled machine and not have to fix very much, but also because of the providers. They are happy and it seems legitimate. Maybe it’s because their systems are optimized, maybe it’s because they don’t have to bill insurance, and maybe it’s because most of their patients are young and healthy with fairly self-limited conditions. Regardless, it’s a good way to experience a different part of the healthcare space and see what pearls of wisdom I can find as I continue on my travels. I’d be interested to hear from student health informaticists – their challenges and opportunities. It’s certainly a bit of a different space for me, but I like it.

What’s your favorite college fight song? Leave a comment or email me.

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EPtalk by Dr. Jayne 8/9/18

August 9, 2018 Dr. Jayne 3 Comments

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Throughout my medical training, my early days in practice, and during countless go-lives, I’ve experienced some degree of sleep deprivation. I look forward to weekends when I’m not seeing patients and when I can sleep in, trying to (at least psychologically) catch up on all those “lost” hours. Today my hopes were dashed, with news that sleeping too much might be bad for one’s health. Researchers conducted their analysis using combined data from three million patients across numerous studies. They concluded that sleeping more than the recommended 8 hours can be associated with a higher rate of death. The study, published in the Journal of the American Heart Association, also proposes that poor sleep quality can be associated with cardiovascular disease.

Sleeping for 10 hours was linked to a 30 percent higher risk of death, where the nine-hour threshold was linked to a 14 percent higher risk. The National Sleep Foundation’s guidelines recommend 7-9 hours of sleep for most adults under age 65 and 7-8 hours for the retirement set. It’s not just about the number of hours, though – increased sleep can be associated with underlying chronic diseases that cause fatigue or increase sleep including thyroid dysfunction, anemia, depression, and other conditions. Decreased activity levels and unemployment can also negatively impact sleep, as can social, psychological, and environmental factors. The authors note that clinicians should further explore both duration and quality of sleep when assessing patients.

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I’ve been doing some work with an organization that is considering enhancements to its clinical decision support capabilities. They’re looking at adding some provider dashboards along with peer data transparency as a way to drive adoption of clinical protocols. A recent study looked at how well physicians adhere to guidelines for prescribing certain cholesterol-lowering drugs. The physicians who had visibility into the prescribing habits of their peers showed a significant increase in prescriptions for statin drugs. The authors designed the study to be outside the EHR in order to better measure its effect and to create an ideal design. They did note, though, that although use of dashboards can increase compliance with guideline-based prescribing activities, the dashboards “may need to be designed to better fit within clinician workflow.” They also surmised that there may be better response to communications from physician and practice leaders rather than from researchers.

More frequent reminders or provision of peer data may also make a difference. I worked with a startup a few years ago that used single sign-on (SSO) technology to make that kind of dashboard data visible for individual patients at the point of care, but they had some challenges with overall adoption of the SSO platform that effectively killed the patient-centric display of data. The authors also noted that their approach allowed for physicians to complete the intervention by prescribing medication outside of an office visit. They note the challenge that “physicians with larger patient panels may face difficulties managing these types of decisions outside of their traditional clinic model when they receive a long list of eligible patients at one time without additional support.” They conclude that there may be benefit in delivering regular feedback over a longer period and leveraging “multiple opportunities to address gaps in care for smaller subsets of patients.”

When I was reading the article, I was having flashbacks to the annual “report cards” that a couple of my insurance plans would send to my practice before the days of EHR. They’d have large lists of patients who were identified as missing services. They were created using only claims data, and since they were only sent out annually, there was a high likelihood that they were outdated. The arrival of the reports would send my staff into a mad scramble of chart-pulling and review, followed by outreach to patients to determine whether they had the services somewhere else, paid cash, or attended a free screening. If not, we’d arrange the services. If they did, we’d have to get copies of the data, update the charts, prepare a response to the payer, and get ready to start the cycle over again once the next payer’s packet arrived. Of course, there was no coordination between the cycle on which I received my reports and when my partner received his, or among payers, so it seemed like we were in a state of constant chart-pulling and review. Thinking back, I have to laugh – we could have completed the exercise in the EHR in a matter of hours rather than days, assuming we hadn’t already identified those gaps in care and acted on them ourselves.

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WalletHub released its list of “Best & Worst States for Health Care” this week. The analysis looked at 40 measures of cost, quality, and access across the 50 states and the District of Columbia. Vermont, Massachusetts, New Hampshire, Minnesota, and Hawaii led the list based on aggregate scores; North Carolina, Arkansas, Alaska, Mississippi, and Louisiana round out the bottom. My own state lands somewhere in the middle, which really doesn’t make me feel that much better. There are also lists looking at average monthly insurance premium cost, hospital beds per capita, physicians per capita, and more.

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I’m a sucker for healthcare IT-related headlines, even though they may be clickbait. I was drawn in by mention of a CMS call to put an end to physician office fax machines by 2020. CMS Administrator Seema Verma delivered this challenge as part of a push for digital health information, leading up to the Blue Button 2.0 Developer Conference that starts next week. There wasn’t much more meat on the bone here, but I was suckered into reading nevertheless.

I continue to see fax machines in most of the offices I visit, even those that are live on nationwide data-sharing platforms. It’s not just physician practices that are complicit in the continuing need for “faxes” even if they are generated and received electronically. I recently had a change in my pharmacy benefit manager, which requires that either my physician fax a prescription to them or that I mail in a paper document. I specifically asked about electronic prescribing and the phone agent said no – even though I know they accept it – so giving that message to patients is not helpful. I mentioned to the phone agent that when I order new contacts, I can send a photo of my script to the vendor to speed things along – no such luck for drug prescriptions. I guess I’ll wait the advertised 10-12 days until my script comes in.

When is the last time you used a fax machine? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/6/18

August 6, 2018 Dr. Jayne 1 Comment

The Atlantic recently ran a great piece that talks about why physicians should read fiction. It discusses a paper recently published in Literature and Medicine that suggests that working with literature can help physicians think more broadly and can help them better understand the situations their patients are facing.

My medical school was progressive in this regard, offering a writing elective for first-year students. We met with a member of the faculty who was also a writer and worked through both reading and writing exercises. Of course, we talked about famous physicians who were writers, such as Chekhov, but also had the opportunity to write about our experiences with medicine both personally and professionally.

Hot on the heels of some short story classes in college, I wrote a story about my grandfather’s having a heart attack and dying at a fairly young age. It was a challenge to think about it from a medical perspective and to try to link together some of the things that occurred prior his death, in the greater context of the disease that ultimately took him. I’m not much of a poet, but one of my classmates wrote some moving verse about her experiences in the neonatal intensive care unit. It was great to see a different side of my classmates, considering we spent most of our time competing for the scarce A grades our professors were willing to award.

In particular the paper, titled “Showing That Medical Ethics Cases Can Miss the Point,” talks about ethics cases that healthcare students might review as part of their coursework. The goal is for students to think how they might react in similar situations, and what different options they and their patients might have to choose from. The paper suggests that the case studies are lacking in style, and don’t include the nuances or tidbits that would help the characters come to life. Author Woods Nash feels the sparseness of the case studies might limit their ability to impact students. He uses examples to show the difference between a story that explains characters and their motivations and a dry ethics case that tries to boil the issues down to a minimum of words.

When Nash works with medical students, he assigns stories that the students have to try to distill to an ethics case study. The students then read each others’ work and talk about whether students make different assumptions about the situations or whether they include the same details in their respective write-ups. The point is to help students understand that style can influence how a case is perceived.

Nash told the Atlantic that case studies might need to fall by the wayside: “The real world is messy, of course, and ethics cases often teach us (implicitly) to clean up that mess by oversimplifying it.” He goes on to say that ethics cases “are themselves a byproduct and reflection of clinical practice’s overemphasis on efficiency. Not just in primary care, but in many areas of medicine, doctors spend far too little time really listening to patients and trying to appreciate the depths of their patients’ problems.”

As our healthcare system continues to press for efficiency, it makes it harder for physicians to listen to their patients. Market forces are driving physicians to only see the sickest patients, leveraging care teams including midlevel providers to deliver the more routine visits, including preventive visits. For younger patients, the preventive visit might represent the sole interaction with a physician each year.

As patients age, their needs increase and those visits become more frequent, resulting in the intensification of the patient-physician relationship. Of course, this assumes that the patient’s insurance hasn’t changed, they haven’t had to move to a different primary care physician, and that they’ve been able to maintain continuity. From experience, it’s much easier to advise a patient and his or her family on end-of-life issues if you’ve known them for some time and have been able to build that relationship. In the world of six-minute office visits, that’s a much taller order to try to fulfill.

The practice of medicine is messy and I’m glad to have come across authors who recognize that and can lead people through some of the challenges we face. A favorite author who is very good at this is Chris Bohjalian, whose book “Midwives” captivated me in medical school. The book deals with a particular medical scenario, where a midwife performs an emergency C-section on a patient who may not have been dead. It goes through the resulting legal issues and trial, and brings up a lot of questions about what happens in the heat of the moment when there is a medical emergency. I hadn’t read anything of his until recently, when I came across “The Double Bind.” It also has some medical overtones as well as being a good read.

Being in healthcare can lead many of us to question our own humanity. I don’t think it’s exclusive to people who are providers, but I think it starts to flow over to people in related fields such as healthcare IT and health policy. As we start to look more at populations and cohorts of people, will that lead us to stop thinking about individuals and their unique situations? Will we be more likely to treat the statistics rather than treating the patients in front of us?

As cool as I think big data is and how great it is to be able to look at population-based data, it’s hard to explain odds and statistics to families who want everything done for their loved ones despite insurmountable odds. Population health is great when it helps us reach patients who might not be receiving recommended preventive services or who are at risk for serious health conditions. The ability to protect patients and preserve health is amazing. At some point, however, population health technology might be used to identify people who are receiving what some might perceive are too many services or too many treatments given their age and condition. Where do we go from there?

I always ask myself whether I’m considering everything a patient is going through when they make what might initially seem like an unreasonable request. Are they just having a bad day, or is there something else going on? What else can we in the healing professions do to help? Those questions are difficult to contemplate in a short visit, but reading about similar experiences may help prime our brains so that we’re better prepared to address complex situations when they come our way. That’s the point of ethical case studies.

Are they as helpful as we think? Will they better prepare us for the challenges we face in healthcare? Does your organization use them? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/2/18

August 2, 2018 Dr. Jayne 3 Comments

From Captain Obvious: “Re: AMA policy advocating for EHR training in medical school. Seems like that horse has already left the barn.” Initially, I was surprised to see that it was just released in June 2018. It seems like something that should have come out way earlier, say back when regulators were cooking up Meaningful Use and other endeavors that would dramatically increase the use of EHRs. Reading a bit deeper, the AMA is alleging that some hospitals and training programs are restricting access to EHRs for students and trainees. That hasn’t been my experience in the local community, where so-called scut work continues to roll downhill to the students and lower-level trainees.

I do agree with the AMA that there are “concerns about the effects of the EHR on student and resident relationships with patients, in that students and residents may be more engaged with the chart and computer than with the patient.” It doesn’t sound like the EHR is restricted, though, if trainees are engaged with it. AMA asks that training include education on “institutional policy regarding copy and paste functions” as well.

AMA also goes on to state the obvious: “Students may receive poor role modeling from faculty, as well as from the entire care team, on appropriate use of and best practices for EHRs.” The document goes on to ask that training programs “provide EHR professional development resources for faculty to assure appropriate modeling of EHR use during physician/patient interactions.” Banging on keyboards and kicking computers on wheels is something I’ve seen more often I care to, so I certainly support that last bit.

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The Medical Board of California launches the first “license alert” mobile app. Rather than searching on the Board’s website to see if providers had new discipline notices on their licenses, the app can directly notify patients when changes are made. Suspensions can be communicated in a matter of hours to panels of patients, who are able to follow up to 16 providers at a time. The Board believes users will want to follow not only their own providers, but also those of close family members. Users will also receive notification of address or practice status changes as well as license expiration. The app is only available for Apple devices, but they do plan to deliver an Android version next year. I’d be game to just subscribe to my own updates, which I’ve been stalking on my State’s board for the last couple of weeks. Every time our practice opens a new site, it’s an adventure to get dozens of providers updated in a timely fashion and I always wonder whether I’m current.

Centene announces its intent to explore a joint Medicare Advantage plan with Ascension. They plan to target several US insurance markets by 2020, creating a “preferred model” for providers in the Ascension health system. Ascension is the largest non-profit health system in the US. The agreement is non-binding with approval required by the respective boards of directors, so there’s always a chance the wheels will fall off before it launches. No details were provided as far as how the plan would operate, how patients would join, any fees, or what would happen if patients need out-of-network care.

This week, CMS finalized three 2019 Medicare Prospective Payment System (PPS) rules, covering Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, and Inpatient Psychiatric Facilities. CMS cites them as victories in the battle for “Patients over Paperwork” along with reducing “unnecessary burden” and “easing documentation requirements” while “offering more flexibility.” The release reads like a game of buzzword bingo, and I honestly had to stop reading it before I lost my mind. I struggle to keep up with the ambulatory payment rules in depth and the inpatient payment rules at a high level. I applaud the people who are able to keep up with all the different rules covering all the different sites of care.

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A recently study presented at the American Society of Clinical Oncology meeting  looked at patient acceptance of genetic counseling using a remote platform compared to care in the community without genetic providers. Researchers hypothesized that remote access to specialists would increase access to genetic testing. The data did suggest that both telephone and video conference can improve adoption of genetic testing, although researchers note that a comparison of video vs. telephone modalities will be needed to identify the best way to drive outcomes. Having been through genetic counseling myself, I know there is a vast body of knowledge that I can’t begin to address as a primary care provider. Knowing how many people are taking advantage of consumer-oriented genetic testing, I’d rather see patients meet remotely with an expert than to be subjected to my efforts at ad-hoc research.

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As we are increasingly connected through technology and social media, it feels like there is a frenzy of competition for our time and attention. I’m not sure if it’s a direct reaction to that phenomenon, but I feel more frequently drawn to getting away where I can think without distraction and experience some of the wonderful things that our continent has to offer. Already in that frame of mind, I came across this piece from earlier this year where former Surgeon General Vivek Murthy talks about the level of loneliness that people are experiencing despite being “connected” 24-7. He recommends that we put down our phones and try to make actual face-to-face connections with the people that are important to us.

Researchers believe that feeling loneliness can be as harmful for health as smoking nearly a pack of cigarettes each day. Loneliness leads to stress and inflammation, which sets us up for illness. Although choosing to be alone is different than loneliness, it can still be risky. Murthy encourages us to “focus on rebuilding our connection with each other.” Having seen many families at airports this summer all staring at phones rather than talking to each other, I endorse his relatively straightforward prescription. Cigna released similar data in May – it’s worth a read.

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It’s hard to believe, but today marks my 800th post for HIStalk. It’s been an amazing privilege to be part of this team and to be able to put my finger on the pulse of healthcare IT. Thank you to all our readers and sponsors who help make it possible every week.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/30/18

July 30, 2018 Dr. Jayne No Comments

I have to admit I cracked a smile when I heard about the proposal to do away with so-called provider-based billing. I always found that term kind of humorous, since it’s actually hospital and provider billing rather than billing for the provider’s services. It’s always felt like a cash grab by hospitals, who snapped up physician practices and added facility fees without so much as changing a light bulb in the doctor’s office. Physicians who became hospital employees during this time often didn’t realize what they were getting into, only to begin to hear from angry patients who didn’t understand why they were receiving two bills for physician services that previously cost less.

It’s being referred to as “site neutrality,” which although accurate, doesn’t sound very sexy. Payment for a given service would be the same regardless of whether it’s delivered in a physician office or a clinic that’s considered an outpatient department of a hospital. Leveling this charge playing field has been discussed for the last several years; endorsed by Congress and the Medicare Payment Advisory Committee; and was been supported by previous administrations, although loopholes have allowed hospitals continue to take advantage of their cash cow by exempting existing outpatient departments from rate cuts.

Including hospital facility charges for basic outpatient visits serves to drive up costs for Medicare as well as patients. Hospital organizations try to justify the charges by explaining that they need to charge more in different ways to make up for shortfalls due to Medicaid cuts as well as money spent on charity care and to finance all the services that are on standby for patients.

The Hospital Outpatient Prospective Payment System rule released this week aims to end this grandfathering for certain services, including routine physician visits. This would result in hundreds of millions of dollars of savings for Medicare, and by extension, should save patients about $150 million through reduced co-payments. The proposal doesn’t touch most of the procedures where hospitals make a great deal of money, however.

It’s not surprising that hospitals are pushing back and litigation may follow. I enjoyed the Twitter thread that followed Farzad Mostashari’s post about it, with various health IT personalities weighing in on his thoughts. The rule also addresses some drug payment issues and promotes movement of services from inpatient facilities to outpatient settings. The hospital lobby is powerful and it’s not clear whether the rule will stay in its current form.

Of the physicians I’ve chatted with since the rule came out, many are ambivalent about the change. Most are employed physicians who didn’t see any increase in their compensation when their employers started charging facility fees, but they did have patient complaints and some lost patients to independent competitors who didn’t charge facility fees. They’re just happy they won’t have to deal with the negative aspects.

Some of the older physicians appreciated that it might help prolong the solvency of Medicare, allowing them to actually take advantage of it as patients. A few of the surgical subspecialists (who were almost universally independent) had no idea what provider-based billing even was, so that they didn’t have an opinion on site neutrality.

They did have an opinion, however, about the movement of services to outpatient facilities since several of them are involved with ambulatory surgery centers. Under the rule, there will be additional procedures payable at surgery centers along with language to ensure payment parity for ASC procedures using high-cost devices. The goal is to help ASCs be competitive, so it’s not surprising that the surgeons’ ears perked up.

I’ve been following along with the CMS campaign for “Patients Over Paperwork” and just saw the July newsletter. This edition was mostly focused on how CMS is trying to address burden in the context of skilled nursing facilities. There were several comments from stakeholders that were included and I appreciated their candor. One example: “Unfortunately, health care has evolved into this: head in a bed, payer, and a pulse – and that’s it. I think everybody has lost sight of the actual … care of the patient. Nobody really looks at that any more.” That sentiment is true at far too many places of service, not just nursing facilities. We’re violating the basics of what we learned in medical school, treating “the numbers” instead of the patients in front of us. We’re checking boxes and following rules and not truly getting to know our patients or how best to help them.

There were a couple of bright spots in the newsletter, although reading through the lines, they were a little bit tardy. One such bright spot was about simplifying documentation, although the example given was a bit of a slap and a kiss at the same time. CMS apparently updated certain payment rules for podiatrists, orthotists, and prosthetists. Now it is “allowing payment for therapeutic shoe inserts made with current technology.” You got it, folks – CMS required providers to take an actual impression of the patient’s foot for them to be paid rather than using the digital image technology that many foot specialists have been using for years. Why this took so long is baffling, and it makes my arches ache just thinking about it since I had my own orthotics created from a digital scan several years ago. I had no idea Medicare still required patients to step on pieces of foam in a cardboard box that was then mailed off to the lab. I’m sure there are mail carriers across the country that will be glad to not have to pick up the boxes at the practice’s front desk.

I hadn’t seen the newsletter previously, so I’ll have to keep an out for it moving forward. This is only the sixth issue, so I don’t feel too bad about having missed it. There is so much to keep in with in my inbox – a steady stream of government announcements, payer updates, drug recalls, and more. Then, there are the fun things such as reader mail, rumors, and industry gossip. And of course, there are the messages for my actual day job, which pays the bills but isn’t as fun as the former.

What’s your favorite part of your inbox? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/26/18

July 26, 2018 Dr. Jayne No Comments

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The American Medical Informatics Association announces the launch of its Fellowship program (FAMIA)  for recognition of professional achievement and leadership in applied informatics. The FAMIA designation will be inclusive, recognizing physicians, nurses, pharmacists, and others working in the realm of clinical informatics. Fellowship candidates must demonstrate eligibility in education, certification, experience, AMIA membership, and AMIA engagement as well as through peer recommendation and commitment to future activity in clinical informatics.

I’m qualified except for the AMIA “engagement” part. I wonder if being the anonymous face of clinical informatics for thousands of readers would qualify under the “other contribution by petition” category? Applications close September 3 and require a $200 application fee.

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New Medicare cards are on the way, with mailings complete in Delaware, the District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia. Patients in those states who haven’t received their cards can sign into www.MyMedicare.gov to confirm the mailing and print a card. I still get questions from practices that are confused about what to do when the new cards start coming in, so make sure your organization has a plan and that it’s well socialized.

Physicians who participated in the 2017 Merit-based Incentive Payment System (MIPS) program are now able to review their CMS-calculated scores and feedback reports. Penalties and incentives based on the data will impact Medicare payments for services rendered in 2019. Providers who have concerns about their performance data can request a targeted review from CMS. Common reasons for review include errors in data submission; physician eligibility issues; problems with the alternative payment model participation list; or issues with previous eligibility.

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For a long time, my laptop would give me trouble when I tried to use the camera during conference calls, so I got in the habit of not using it. It’s probably a good thing, since my work-at-home schedule sometimes involved prolonged wearing of pajamas, followed by workout clothes, followed by wet hair. I did get my camera issues resolved and have been trying to make a point of having more of my calls with video.

I’m always worried I will do something dumb because I’ve forgotten that I’m on camera, but I’ve seen enough botched video lately to know that I probably look good by comparison. This week’s highlight reel: a call with someone who immediately got up from the computer and walked away, but insisted he was there reading the materials I was showing; camera angles that gave me a great view of one client’s nasal passage; and my favorite – someone trying to take a call from his boat, resulting in plenty of squinting against the sun and ambient noise from seagulls.

I was glad I wasn’t on camera for one call (the client doesn’t do video, so I don’t feel obligated to do it, either) because I am not sure I could have kept a poker face after hearing this quote from a newly-minted VP of operations: “I assigned this to you because I didn’t know who else to give it to.” I’m betting it didn’t build confidence among his new direct reports, so we’ll be doing some coaching on that approach later.

I was recently asked to provide a reference for a former colleague as she looks for a new position. Her hospital was acquired by a large corporate organization and the entire IT team was cleaned out. She’s applying at one of the only hospitals in our region that is still independent. I was surprised to receive a web link from the hospital, leading me to provide the reference through a short survey. It didn’t appear to really provide a mechanism to provide a peer reference vs. an employer one and gave no opportunity for narrative comment. I was forced to choose “yes” or “no” to a “would you rehire?” question despite not having been her supervisor.

I suspect that the HR department involved is just using these “references” as a check-the-box step rather than using them for actual content. It’s unfortunate, because she was great to work with and I think she would be an asset to anyone, but didn’t have a mechanism to share that information.

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My office pre-books their order for flu vaccine as soon as our distributor will take it and requires all employees to receive vaccination as a condition of employment. Since we’re just about six weeks out from the start of the vaccination season, I was glad to see that the CDC’s Advisory Committee on Immunization Practices (ACIP) has included nasal flu vaccine in this year’s recommendations. There are quite a few people who are reluctant to have a shot but will accept the risk of a live (although modified) vaccine up their nose.

Last year’s flu season was particularly gruesome, and I hope we have an easier time this season. ACIP also delivered new guidelines on anthrax vaccine for post-exposure prophylaxis and updated recommendations on HPV, mumps, zoster, and pneumococcal vaccines. EHR vendors, start your engines – it’s time to update your logic. EHR clients should make sure they’re taking updates so that they have the best information available in their systems. I would estimate that more than half of the clients I work with don’t take regular updates to their systems unless they’re automatically applied in the background.

I was hanging out on a conference call the other day, waiting to figure out whether my client was just late or was going to no-show. I came across this site offering lab coats “for the perfect poise” that will ensure that “customers are enabled with confidence and grace through its sophisticated but classy appearance.” They ought to be pretty enabling since they start at $178 and run to $340. I found several other sites with pricey coats, and although they were more stylish than what I usually buy, given the things that are occasionally splashed on us at the office, I think I’ll stick with my $25 version.

I’m not sure whether it was worse for him to no-show or to have to endure the call I was on next, which featured an attendee who was doing the “I’m on two calls at once” routine but had the other call on speaker so that everyone else could hear it. Unfortunately I wasn’t the host and my client thought it was OK, so I was forced to play along. I still struggle to understand how someone can think they are able to meaningfully participate in two calls.

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Given challenges in staffing and an overall nursing shortage, one hospital has come up with an innovative solution for staff retention. Pediatric nurses at Mercy Children’s Hospital can opt for a “seasonal staffing” program that allows them to work nine months out of the year but maintain their full-time benefits while taking summers off. The move addresses low census issues during the summer while expanding time off to travel or care for children out of school for the summer. Hospital leaders also hope it will allow nurses to recharge and return to work with “excitement for nursing.”

Having grown up as the child of a teacher, there’s something to be said for being able to have family adventures when school is out for the summer, even if there’s a chance your mom might want to leave you at a scenic overlook because you’re a grumpy pre-teen.

What’s your favorite childhood vacation memory? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/23/18

July 23, 2018 Dr. Jayne 1 Comment

Every time CMS releases new proposed rules, I feel like the circus has come to town. The most recent offering includes 1,472 pages of bliss and is open for public comment until September 10.

I used to try to read them on my own, but found it too hard to get through them in a timely manner. I’m grateful to the people who have dedicated time to review and summarize them for the rest of us. It seems like most healthcare media outlets are trumpeting the “historic shift” for ambulatory Evaluation & Management (E&M) codes, so I decided to do a little deeper dive myself. Most recent federal proposals trumpet their aim to reduce administrative burdens, so I was curious whether they had truly found the “easy” button.

This document is a double whammy, addressing both the Medicare Physician Fee Schedule and the MACRA Quality Payment Program. There’s a whopping 0.13 percent increase in the fee schedule, which frankly I would rather have had them just keep it static than to try to explain various updates and adjustments. There are new G codes for preventive telehealth services that may be enticing for primary care physicians.

Our enthusiasm is curbed, though, by the continued insistence on EHR support for Appropriate Use Criteria for Advanced Diagnostic Imaging. That’s a measure that has been created, delayed, stayed, and revisited for the last several years and now will start in January 2020, with a year-long testing period but no enforcement. Providers can apply for hardship exceptions if they have poor Internet access, EHR vendor issues, or uncontrollable circumstances. CMS is relaxing a bit in allowing AUC tasks to be performed by ancillary personnel rather than requiring the provider to do the work, so that’s a good thing. It will be interesting to see how much of a difference the use of AUC really makes. In my market, we’re already well trained by commercial payers so that we don’t order tests that aren’t indicated.

The Accountable Care Organization programs received an update, with some measures being retired and a new one added. I didn’t spend too much time on the ACO part of the rule, since it’s expected that CMS will release a separate ACO regulation in the near future. I jumped to the part about outpatient E&M coding, which wasn’t as exciting as I expected. Providers will have the choice to document and code their visits based on the current schemes (formulated in 1995 and 1997) or through either a framework around time and medical necessity, or one around medical decision making. Rather than the distinct charges we have now for visits under the 99202-99205 and 99212-99215 codes, a blended rate is proposed.

Not surprisingly, there is a shift towards the lower end of the range rather than a shift towards the higher end, and for those of us used to performing and documenting high-level visits, it will be a cut. This may be made up for by the reduced documentation requirements, but for providers used to maximizing their use of macros, personal defaults, and templates, the perceived reduction in work isn’t going to make up for a more than 10 percent reduction in payments. If you’re not optimized on your EHR or don’t document efficiently, it may be a boon, but not for every practice.

As far as MACRA, MIPS, and the Quality Payment Program, CMS is just shuffling things around again. Advancing Care Information has been renamed Promoting Interoperability, and additional providers are being invited to the party: physical therapists, occupational therapists, clinical social workers, and clinical psychologists. From a quality perspective, all-cause readmission is being added as a measure for groups. Quality reporting will remain full-year, despite provider groups lobbying for a change.

Quality measures that CMS has identified as ineffective will be dropped, potentially saving physicians $2.3 million. Additional quality measures will be added, including four that address patient-reported outcomes. Reporting for Improvement Activities will be 90 days, however, along with Promoting Interoperability. Use of Certified EHR Technology that complies with the 2015 edition is mandatory. Within the Promoting Interoperability category, new elements are available for Prescription Drug Monitoring Program (PDMP) query, verification of an opioid treatment agreement, and expansion of electronic referral loops by receiving and incorporating information. Vendors will need to incorporate functionality to track and report on these elements, and I suspect that many do not currently have that capability.

Security Risk Analysis remains a required element. I continue to find practices that think that this is somehow the responsibility of their EHR vendor and who don’t understand that it’s the covered entity’s responsibility, with EHR vendor compliance being only one piece of it. Organizations are required to assess how they handle Protected Health Information in a variety of different settings, whether in person, on paper, on the phone, etc. which may or may not have anything to do with the EHR. If you don’t know your organization’s plan for Security Risk Analysis, it might be worth a discussion.

As was true previously, participation in an Advanced Alternate Payment Model such as an Accountable Care Organization means a practice doesn’t have to keep track of all the changes in the Merit-based Incentive Payment System (MIPS) model. The APM track is definitely where CMS wants providers to be, adding a 5 percent bonus for them. CMS is also pushing providers to be ready for programmatic updates on a regular timetable with its move to combine QPP with the Physician Fee Schedule. If this holds, providers can plan for updates to both in July and November instead of playing the waiting game.

Still, each time a new rule or proposed rule comes out, the chatter in the physician lounge increases. In my market, we’ve seen a number of established clinicians opt out of Medicare and even more choose to move to cash-based practices whether they involve retainer / concierge fees or not.

My practice remains firmly opted out of MIPS although we accept Medicare patients without restrictions. It remains to be seen whether there will come a time that the penalties outweigh the extra work that will be required to avoid them. So far, we’re diversified enough that it’s not an issue. As I work with practices that don’t have the luxury of non-participation, I’m thankful for that day a couple of years ago when we disabled the “Meaningful Use Content” checkbox and our lives got quite a bit easier.

Given the published comment period on this proposed rule and the typical CMS schedule, we’ll know in a couple of months whether any parts and pieces will be thrown out or modified. Based on this proposal compared to all the feedback that has been submitted on other proposed rules, I’d bet there aren’t too many material changes.

What is your take on the proposed rule for MPFS and QPP? Leave a comment or email me.

Email Dr. Jayne.

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