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EPtalk by Dr. Jayne 3/1/18

March 1, 2018 Dr. Jayne No Comments


The countdown to HIMSS18 is reaching its end and I’m in my final stages of preparation. I’ve developed some strategies over the years for making the meeting productive without being too exhausting. I was talking with a colleague who is attending his first HIMSS this year and he made the comment that what I was suggesting sounded a lot like the strategy he used when taking his small children to Disney World. I have a fondness for the chocolate-covered Mickey-shaped ice cream bar, but I don’t think I’ll be seeing any of those on the floor of the convention center. I guess I’ll (hopefully) have to settle for some fresh-baked scones.

My first general rule for HIMSS is to plan travel to arrive a day early if possible. This allows me to get settled in and possibly squeeze in a couple of social-style meetings on arrival day, such as a lunch or coffee, drinks, or dinner. It’s nice to be able to connect without all the hustle and bustle of the exhibit hall and sessions. It also makes it easier to meet with people that might have booth assignments during the show and who would otherwise be working the floor or too tired to get together.

I’m breaking my own rule this year for a couple of reasons. First, because we’re in Las Vegas, where the shift in the start/end times that happens when the meeting is there always throws a wrench in things. We also recently opened several new locations in my clinical world, so we’re a little thin on physician coverage and I have to see patients Sunday. I’ll be heading out before the sun arrives on Monday, though, so I should have time to meet with a couple of people and get settled.

My second general rule is to choose a hotel that doesn’t involve a significant commute, or if it does, that I’m OK with it. In the past, I’ve stayed at places that are a bit of a hike from the expo center, mostly due to cost, with varying degrees of shabbiness. I learned from experience in Orlando that you have to book early to get the hotel you want for the dates you want, so I book as soon as the room blocks open up.

The last time HIMSS was in Las Vegas, I stayed at TI due to closeness and cheapness, but I wasn’t thrilled with having to walk through the smoke to get to the elevator tower. This year I’m splurging and staying at the Venetian. I’m sure there will be smoke I’ll have to walk through, but the proximity to the meeting should be a bonus. I know Mr. H is a fan of staying off strip and you certainly can get more value for your money that way, but I don’t want to hassle with figuring out transportation. It’s kind of like staying on property at Disney – it’s more expensive, but it might just be worth it.

Planning what to wear always requires some thought, although this year I’m eerily relaxed because I don’t have to figure out what to wear for HIStalkapalooza or feel the pressure to find the perfect dancing shoes. The black cocktail dresses are staying at home, which also makes packing easier. I generally dress for exhibits and sessions in layers since the climate control at most convention centers ranges from arctic to subtropical. Since I’m not representing anyone other than myself (and HIStalk anonymously), I skip the suits and go for comfort. I’m not going to surf the hall in jeans, but I don’t think suits are mandatory. Unless you’re job interviewing, which a lot of people do at HIMSS.

Planning shoes is always a big deal and becomes more important as my feet get older. My favorite trade show shoes gave up the ghost last year, and despite having been comfortable for years, they became a liability because they were a little stretched out, resulting in blisters. This year is all about comfort, with some dressy clogs and cozy loafers. Usually I worry about being able to go day-to-night with whatever I’m wearing and throw an extra pair of shoes in my bag, but I’m hoping that being closer to the action will reduce the need to haul around a spare pair of shoes. If I get too tired, I’ll wear running shoes to the exhibits on Thursday, because by that point no one cares what you’re wearing.

Also like Disney, it’s important to plan what attractions (or booths in this case) are must-see, want-to-see, or just possibilities if there’s time remaining. As I hear about different vendors and products throughout the year, I keep a list of them and use it to create my HIMSS to-do list. I make appointments for the most critical things I want to see, but the rest are just drive-bys, partly to see how the booth team interacts with a random CMIO that walks in. I do also take a peek at all the mailings that arrive, to see if something catches my eye.

This year was slim on the mailings, with fewer than a dozen pieces arriving at the house. The Imprivata goodie box that I mentioned a few posts ago was an attention-grabber, but the rest of the mailings have been largely post cards, with only two of the “bring this to our booth and see if you’ve won” or “first 50 people to the booth get a prize” type of offerings. That’s way down from the past. Usually there is at least one vendor that sends a playing card or poker chip promotion when we’re in Las Vegas. Of course, that’s not to say that those mailings won’t arrive after I leave, which also happens. I typically find at least a handful of vendor marketing pieces in my held mail when I return.

Speaking of marketing pieces, the one mailing I received that really caught my attention is from a vendor that won’t be at HIMSS but didn’t acknowledge that in their mailing. Vendor advice: if you’re doing a mailing to launch a new product in February, you might want to mention “although you won’t see us at HIMSS this year, we’d love to hear from you, here’s how” or something similar. To not even acknowledge it makes you seem like you don’t know what’s going on in the industry. Even if you’re not a fan of HIMSS, it does exist and sucks up a lot of people’s attention.

My last piece of Disney advice is to be flexible. Sometimes you arrive to something you want to see and find a long line that you don’t want to deal with, There is no Fastpass available at HIMSS. Sometimes your attention is grabbed by an attraction you didn’t know existed and you rearrange to accommodate it. You never know what you’re going to see at HIMSS or who you’re going to run into, but there is always plenty to look at and learn.

I’m putting together my final lists today. I’ll see you in Las Vegas!

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/26/18

February 26, 2018 Dr. Jayne 1 Comment


I spent a good part of last week trying to help a client sort out their strategy for Patient-Centered Medical Home. The client is a mid- to large-sized multispecialty group, which started as a mostly primary care group that was forced to take on specialists as it acquired smaller multispecialty groups. They didn’t really think much about having to integrate the specialist documentation with the primary care documentation until they decided to enter into some risk-sharing contracts. They’re also trying to attest for just about every incentive program out there, including smaller, payer-centric contract bonuses, and trying to navigate from the older NCQA Patient-Centered Medical Home requirements to the redesigned program and are really struggling.

Their EHR vendor supports both primary care and specialty workflows, which are often siloed because of how the content was developed. For example, there’s a completely separate “urgent care module” that some of the primary care physicians have taken to using for the half days when they are assigned to see only acute patients. They like the separate module because the documentation is faster and easier than what they typically do for “regular” primary care patients, but the problem is that the data doesn’t always flow to the same tables used by the rest of the documentation screens. This is creating a problem with their Patient-Centered Medical Home reports, which were custom built by a third party that didn’t know the application and so only designed them to use data from a single workflow.

This isn’t the first EHR I’ve seen that works like this, with different pieces being built at different times and not being fully integrated with the rest of the application. In addition to the urgent care workflow, there are separate streams for documenting OB/GYN and GI procedures that account for integration with different ultrasound and imaging devices. This is frustrating to the client as well, since of course the supported devices aren’t the ones they use in their clinic. When they talked to the vendor about it, they were told that the specialty flows were built as contractual requirements for specific clients. When vendors enter into those kinds of agreements, it’s more likely to result in workflows that don’t necessarily meet the needs of the entire client base, but work well for a unique client.

As we began to dig deeper into the needs for Patient-Centered Medical Home, it became evident that the client had entered into some agreements that were going to cause challenges for designing an ideal documentation path. They recently agreed to work with embedded care managers from insurance companies, who will be documenting in two separate systems depending on the insurance coverage of patients selected for the care coordination program. The IT team decided that they would bring the documentation from those systems back into the client EHR as a PDF, which would then be inserted into the document management system. Of course, that means no discrete data and no availability for the Patient-Centered Medical Home reports to make use of the information that represents the work that has been performed.

Situations like this always lead to discussions of governance and a need for greater understanding of how this client’s situation evolved to put them in this place. The chief medical officer is apparently the one pushing the Patient-Centered Medical Home agenda, but the director of nursing lobbied the group to engage in the embedded care management programs. The nursing side of the house saw participation in the program as a way to get some flex on staffing since they were struggling with care management services, but didn’t understand the ramifications of having those coordinators documenting outside the EHR. To their credit, nursing worked with the IT team to make sure the patient contacts made through that program were represented in the EHR and IT found a relatively easy solution, but neither of those groups understood the impact on PCMH.

The CMO didn’t do a great job helping the rest of the team understand what was going on with Patient-Centered Medical Home and its requirements or that they were having customized reports created to meet those needs. IT wasn’t involved with the creation of the reports since the CMO outsourced them at a time when he perceived the IT team to be too busy implementing newly-acquired practices. And while the third party that built the reports did a great job creating really nice reports, they didn’t understand how the different specialties work together and just built what the CMO had described in a broad-strokes overview. It’s one of those situations where they built exactly what was requested but didn’t know that the request wasn’t completely formulated. As a result, IT is doing a lot of finger-pointing at the third party, which is defensive and doesn’t understand why their beautiful reports are being questioned.

The other wild card here is the group’s understanding of the redesigned Patient-Centered Medical Home program. They’re trying to make the transition from being at a low level of recognition under the previous program to being more robust participants in the new program, but haven’t identified sufficient resources to learn the new requirements and figure out how to mesh them together with what the group needs. They brought me in specifically to deal with the new requirements, but as is common with organizations like this that are trying to dive into many different pools at the same time, we’re peeling back the layers and finding out there are many more issues that need to be addressed.

My task for this week is to bring together the administrators and to lay out the various initiatives and how they interact and/or compete. The goal is to get them to prioritize which programs they want to lead with, along with getting them to all start moving in the same direction. No one has infinite resources and they’re not likely to be successful if they continue to try to do all of this at the same time and all of it in a way that is under-resourced and doesn’t really fit in with a long-term strategy.

Although it sounds easy to lock everyone in a room and lay things out, I’ll be particularly challenged by the fact that this group just came out of their annual strategic planning retreat and thinks they have a master plan and a strategy. Either these items weren’t discussed at the retreat (which I’d say makes it less than strategic) or they weren’t discussed in a way that had meaning for everyone and led to actionable decisions.

Sometimes these conversations can turn towards the consultant with a bit of hostility or there can be a lot of finger-pointing, so I’m readying my strategies to try to wrangle this meeting. I haven’t been working with them long enough to know if they’re open to some give and take, or it’s going to be a turf battle, or I’ll end up the bad guy. Consulting is like a box of chocolates – you never know what you’re going to get.

How does your organization prioritize initiatives? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/22/18

February 22, 2018 Dr. Jayne 2 Comments

The pre-HIMSS madness has started, with companies starting to churn out press releases that try to act very important but don’t actually say much. More than a few vendors save up even the smallest tidbits to try to release them for HIMSS, but miss the fact that their news is just going to get lost in the shuffle. The buzz words are out in full force, so for those of you playing along at home I offer up a HIMSS18 Buzzword Bingo card for your enjoyment:


Some vendors are sending out sneak peeks of what will be in their booths, but quite a few others are sending cold-call type emails that are sometimes registering as spam. One arrived today thanking me for my interest in a particular company and asking me to click to verify my email address. It was a mainstream vendor, so I didn’t think a lot about it, but on the other hand, it sounded more like phishing so I decided to take a pass. Vendors need to think twice about the wording in their messaging (or hire public relations people who will think about it) if they want to truly get attention and not be accused of spamming people.


Other vendors are going for the “wow factor,” with Imprivata shipping this HIMSS survival kit. In addition to protein bars and 5-hour energy shots, it has both plastic and metal water bottles, along with lip balm. The red survival kit has tissues, hand sanitizer, vitamin C supplements, and lollipops. The cutest part is the little black trinket stuck above the Imprivata logo – it’s a camera cover for your laptop, that slides to cover or reveal the lens depending on your needs. Usually I keep a piece of tape over my camera, but I’m going to test drive their slider and see how it does. I had some accidental camera exposure on a call several weeks ago, when I had to switch laptops at the last moment. It was one of those “crazy ponytail” days with an unmade hotel bed in the background, and the person I was talking to wondered why I covered my camera abruptly.

CMS announced its Annual Call for Measures for Eligible Hospitals and Critical Access Hospitals participating in Medicare EHR incentive programs. They’re looking for measures to be included for rules that are made during 2019 and would be optional in 2020 and required starting in 2021. CMS is looking for measures that build on Certified EHR Technology and increase interoperability, along with those that might improve program efficiency, effectiveness, and flexibility. Last on their list (although most clinicians might say it should be first) are measures that address patient outcomes and emphasize patient safety.

Much as there is increasing research into distracted driving, I’d like to propose some evaluation in the latter two categories that would look at distracted practicing. It’s increasingly hard to focus on the patient when you’re busy with data gathering, finding the right fields for documentation, and fielding clinical decision support popups. As systems become more sophisticated, I sometimes feel like I’m in the cockpit of a fighter jet rather than trying to care for patients.

CMS is also eager to find measures that would reduce reporting burden, avoid duplication of previous measures, and include an “emerging certified health IT functionality or capability.” It’s sexy to focus on new features, but how about allowing physicians to focus on the technology they already have and learn to use it well? I see numerous physicians who are underusing features such as order sets and clinical decision support, which should be able to drive clinical outcomes, reduce inappropriate ordering, and improve efficiency. They also tend to under use features that would make them not only more efficient but more satisfied with their systems, such as personalization features and individual preferences. Those features take time to set up on the front end but pay dividends on the back end, Shortsighted physicians who skip the pre-work wind up with many more clicks down the road.

Speaking of CMS programs, physicians continue to vote with their feet, not only opting out of the incentive programs, but by opting out of Medicare altogether. Based on data from the Provider Enrollment, Chain and Ownership System (PECOS) as of the end of the year, more than 16,000 physicians have filed affidavits to opt out of Medicare. The number was down in 2017 from a peak of more then 7,000 in 2016, but the overall trend is concerning. I recently received my letter from the Department of Health and Human Services detailing the penalty I’ll be taking this year. Since I’m in an employed situation and my practice isn’t participating in the incentive programs, there’s not much to be done. But if I were back in private practice, I might start thinking twice about CMS participation vs. moving to a practice that doesn’t have a payer-based compensation system. Nearly 40 percent of my residency class is now in practices that are either retainer-based or offer substantial savings through cash-only services.


I’m in a no-travel zone leading up to HIMSS, which I desperately need after my most recent travel experience. After a flight that included some turbulence that felt a bit like the prelude to astronaut training, I made it to my hotel and found this little guy in my bed. Fortunately I spied him (or her) right when I came through the door and not after I had gotten settled in. I’m not sure what it is (it seemed too large to be a bed bug and not quite the right shape), but I am waiting to hear back from an entomologist friend. Although the hotel was apologetic (and moved me to a top floor corner suite), it’s unsettling. I’m hoping the only living thing in my room at the Venetian is a CMIO with tired feet, although a plant would be OK too.

What’s the weirdest thing you’ve found in a hotel room? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/19/18

February 19, 2018 Dr. Jayne 2 Comments

From time to time, I contemplate heading back into the CMIO trenches full time. Although I do a lot of CMIO work in my consulting practice, it’s usually episodic and I miss seeing projects come full circle. I also miss being part of the strategic planning team, helping lay out the vision for an organization and how it plans to support patients and providers.

When I serve as an interim CMIO, I’m usually charged with keeping the ship afloat rather than deciding where the ship is going or what kind of cargo it will be carrying. Or perhaps I’m brought in as a consultant, tackling projects that the CMIO should be doing but doesn’t have the bandwidth to handle. There are some times where maybe the CMIO wants to do the project, but it’s politically charged and leadership feels having third-party assistance will help steer them through a rocky course. Those are challenging but often fun, although they can be stressful.

As I’ve talked to recruiters and looked at various job postings, I’m seeing some trends in CMIO job descriptions that I’m not sure I’m fond of. It might be a function of the duration clients have been using clinical systems, but I’m seeing more “maintenance” type job responsibilities and fewer “leadership” elements. Organizations are recruiting CMIOs to manage systems and data and people, but not necessarily for the ability to shape mission or to help architect strategies for delivering care in increasingly complex environments.

It feels like the role is being diminished somewhat, and the salaries are commensurate with that change. Of course, I have to remind myself that the positions I am looking at are sometimes in organizations that have struggled with even having a CMIO, let alone keeping one. If they were a great place to work and had found the right person, they wouldn’t have a vacancy.

Regardless of the situation, though, and the reason for the vacancy, it’s difficult to look at positions that are less C-suite and more director level, regardless of the title. Usually those positions have a salary range that is also less C-suite and more middle management. I recently spoke with a recruiter about a position with a salary range that was closer to that of a new graduate fresh out of residency than to an executive-level position, and certainly far less than one could earn in clinical practice. When asked about how they see the range as being supportive of the position, they mentioned that it was less than they pay their staff physicians “because it doesn’t have all the stress that comes with clinical medicine.”

When you hear comments like that, you know immediately that a position isn’t going to be a good fit. I would argue that anyone who thinks that being a CMIO is less stressful than other physician roles probably doesn’t understand what typically falls under a CMIO’s responsibility. I also didn’t like the fact that they were comparing the roles like that, because frankly being a physician is stressful and being an executive is stressful, but in different ways on different days. I don’t think that comparing stress levels across the organization as a means to justify salary shows that an organization is very progressive. It also highlights the risk that they might be in the habit of pitting various constituencies against each other in the hospital, which again is not a good sign.

I’m also struck by the lack of diversity in some organizations’ leadership profiles. At one organization, a large community health center that sees a very diverse population, the entire leadership team was composed of Caucasian males over age 55. I try to judge a potential job based on the job, but given the fact that I didn’t feel welcome during the interview, I didn’t think I’d feel welcome on the leadership team. Having grown up around many hunters and fishers and being fairly outdoorsy, I can talk hunting and fishing in a passable fashion, but it was nearly impossible to steer them away from conversations about who had the better deer lease and whether the wives would be coming to hunting camp this year or not. There were also conversations about how much money their stay-at-home spouses spent that were entirely inappropriate for an interview situation and made me concerned about how my potential peers viewed women in the workplace since none of the wives discussed work outside the home.

Another organization had an interviewer that asked me directly whether I had children. Although it was offered in a folksy tone under the banner of “help us get to know you,” it’s irrelevant to the job and role and was an immediate turn-off. It also said that this is an employer who doesn’t even understand the basics of employment law. As a seasoned people manager, that’s not something I want to sign up for. Given the desire of employees to have work-life balance along with the challenges of a graying society, rather than asking those kinds of questions, potential employers should be trumpeting whatever provisions they have in place to allow people to have children, build families, and participate in the care of aging family members.

Other organizations have been much more welcoming and have been proud to showcase provisions they have in place to keep their workforce healthy and productive. I’ve seen some fairly generous sick leave policies and concepts such as floating holidays to ensure that employees get time off on days that are significant to them and to their families. Vacation tends to still be a bit of a sticking point, though. Although I understand having people “earn” multiple weeks of vacation as they build tenure with a company, offering a senior-level applicant two weeks of vacation with the option to have a whopping three weeks of vacation after five years of service is a bit of a non-starter. We know the US lags behind the rest of the world with vacation days, and as a potential applicant who’s well established in the workforce, it’s a concern.

The issues I describe aren’t unique to finding CMIO positions and they apply to many other situations I see in the workplace. Potential employees want to feel valued and they want to feel like they’re moving to something better that offers more opportunity and/or rewards than their current situation. They don’t want to feel like they’re making a lateral move, let alone a downward move. I’ll be meeting up with some of my CMIO colleagues at HIMSS and will be interested to see how they feel about where they are in their careers or what the future holds. Until then, I’m off to the airport on my next adventure.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/15/18

February 15, 2018 Dr. Jayne 2 Comments

Lots of people are catching Olympic Fever. I’d much rather see that in the community than influenza. I’ve been catching some figure skating and snowboarding on the TVs in the patient rooms, which I much prefer to the omnipresent HGTV.

This Winter Games marks the debut of GE’s Athlete Management Solution, which sounds like a cross between an EHR and a clinical data repository with a side of SNOMED. GE Healthcare’s CTO noted, “Olympians train for many years to represent their nations at the games. Their Herculean efforts must be matched with superhuman clinical speed and quality.” I’d like to see some superhuman clinical speed in my own EHR, but would settle for seeing what GE has in store for both these games and those upcoming in Tokyo in 2020. If any readers are at GE, let me know if you can refer your favorite anonymous blogger for a demo.


Gallup and Sharecare recently released the “2017 State Well-Being” rankings. I’m not surprised that well-being is on the decline given the political turmoil we’re exposed to on a daily basis along with the pressures of social media and an unpredictable economy. No states showed a statistically significant improvement in the score, and 21 states experienced decreased well-being. The declines were driven by decreased numbers in social well-being and purpose along with the mental health aspects of physical well-being. The highest score was South Dakota with a 64.1 out of 100, followed by Vermont at 64.09. Louisiana and West Virginia rounded out the bottom. I’ll be taking a trip to the latter next summer and will let you know if the beauty of the New River Gorge improves my wellness and sense of purpose.

A reader asked me to further clarify my recent Curbside Consult comments regarding information blocking. In my travels, I frequently encounter major health systems that are guilty of information blocking, throwing up barriers in the way of patients who want to share their information. Examples include telling patients that outside physicians aren’t in the EHR directory for sharing records, refusing to send records by Direct protocol, citing HIPAA as a reason for not sending records to a consulting physician, failing to release specifically requested portions of the record, and downplaying the known interoperability features of their respective systems. Unaffiliated (read independent) providers are blocked from accessing clinical data repositories unless they sign cross-marketing agreements.

People are quick to blame EHR vendors for so-called information blocking, but in my experience, there are plenty of tools available but too many policies and procedures that discourage their use. I guess the theory is that if you make it harder for an independent consulting physician to receive your patient’s data, maybe the patient will be frustrated and choose an employed physician who documents on the shared hospital EHR, therefore solidifying the hospital’s market share.

Failing to accept labs sent from “outside providers” because of perceived compatibility issues and forcing patients to endure duplicate tests is also something I’m seeing more and more of as well. I’m proud to be an independent provider, but given my history in the world of big healthcare, I wish we could all just get along and put the patient at the center of what we do.


The Medicare Quality Payment Program attestation season is in full swing, with practices starting to realize that perhaps they weren’t as prepared as they thought. Organizations have until March 31 to submit their data for the 2017 calendar year reporting period. I’ve already gotten a couple of calls from organizations asking me to do the EHR equivalent of cooking the books, claiming that providers had the right information but just documented it in the wrong place in the EHR or maybe documented it incompletely. We’re 45 days into the new calendar year and I’m not about to manipulate someone’s database regardless of how well-intentioned they act or how much they beg.

The bottom line is that practices need to be monitoring their providers and their respective documentation habits (or lack thereof) throughout the year and catching problems early enough so that a mitigation plan can make a difference. I’ve had a couple of practices complain that their vendor didn’t have their 2017 measures packages ready at the beginning of the year, so they had nothing to run. I remind them that they could have kept running the 2016 packages to at least get an idea of the numbers since some of the measures didn’t change much, or that they can always create their own reports or use a third party to create interim reports. I know there are consultants out there that will help these clients massage their data, but I’m not eager to become one of them.


I spent Valentine’s Day with the good folks at the Marriott, but at least I had some time to read #healthpolicyvalentines and feel the love. This one from California ACEP is my favorite. I also want to give a shout out to Alexander Gaffney @AlecGaffney for sharing the best FDA labeling letter ever:

Misbranded Food:

  • Your Nashoba Granola and Whole Wheat Bread (wholesale and retail) products are misbranded within the meaning of section 403(i)(2) of the Act [21 U.S.C. § 343(i)(2)] because they are fabricated from two or more ingredients, but the labels fail to bear a complete list of all the ingredients by common or usual name in descending order of predominance by weight as well as all sub-ingredients, as required by 21 CFR 101.4. For example,
  • Your Nashoba Granola label lists ingredient “Love.” Ingredients required to be declared on the label or labeling of food must be listed by their common or usual name [21 CFR 101.4(a)(1). “Love” is not a common or usual name of an ingredient, and is considered to be intervening material because it is not part of the common or usual name of the ingredient.

There you have it, folks. Beware of foodstuffs made with love! In other news, chocolate is under scrutiny for its purported health benefits, with critics alleging bias through industry-funded studies. I see their point, but I do know that dark chocolate makes me smile, so I’m counting on it to help raise my personal well-being index.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/12/18

February 12, 2018 Dr. Jayne 1 Comment

I was heartened this week to see the American Academy of Family Physicians engaging with ONC in an attempt to “reduce clinician burden from health information technology.” AAFP has been meeting with CMS and ONC as part of the Patients over Paperwork initiative, and submitted what amounts to a wish list of items to discuss at a follow-up meeting later this month.

The letter opens with commentary about the regulations that physicians are subject to are “daunting and often demoralizing.” AAFP cites lack of standardization among payers, whether public or private, as a significant challenge.

The letter cites family physicians as possibility participating with 10 or more payers, which is a significantly smaller number than what we see in our community. In my family medicine heyday, I was contracted with nearly 35 payers, including Medicare and Medicaid for two states. Just the credentialing paperwork alone was mind-numbing, and the actual paperwork that needed completion to actually care for patients was soul-crushing. Every plan had a different pre-authorization form, certification process, and appeals framework. Although I was part of a large health system, my personal office staff spent a significant amount of time dealing with it since we had no centralized resources to assist.

AAFP refers to their wish list as “consensus principles on administrative simplification” and many of them seem like common sense measures. First, they call for CMS and ONC to work with Congress to reduce the reliance on healthcare IT usage measures. Their point is that programs such as MIPS are already measuring quality, cost, and practice improvement, so measuring the usage of IT systems is no longer necessary. AAFP calls for policies that mandate health IT use to be assessed to identify “evidence of benefit and burden in real-world practice prior to their implementation.”

I agree with this request wholeheartedly. Many of the requirements found in these programs seemed like a good idea to the people who designed them, but when they’re placed into practice, they fall flat. An example is the requirement that physicians send certain percentages of prescriptions electronically, including controlled substances. There was no corresponding requirement to mandate that pharmacies update their systems, resulting in delays for physicians who wanted to use the technology and frustration for those whose service areas didn’t have adequate pharmacy adoption. Requiring certain numbers to be met also doesn’t take into account the preference of certain patient populations who want a hard copy of the prescription to take with them.

Many of my older patients didn’t trust electronic prescribing or had experienced delays or misadventures with it previously, and simply wanted paper prescriptions. Even if I tried to e-prescribe and then print a backup copy for the patient, the way our EHR calculated the transactions, I would still be on the hook for a printed prescription. Meeting my patients’ needs and preferences for care put me at risk for a penalty, which just seems wrong.

One of the more hot-button requests in the AAFP letter is a request that the CMS Documentation Guidelines for Evaluation and Management Services (E&M Coding) be overhauled. It notes that, “adherence to E/M Documentation Guidelines consumes a significant amount of physician time and does not reflect the workflow of primary care physicians.” They cite the creation of the Guidelines for the paper world as being part of the problem, and that the Guidelines don’t take into account how EHRs support care and documentation.

They go as far as asking that guidelines for new and established office visits be eliminated for primary care physicians. That’s certainly a big ask and personally I don’t see it happening, but I’m glad they’re trying. I’d love to see the guidelines at least modified to allow for different types of documentation to “count” for coding points. For example, when my patients come in with rashes, I’d love to be able to drop in a couple of pictures of the rashes and call it a day rather than trying to find the right checkboxes to click to try to describe a rash in a way that may not convey what I saw. Under the current requirements, I can drop that photo in, but I still have to use words in order to get billing credit.

My favorite request in their list is a request that the Medicare Program Integrity Manual be updated “to allow medical information to be entered by any care team member related to a patient’s visit” and that it be changed across the board for all Medicare contractors, Medicaid programs, and private payers. We’ve been living in a world with arbitrary boundaries where staff can document the Review of Systems but not capture any History of Present Illness (HPI) data, even if the patient volunteers it. Of course, this is if your employer follows a strict interpretation of the rules, which many do. Other practices may allow staff to collect HPI data and have the rendering provider review it, which saves time and effort, but I see that less commonly.

The original E&M guidelines also don’t fully address the requirements of patient documentation when scribes are used, and whether documentation can be performed differently depending on the training and education of the scribe. For instance, if I have a registered nurse scribing for me, I may get more detailed documentation than if I have a less-trained scribe, because the nurse may pick up more specifics from my descriptions. A patient care technician might enter my statements verbatim (I often speak in lay terms to patients when I explain their exam findings) where a nurse may translate these descriptions to accepted medical terminology.

AAFP also calls on CMS and ONC to go after those who are guilty of information blocking. Administrators, listen up: when you’re ready to go after some major health systems, give me a call. They’re the biggest offenders in my metropolitan area and the EHR vendors don’t have anything to do with it. It’s all about controlling your referrals and managing your ACO and not about enabling patient choice or sharing of clinical data. Too bad there’s not a whistleblower clause since  maybe I could retire early.

The letter evokes the myth of interoperability, where many of us are exchanging reams of irrelevant information that we don’t have time to wade through. Even though I haven’t been a family physician for years, I still appear in many patients’ records and receive C-CDA documents on a frequent basis. Most of them are unintelligible, and one local hospital is guilty of including every medication the patient has ever been on, which I imagine makes medication reconciliation nearly impossible for the receiving party.

The letter notes the need for consistent data models created by clinicians rather than by legislators or software engineers. I deal with several EHR vendors that don’t even really have a data model of their own, which is amazing to me in this post-Meaningful Use age. When data comes in from another vendor, it creates a mess that is hard to sort out and adds considerable junk to the patient chart. It also notes the need to continue to harmonize clinical measures, so that physicians don’t have to report data that is similar but not identical to different payers.

Other factors mentioned should be no-brainers in this day and age, such as removing the need for physicians to fill out new forms for items like diabetic supplies when a patient switches brands. Especially if we are trying to allow patients to be empowered and make choices about cost of drugs and supplies, having to write for “WonderGlucose Harmonious Precision Extra” as opposed to “glucometer test strips” is silly.

The letter closes with a request for CMS and ONC to reach out to Steven Waldren, a family physician who is the Director of the Alliance for eHealth Innovation. I had a chance to meet Dr. Waldren a couple of years ago at HIMSS and he’s a knowledgeable physician with a good head on his shoulders. For some reason, however, I don’t suspect that his phone is ringing off the hook with regulators asking how they can help. I’m interested to see if other specialty organizations follow suit and whether we see any changes.

What would you do with your free time,should E&M coding be eliminated? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/8/18

February 8, 2018 Dr. Jayne 3 Comments


We’ve heard a lot of stories lately about people behaving badly (not to mention criminally), and frankly there are too many stories of harassment to count. The AMIA Board of Directors released a new anti-harassment policy that applies to future meetings. I was pleased to see that they called out the unacceptable behavior of “real or implied threat of professional or personal damage.” Fear of retaliation or professional retribution are powerful forces that keep people from reporting harassing and unprofessional behavior. Simply having a policy isn’t going to stop abusers, but it may make them think twice about their actions. Regardless, I’ve seen too many institutions sweep inappropriate behavior under the proverbial rug, so kudos to AMIA for providing leadership.

In the current climate, organizations need to get serious about educating their employees about problematic behaviors and reducing situations where harassment and abuse can occur. HIMSS is coming and it will be interesting to see if the parties are any less alcohol-fueled than in previous years. I was harassed by a vendor sales rep the last time HIMSS was in Las Vegas and didn’t say anything because I just wanted to get away from the situation and forget about it. Thinking back, I’m still disheartened that the other sales folk that witnessed it didn’t say anything either, because they were people I had known for many years. I’m hoping that both victims and witnesses are increasingly empowered to say something and make sure that abusers know their behavior is not OK.


Speaking of HIMSS, if you’re planning your wardrobe, too bad you can’t get a pair of Intel’s new Vaunt smart glasses yet. A worthy successor to Google Glass, they don’t look too different from typical spectacles. The main feature is retinal projection, which makes you feel like you’re looking at information on a screen. The glasses don’t have a speaker or a microphone, which saves on weight and adds more normalcy. An early access program will launch for developers later in the year. If they’re looking for any sassy physicians to give it a try, I’m definitely game.


I was beyond disappointed to hear of Jamie Dimon’s comments that walked back the Amazon, Berkshire Hathaway, and JPMorgan Chase healthcare venture. Apparently now it’s only going to be targeted to benefit employees of the three companies, and are sounding more like a group purchasing arrangement than the lofty endeavor we heard about last week. We need someone to shake up healthcare, but to do it in a way that includes a rational business plan rather than hype. I had hoped that these companies would be the real deal, but they’re already sounding like a fizzle.

In actual news that might help patients deal with the high cost of care, the FDA reports that 2017 was a record year for approval of generic drugs, with 843 medications receiving full approval. I haven’t seen any statistics on “formerly generic drugs that we let manufacturers re-brand and drive up the cost” such as Colcrys, but I’d like to see what that category looks like over the last several years. Despite a generic being available again after the three-year period of exclusivity for Colcrys, prices haven’t dropped anywhere near the historical price of generic colchicine. It was around 10 cents a pill prior to Colcrys, then went to $5 per pill, and even the generic still sits near $4 per pill ($2.50 if you can find a really good coupon). I get that it’s capitalism at its finest, but for patients, it’s terrible.

Even though we’re seeing a spike in flu cases, we have many patients coming in with severe illness because they’re trying to avoid medical costs. Patient deductibles reset on January 1, and with many more patients using high-deductible plans, cost of care is right in front of them rather than months later when the explanation of benefits arrives.

My practice’s cost of care is higher than it might be at a primary physician, but still significantly less than the emergency department, so patients are often pleasantly surprised at the end of their visit, especially if we’ve had to do a significant procedure such as a laceration repair or a CT scan. Our physicians are very conscious of our charges and how we fit into the overall healthcare expenditure scheme, so we can educate our patients as they make choices.

I wonder how many physicians truly understand how much the care they’re delivering costs and what value it does (or does not) bring. Every day I meet physicians who are having quality metrics data entered on their behalf and reported behind the scenes so they can check a box to avoid payment penalties. They have no idea what their actual numbers look like and aren’t using them to change how they deliver care. Now that is truly a waste of time, money, and effort.


The best thing I did this week was rearrange a meeting to be able to watch the Falcon Heavy live stream on Tuesday. Many kids dream of being an astronaut, but I took it one step farther and wanted to be the first doctor on a permanent space station. I figured by the time I finished medical school and residency, certainly we’d have civilians living and working in Earth’s orbit. That dream wasn’t to be, but I still find the idea of space travel fascinating. In some ways, my generation became somewhat spoiled by the seemingly “routine” nature of the Space Shuttle program even with its tragic accidents. Movies like “Apollo 13” and “Hidden Figures” gave us a new appreciation of what it took from a STEM perspective to make space travel possible. I still can’t believe we put people into orbit and later went to the moon with human computers and slide rules making it possible behind the scenes.

Hopefully a new generation of kids will be inspired by what they saw this week and will do some deeper digging. The Tesla may have been the first midnight-cherry roadster launched into space, but three other electric cars went before it on Apollo 15, 16, and 17. The story of our journey up to this point, both manned and unmanned, is inspiring. We need many more young people to be as fascinated by science and engineering as they are by pop culture and social media if we’re going to solve some of the biggest problems we’ll face in the next hundred years. If you didn’t have a chance to watch the launch, I highly recommend viewing the video, especially when the side boosters re-enter and land, starting around seven minutes into the flight.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/5/18

February 5, 2018 Dr. Jayne No Comments


I receive quite a few requests from readers wanting to pick my brain about various topics. This week brought questions about Apple’s new Health Records. There are concerns that patients can change or hide information, which makes them less reliable should patients want to show them to physicians. A reader asked what I thought about it.

Frankly, hiding or changing information is nothing new. Patient-provided medical records of the past (mostly from memory) can have dramatically variable reliability. Sometimes people don’t remember a procedure or lab they’ve had done or don’t think a piece of their history is relevant. Other times patients intentionally alter the facts, leaving out details that they think might negatively impact their interaction with the physician or that might make it into records for potential release.

One of the best examples of this is asking patients about their alcohol intake. In medical school, we often joked about the rule that whatever the patient says should be doubled. The advent of EHR documentation has forced our questions to be much more detailed, so it’s difficult to tell whether that still holds true.

Does asking for more detailed information make the data more reliable? Do patients just round down because they’re tired of answering so many detailed questions? I would be interesting to study, although I don’t see such an exercise being funded any time soon. Patients also tend to intentionally leave out other confidential information such as sexual history, drug use, incarceration, and more. This happened in the paper world, and whether it’s worse in the digital world or not remains to be seen.

Then there are situations where patients might want to remove information because it’s inaccurate. I’ve had it happen to me, where an erroneous diagnosis was entered into my chart. Once that happens, it becomes nearly impossible to remove it. I’m surprised by how many ambulatory organizations don’t have good records correction policies. As long as an audit trail exists, erroneous information that hasn’t been acted upon should be able to be removed from the chart in a way that it doesn’t continue to haunt the patient. Of course, it’s a different story of the erroneous information has been acted upon, and it might need to remain in the chart in a modified fashion to document a decision process or an adverse event.

In many instances, a patient-curated chart might be more accurate than some of what we inherit from other physicians, especially if the patient is engaged and has a high degree of health literacy.

In short, I don’t think the fact that Apple will let people edit their records is a big deal. I personally don’t see the app getting a huge amount of traction, but we’ll have to see what the coming months bring once people start downloading and using it.

Another reader wanted to pick my brain about why I still attend HIMSS. As the cost of attending continues to rise, it’s something I weigh each year. So far, the benefits continue to outweigh negatives, and as long as they do, I’ll likely attend. What do I find beneficial?

  • It’s an easy way to pick up 20 of the magical LLSA Credits that those of us who are board certified in clinical informatics need. Many of the sessions are actually relevant to what we do as informaticists, unlike some of the other LLSA-eligible coursework out there such as undersea / hyperbaric medicine and occupational health. Even though some of the sessions can be stale, there is often lively discussion and I’ve met a good number of people with similar interests in sessions that I correspond with.
  • Meeting people face-to-face is valuable and HIMSS is an easy place to do it. Many companies don’t send people to the conference and don’t exhibit, but they know that there is going to be a critical mass of people wherever the conference is held. Last year, I had at least a handful of vendor meetings with people who weren’t registered for HIMSS but came to town to do business. I was able to use the opportunity to make decisions on products and strategy for my clients.
  • Some of the less-flashy parts of the meeting are good opportunities to talk to people in the trenches. I spent a fair amount of time in the Interoperability Showcase over the last couple of years, talking with the people who actually build the solutions that are in the field. Once you get past the demos (which can range from engaging to lackluster), people are eager to talk about the work they’re doing and how it’s behaving in the real world. Presenters seem willing to talk about what they’ve seen go wrong as well as what has gone well, and that’s where real learning happens.
  • The exhibit hall, in its own crazed, deranged, over-the-top way. It’s interesting to see what companies decide to put front and center. Sometimes it’s something truly interesting, and sometimes it’s just a smokescreen for the fact that they really don’t have anything new to talk about. It’s a decent way to check out comparable products from different vendors without having to schedule people to come to the office, and to be able to go back and forth and make purchasing decisions. I did this a couple of years ago with workstation carts. The time it would have taken to try to do real comparisons while meeting with vendors in the hospital would have been untenable, but having all the competitors on the same show floor was a timesaver.

I have to admit, I have a love/hate relationship with the exhibit hall, though. The excess makes me nauseated, as do the reps that can’t engage and the companies that think prospects aren’t smart enough to figure out that they’re showing vaporware. I’m tired of the luxury cars, jet skis, and Vespas, yet I’m entertained by the magician. For someone who spends most of their day being cool, collected, and logical, the fact that it’s so overwhelmingly overdone makes me think in a different way. And then there’s the scones — can’t forget those for putting a smile on your face.

I also have a bit of a love/hate relationship with the parties and social activities, of course with the exception of the late HIStalkapalooza. I enjoy the networking and meeting new people and learning what’s going on elsewhere in the industry, but attending both as me and as my alter ego can be tricky. I think the kind of event that a company throws says a lot about their strategy and how they see themselves, as well as how they’re trying to position their products. Are they the wild and crazy party guys? Are they the quiet trip to the symphony? Are they the people that invite you and then un-invite you? If the latter happens, that’s a huge red flag for a company you do not want to do business with.

I do love some of the social media meet-ups, even though I attend incognito. It’s good to talk with people who face some of the same challenges that I face in writing every week and trying to keep things fresh in an industry that sometimes feels like it has a deadly undertow. There’s no one in my real life that I can talk to about blogging or how to navigate the industry.

Last but not least, HIMSS is the one time of year I get to see my HIStalk family. What we do is usually a solitary activity, so it’s great to be able to spend time together and get to know each other as people rather than just lobbing columns and articles and “hey, did you see this?” messages back and forth.

I’d like to see HIMSS dial it down a little and work on providing a better value proposition for more attendees, but I’m not too hopeful that they’re going to change the recipe (or the venues, for that matter, since we’re likely permanently locked into the Las Vegas-to-Orlando death march).

Now that my brain has been thoroughly picked, let’s hear from some readers. Why do you attend or not attend HIMSS? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/1/18

February 1, 2018 Dr. Jayne 1 Comment


Lots of chatter among my clinical colleagues about two main topics: Amazon getting deeper into the health space and the State of the Union address.

The Amazon topic definitely got a lot more traction, namely because of comments that the Amazon, Berkshire Hathaway, and JPMorgan Chase venture would be “free from profit-making incentives and constraints.” Many physicians blame the current healthcare crisis not only on hospitals trying to make a buck, but on payer executives focused on shareholder profits and their own career advancement. Healthcare industry stocks declined, including Express Scripts, CVS Health, and UnitedHealth Group.

The new company was also quoted as planning to center on “technology solutions that will provide US employees and their families with simplified, high-quality, and transparent healthcare at a reasonable cost.” There is an incredible amount of waste in our healthcare system, with estimates of up to 35 percent lost through several categories. Don Berwick broke the categories down in his 2012 piece on “Eliminating Waste in US Health Care” and I don’t know that they’ve changed significantly since then:

  • Clinical waste (14 percent). Could be improved with high-quality care, use of cost-effective treatments, or standardization of best practices.
  • Administrative complexity (9 percent). Could be improved through standardization of billing and collections, credentialing, and compliance.
  • Fraud and abuse (7 percent). Payments for services not provided or billed by deception.
  • Excessive prices (5 percent). Could be improved by tying prices to efficiency, outcomes, or fair profit.

There are some interesting findings in those numbers. Many of the laypeople I encounter assume that the entire problem with healthcare is with excessive prices, because they see the prices that hospitals and healthcare providers charge and the dramatic reductions through allowable charges and other adjustments. The higher “list” prices are often billed directly to patients without insurance if they don’t know to specifically request a cash price or adjustment.

Health-related businesses should be able to earn a fair profit, I don’t dispute that, but then there are the stories of price gouging, particularly in the drug industry. There are games that manufacturers play, such as purchasing a generic and finding a way to get a new patent so they can raise prices and control the market. Then there are unconscionable acts, such as grossly inflating the prices of medications that cost modest amounts to produce.

Those sources of waste, even coupled with the nefarious category of fraud and abuse, still pale in comparison to the losses via administrative complexity and clinical waste. I spent a good chunk of my clinical day trying to talk patients out of treatments they don’t need even though they think they do because they heard about them on TV or read about them in an article about “things your doctor doesn’t want you to know.” I also watch patients pay urgent care prices for treatments that should be performed in the primary care office, where they can’t get an appointment because we have a serious shortage of primary physicians in our community. I watch our practice spend incredible amounts of money on the billing and collections process, dealing with rejections, denials, and other attempts by payers not to actually pay. We experience these things on a daily basis while we work with patients who lack the resources to get the care they need. I can’t help but think the disconnect between waste and need contributes to the burnout that many of us feel.

When we hear that someone as upright as Warren Buffett wants to get into the fray, we can’t help but be hopeful. And despite what one may think about Amazon and their takeover of the marketplace, the company does seem to get things done and provide excellent service, which people crave. And when it sounds like they’re going to try to take down payers, which many of us find cocky and distasteful, that makes it even better.

The devil is in the details with an endeavor like this one, and it remains to be seen if they can make a difference where others have not been successful, or where they have failed to appreciate the complexity of healthcare economics.

Failure to grasp the complexity of healthcare leads us to the State of the Union address, where much was promised. Addressing drug prices will be a priority, with lowered costs and improved access to breakthrough drugs. Anytime someone talks about breakthrough drugs, many of us are skeptical – precision medicine sounds sexy, but the costs are substantial. The real savings may lie in figuring out to incent manufacturers of generic drugs and reducing the need for drugs through prevention and lifestyle change.

The State of the Union address also covered “right-to-try” legislation that would expand access for patients with terminal conditions so they can try experimental drugs that have not been approved by the FDA. It’s dramatic to talk about patients going “from country to country to seek a cure,” but in reality, the number of patients impacted by this would be much smaller than the number of patients who could benefit from basic, affordable healthcare. In some circles, right-to-try”is spoken of as cruel since treatments themselves may cause suffering with little promise of improvement. I’ve seen my colleagues in hospice care in tears while they care for patients and their families who have been given false hope.

The speech also touched on the need to address widespread opioid misuse. Since my practice just began a groundbreaking partnership with our local sheriff’s office to try to better support opioid addicts as they attempt rehab, I’m all for efforts to stop this serious epidemic. I don’t see big increases in government funding in the future, however. That’s one reason why our practice started this new protocol – addicts in our area have a high risk of relapsing before they can even make it to rehab because there are so few rehab beds available, and those that are open come with a great cost. We help bridge patients through opioid withdrawal while they try to stop using during their wait. The strategy has worked in other communities and we’re happy to bring our resources to bear.

There’s a lot going on in the industry today and frankly it’s been refreshing to hear providers talk about something other than how much they hate their EHRs and how much they think they’ve been meaningfully abused. I’m interested to hear what non-providers think about these recent developments.

Ready for Amazon to get in our business? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/29/18

January 29, 2018 Dr. Jayne 1 Comment


We talk quite a bit in the health IT world about efficiency strategies such as muscle memory, use of order sets, care plans, and team protocols. Those strategies and solutions are mandatory if you’re going to try to get through a day filled with dozens of patient encounters while keeping your sanity and trying to finish your documentation before you go home.

In my office, the clinical team works in an open area in the center of the clinical suite. Patient rooms, procedure rooms, the laboratory, and radiology areas are wrapped around the outside. In many ways it’s good, because you can see what’s going on with patients – whether they’ve gone to x-ray yet, whether they’re back from the restroom, etc.

In some ways it’s a challenge because you’re always “on stage” when patients walk by on their way to an exam room or another destination. You have to manage your own positive or negative energy in that situation, and avoid scowling at the EHR or expressing your frustration when patients roll in the door 10 minutes before closing time with a chief complaint they’ve had for weeks.

Our practice is a high-touch, high-service environment where we work hard to make patients feel that we appreciate their business and are invested in their well-being. You get used to wishing patients a “feel better” or “thanks for coming in” as they walk by on their way out.

At times, the muscle memory becomes a bit reflexive, though. My staff had some laughs at my expense this weekend. I was heads-down documenting and a couple of patients had gone by with the usual comments – “Thanks for coming in, we’ll call in a few days to check on you” and “Let us know if you’re not getting better” and so on. Another figure headed my way and I was on autopilot as I thanked him for coming in and said that I hope he feels better. He looked at me a little quizzically but smiled. As he went around the corner, my staff erupted in laughter — he was the evening pickup driver from the reference lab and I completely missed his uniform and the fact that I had not seen him in the exam room.

It was a good lesson that sometimes our quest for efficiency can blind us to the details of our day and that we have to stay vigilant to make sure we’re doing the amount of listening, data gathering, and synthesis of information that we really should be doing. Being on auto-pilot is not necessarily a good thing. I’m sure it’s not the first time the lab rep has encountered someone who commented as I did, but it certainly made me think twice about being more attentive as people are walking by the clinical work area.

The weekend was super busy and confirmed that influenza is not yet on the wane. We’ve had to temporarily shut down our online check-in system because of the patient volumes we’re seeing. The automation was allowing large queues to build without the ability to intervene. When we have people arrive at the office instead, we can let them know what the wait time is at their location as well as where the next-closest location with a shorter wait time might be. I have four days to recover before my next clinical shift, and after tonight, I definitely need it.


I’m starting to do my HIMSS planning and happened across this graphic along with encouragement from HIMSS for people to join in order to save on registration. Even with the “member discount,” HIMSS is still an expensive proposition, with some of the more convenient hotels that are close to the convention center being some of the most expensive. I’ve stayed in enough budget hotels that are hike from the convention center to have earned a little splurge this year, which should be good for trying to rest and refresh between the conference and evening activities.

I tried to eyeball the session schedule, partly in response to some teasers in the HIMSS18 Preview edition of Healthcare IT News. Unfortunately, the one session I wanted to put on my calendar was advertised as being on “Wednesday, March 8” which unless I’m missing something, isn’t a date on this year’s calendar. I searched for the session on both Wednesday the 7th and Thursday the 8th and couldn’t find it on either, leading me to believe that perhaps it’s in another space/time dimension.

I’m also starting to put my evening plans together and there are openings in the social schedule. If you are interested in having Team HIStalk drop by your event, send along an invitation. We register anonymously so you won’t know exactly whether Dr. Jayne or anyone else will be in the house, but we’ll be sure to mention your event in our daily HIMSS recap. If your event is open to HIStalk readers, let us know and we’ll include it on HIStalk as we prepare for the big show. I love meeting new people at events and hearing their impression of HIMSS and the industry as a whole. Plus, I’ve got some new dancing shoes and am looking forward to being out on the town.

One of my medical school classmates reached out to me over the weekend knowing I’m in touch with the EHR industry. He’s trying to figure out how to attach his practice to the class action suit that was filed against Allscripts, alleging that the company “intentionally, willfully, recklessly, and/or negligently” failed to take precautions to prevent or minimize the recent SamSam ransomware attack. The filing is actually an interesting read and provides a primer on ransomware and previous similar attacks.

I explained to my colleague how a filing is laid out and that the responsible attorney is listed at the end. I’m not sure how serious he is about joining the Class or getting involved, but if he does and provides updates, I’ll certainly pass them along. Allscripts has tens of thousands of physicians using its platforms, but it’s unclear how many of them were on the impacted systems.

Are you ready for a ransomware attack? If not, why? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/25/18

January 25, 2018 Dr. Jayne 1 Comment


The hot topic of conversation around the physician lounge this morning was the Apple announcement about integrating EHR records into its Health app beginning with the iOS 11.3 beta. My physician colleagues are almost universally iPhone users, with many having Apple watches. There are some big-name hospitals and health centers involved, including Johns Hopkins Medicine, Rush University Medical Center, and Cedars-Sinai. There are a number of tantalizing articles about the solution, promising that records from different organizations will be integrated into a single view. It sounds largely like C-CDA data, including allergies, medications, diagnoses / problems, immunizations, lab results, procedures, and vitals. I didn’t see any mention of visit notes or diagnostic testing reports.

Apple’s COO Jeff Williams said that, “By empowering customers to see their overall health, we hope to help customers better understand their health and help them lead healthier lives.” Speaking as a clinician, there’s a significant leap between viewing data elements and truly understanding how they relate to overall health. It will be interesting to see how Apple displays laboratory results, including flagging and trending – it’s hard to tell from the screenshots I’ve seen. Hopefully they’ll integrate educational resources either from the patient portals they’re pulling data from or from other reputable sources.

I agree that having health data on your iPhone might be a tool to make people aware of what’s in their medical charts, but many patients are going to need time with a clinician, health coach, or other health advocate to make sense of some of it. Clinicians beware: many more patients may be seeing their data, so it’s time to get those diagnoses and medication lists cleaned up.


Just when you think things can’t get any wilder with CMS, some portion of a rule or requirement jumps up to remind you there is always something more mind-numbingly tedious on the horizon for clinicians. This time it’s the CMS Patient Relationship Categories and Codes, created under the CMS Quality Payment Program. Although CMS frequently says it aims to “minimize the burden of participation” and to enhance “clinician experience through flexible and transparent program design and interactions with easy-to-use program tools,” they always seem to come up with something that adds clicks to our workflows with questionable return on investment.

Flying in under the MACRA radar was a subsection on “Collaborating with the Physician, Practitioner, and Other Stakeholder Communities to Improve Resource User Measurement,” which mandates the creation and use of new sets of codes to be attached to claims. There are care episode and patient condition groups and codes, along with patient relationship categories and codes designed to enable attribution of patients and episodes of care to clinicians acting in different roles. This all boils down to helping further assess the cost of care.

The MACRA legislation requires CMS to create a process with clinician and other stakeholders to review proposed codes. The draft list of patient relationship categories and codes was posted on the CMS website in April 2016 and opened to public comment. Clinicians were to be categorized based on their relationship to the patient. Initially there were five groups of clinicians in three relationship categories, broken down by whether they were acute or continuing care, whether they were primary or specialty care, or whether a consulting provider was involved.

Additional comments were solicited in December 2016 with an update to the categories:

i. Continuous/Broad relationship, namely primary care providers in continuity

ii. Continuous / Focused relationship, namely subspecialists caring for chronic conditions

iii. Episodic / Broad relationship, including physicians caring for a broad spectrum of conditions for a short period, such as hospitalists

iv. Episodic / Focused relationship, including specialists caring for time-limited conditions

v. Only as ordered by another clinician, including reading radiologists

The codes were to be operationalized using CPT modifiers, and discussions are ongoing as far as how clinicians should be preparing to use them on Medicare claims. Originally the codes were supposed to be mandated on claims after January 1, 2018, but I’ve heard very little about them until recently. The last update I could find from CMS was from November 2017 and it notes that use of the codes is voluntary, with CMS saying “We anticipate that there will be a learning curve with respect to the use of these modifiers, and we will work with clinicians to ensure their proper use.”

I’m not finding a lot of communication from CMS about the codes to help me with my learning curve, but there’s always a possibility I missed it among the dozens if not hundreds of requirements that physicians are trying to keep track of. I also haven’t received any communication from my EHR vendor as far as classes to learn the workflow to apply the codes and they’re usually very much on top of things like this. Even Google didn’t bring back many current results for something that supposedly went into use less than a month ago.

Regardless, I think many physicians have become so inundated with requirements, reporting, and regulations that they start to tune things out. I’ll have to start keeping an eye out for additional instructions. As an urgent care physician in a market that’s short on primary care physicians, I tend to perform services that fall into all of the categories. We’ll have to see when our EHR is ready to handle the new codes and what the real implementation timeline looks like.

I’m heading to the clinical trenches for the next three days, in a state with some of the highest influenza rates in the nation. Normally I truly look forward to my patient care days, but I’m dreading this schedule block a bit. I’ll be doing all the handwashing and cough-avoidance that I can and am considering spending the day with a mask on. It’s not an ideal way to see patients, but when 60 percent of the patients coming through the door are there because of flu-like symptoms, it might be worth the inconvenience. We’ve had several of our physicians and quite a few staff end up with the flu, and the recovery times have been long.

Here’s to staying healthy as long as you can, or at least until the influenza surge breaks. Got flu? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/22/18

January 22, 2018 Dr. Jayne 2 Comments


I had several people calling me over the last couple of days, wanting to talk about the recent Allscripts ransomware issue. A couple wanted my advice on protecting themselves, even though they use different vendors and have different system configurations. I have some good friends who spend the majority of their time during security risk analysis and white-hat hacking, so was happy to hand them over to the experts. One was a physician liaison at my former hospital, who wondered if I would write a guest column for their newsletter to help community physicians be more aware of the risks of ransomware. Their deadline is a couple of weeks out, so I’m happy to help.

Another was from a friend who uses Allscripts and wasn’t sure if her practice was impacted or not, so I got to explain the difference between being self-hosted and vendor-hosted. It sounds like her system is self-hosted but connected to vendor-hosted subsystems that have been impacted. For the most part she was just glad that she could see her charts and also glad to have “someone who speaks IT and can translate” available. She had been getting emails from her practice that included language forwarded from Allscripts that didn’t meet the need for understanding.

I also received a call from a former colleague who now works for a vendor and who “just wanted to catch up.” The call quickly turned into the most glaring example of schadenfreude I’ve seen in a long time. He went on and on about how this is going to be the death knell for Allscripts and how he was going to hit his territory hard and try to make sales. I had to remind him that his company has had its own share of issues, not necessarily with ransomware, but with outages on its own hosting platform.

There is plenty of quicksand for any vendor to land in, and sometimes I think only dumb luck prevents vendors from falling into the pit. Not to mention, going into a practice that has been impacted by a major outage and trying to sell a replacement system might not be a good idea in the short term. The proverbial corpse isn’t even cold and practices are still down, so a little patience and respect might be in order.

I have always preferred vendors who sell their products based on their own merits rather than by tearing down their competitors. Trying to make a purchaser feel bad about their current vendor calls into question their past decision-making and isn’t a way to win friends, in my book. Outages aside, every system has flaws and there isn’t one perfect solution out there. For every rock-solid feature, it seems like there’s something clunky hiding in the background to haunt you after you’ve already signed the contract. EHRs aren’t different from any other technology. As features evolve, sometimes they hit the mark and sometimes they don’t. It’s like buying a car – there’s always something you miss from your old car, or something you didn’t find on the test drive that becomes a daily annoyance.

I feel bad for the hosted physicians who are having to deal with the consequences of the ransomware and are being told to plan to be down on Monday. Although Allscripts is working on a read-only solution, it’s not clear how they’re going to deploy it or what it will include. This should be a wake-up call to physicians and hospitals and a good prompt to review their downtime solutions and maybe even give them a test. At my practice, we have monthly reviews of the downtime process and site leads have to check weekly that their downtime supplies are ready to go, but despite the preparations it’s always at least a minimum level of mayhem when downtime hits. The reality is that although ransomware and hacking get the spotlight, the majority of downtime events have more conventional or mechanical causes.

I’ve personally been the victim of the guy with the backhoe that cuts the fiber, the guy who accidentally triggers the Halon fire suppression system, and the lady who crashed into the data center and knocked out the electrical transformer. There’s also the winter storm that took down power lines, the system that froze because the server was out of memory, and the person who triggered a giant report to run against the production server in the middle of the day. Any one of those issues can make a system unusable and lead to a downtime event.

In my career at Big Health System, we had a utility that created a “lite” version of charts each night, sending records for all the patients in my panel to a local desktop. The lite chart basically contained the medication list, allergies, diagnosis list, and six months’ worth of laboratory and radiology data. It didn’t include scanned documents, but was enough to field a patient’s phone call. The utility also sent a “full” version of the chart for each patient scheduled for an appointment in the next 72 hours, which included the lite chart plus six months’ of chart notes and scanned documents from the laboratory, radiology, and consults filing structure. Theoretically, that would be enough to get one through an office visit with enough essential information.

That solution was great for a network outage but not for a power outage, so we had to make sure we had a fully-charged laptop with either a wireless modem or the ability to tether to a cell phone in the event that we lost power. The belt-and-suspenders coverage provided by this combination served us well through a variety of challenging situations. Of course, we also had a full disaster recovery plan, with distant servers and near-real-time fail-over processes, but thankfully I only had to experience that situation a couple of times.

Not every practice is fortunate enough to have staff dedicated to ensuring a smooth downtime. Still, you’d think with all the natural disasters we’ve seen in the past two years, that people would be doing a better job of it. I look forward to the day when I no longer hear about a practice whose only downtime preparation includes some photocopied visit note forms and a hope that someone printed a copy of the patient schedule before they went home last night.

For vendors servicing smaller practices, offering services to help clients put together a solid downtime plan would be great. I’d be interested to hear what vendors offer support for that type of a solution, and what other organizations small practices look to for downtime advice.

In the short term, however, I’m wishing the best to my colleagues on Allscripts. I hope the outage is short lived and your sanity makes it through mostly intact.

Have you been impacted by ransomware? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/18/18

January 18, 2018 Dr. Jayne No Comments


The US News & World Report “Best Health Care Jobs” list is out, with a confusing Top 10 that illustrates how the list has become irrelevant. Pediatrician and obstetrician / gynecologist are ranked separately from physician in the top 10, and looking into the top 25, we find that anesthesiologist, surgeon, and psychiatrist are also separated out. Perhaps they’re confusing “physician” with “primary care physician,” but that doesn’t make sense with the separation of pediatrician.

Regardless of how you slice and dice the MDs and DOs, the physician assistants and nurse practitioners beat us at #2 and #3, respectively. Topping the list was dentist.

Even if you go into the “Best Health Care Support Jobs” list you don’t find healthcare IT folk, which is sad since I think we have some of the best jobs in the business. We get to play a key role in supporting all the other healthcare jobs and figuring out ways to get them the information they need to do their jobs better. We also keep the time and attendance systems running to ensure people get scheduled, the payroll systems up to ensure they get paid, the learning management systems available to train, the drug cabinets dispensing, and the equipment tracking and bed board systems running, not to mention the countless other systems we support. Here’s to healthcare IT!


The hot topic around the physicians lounge this morning was the President’s recent physical. Everyone had an opinion despite not having examined the patient. There was quite a bit of debate about the inclusion of cognitive testing, which isn’t part of a traditional examination of the President. The Montreal Cognitive Assessment was administered, and as of Wednesday afternoon, the website was down with a message that it was “under maintenance.”

It would be simplistic to say that passing that test means someone has ideal mental health. It screens for mild cognitive dysfunction, looking at memory, attention, and other processes. It doesn’t screen for depression, anxiety, personality disorders, or a host of other conditions that fall under the spectrum of mental health. Focusing on this test as a sole marker of mental health does a tremendous disservice to the many patients who face mental health issues every day.

There was also quite a bit of discussion regarding Eric Topol, Sanjay Gupta, and their curbside reviews of the released Presidential cardiovascular data. There was much debate about the definition of “excellent” health as mentioned by the Navy physician. I don’t know anything about the physician who performed the examination and his usual patient population, but I know that many of us in the trenches (and anyone who has been sued) tend to avoid such superlative terms when speaking with or about patients. We’re more likely to say someone’s values are within established guidelines or are within the published normal range, or to say they have average risk based on their history and physical, than we are to say someone is in “excellent” health. I haven’t seen physicians be so passionate about a “checkup” in a long time, but I doubt it’s going to lead to a boom in primary care careers.


Props to ONC for its new handout (which it refers to as a graphic novel) outlining how sharing medical information can help care teams make better decisions, and how not sharing information can lead to negative outcomes. It uses the example of someone in substance abuse recovery who might end up being prescribed opioid pain medication, which is a real-world scenario that I see often in my line of work. As much as many of us complain about ONC, their efforts in this situation are appreciated.


AMIA has issued a Call for Participation for its 2018 Annual Symposium, to be held November 3-7, 2018 in San Francisco. This year’s overall theme is “Data, Technology, and Innovation for Better Health” and submissions close March 8. AMIA seems to love San Francisco, Washington, DC, and Chicago for conferences. For those of us on limited conference budgets, how about some variety venues such as Denver, San Diego, Dallas, or Atlanta? Most of those have pretty decent weather in November.

Weird news of the day: BMJ Case Reports documents a situation where a man who tried to hold in a sneeze ended up with a perforated throat. Since sneezes can propel droplets at over 100 miles per hour, I appreciate his willingness to keep it to himself. He probably would have been better off sneezing into a tissue or into his elbow if no other alternatives were available. Blocking a high-pressure sneeze can also result in damage to the ear drums and pulled muscles.

A reader reached out in response to my recent ponderings around Epic’s Share Everywhere. It went live recently for patients at UCSF. I asked whether there are any patient case stories yet, but haven’t had a chance to hear back. Several of the hospitals in my area use Epic, but I haven’t heard of any recent upgrades. I’m heading back to the clinical trenches this weekend and will remain hopeful that a patient will roll in, give me a token, and grant access to a wealth of medical records.

That’s more of a pipe dream, as is the hope that the regional influenza peak will start winding down. Our patient volumes continue to be more than double what they usually run, so staff is really getting worn down and we’re ready for some relief. There were thousands of new cases of flu across the state this week, which is roughly 20 percent of the cases reported this season, so I’m not thinking we’ve hit peak yet. Just short of 700 people in our state have died of influenza this season and several colleagues are reaching out to patients asking them to cancel office visits if they have flu-like symptoms.

Good luck to everyone as you try to stay healthy and avoid influenza – wash your hands, avoid crowds, and cover your cough, but don’t stifle your sneeze.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/15/18

January 15, 2018 Dr. Jayne 1 Comment


Wintery weather has snarled my travel plans somewhat. I’ve been feeling a bit like the characters in “Planes, Trains, and Automobiles” having to cobble together various arrangements to get from point A to point B.

My laugh of the trip occurred after dealing with a canceled flight from Chicago’s Midway Airport. Fortunately, I was able to quickly book a rental car, then grabbed some caffeine at a local restaurant and headed on my way. Since I was in a hurry to get ahead of traffic, I didn’t look at my receipt in detail until I was several hours away, snug in my hotel and working on my expense report. Apparently Diet Coke is now a “sweetened beverage,” at least according to this charge under the Cook County Sweetened Beverage Tax. I did a quick Internet search to see if it applied to all soda or just drinks with sugar and found out that the tax has been repealed and actually expired December 1, 2017. I guess a software update is in order for this point of sale system.

I was immediately missing my other clients who are located in warmer climates, but enjoyed working with a new chief medical officer who wanted an independent opinion of his hospital’s long-range plan. It was a good change to be able to do some forward-looking work rather than the clean-up and troubleshooting involved in some of my engagements.

As more seasoned physicians retire, I’m seeing younger physicians move into leadership positions. These newly-minted leaders may have MBAs or MHAs, but not a lot of experience managing their peers, especially if those colleagues have been on staff for a long time. Larger organizations may have resources in place to mentor these physicians, but others hope they’ll just grow organically into what the hospital needs. I’ve been through enough formal leadership development exercises to know that the skills they will need aren’t going to just appear overnight.

Various organizations including EHR vendors offer “boot camp” programs for new medical leaders. The ones I know of are pretty solid programs, but some of them are expensive and might be only offered once a year. They are generally a couple of days of intense meetings and quite a bit of instruction.

For a new medical leader, it can be a bit like drinking from the proverbial fire hose. Then, when you return to your day job, it can be hard to try to apply some of the strategic concepts that you were presented with when you’re struggling with day-to-day issues. You might also be trying to learn the EHR systems while building a clinical practice. You may also have to figure out the best way to deal with colleagues who are looking to possibly manipulate new leadership into giving in to their demands. We’ve all heard stories of medical members that set upon a new chief of staff or chief medical officer and try to convince him or her that the EHR is the root of all evil and needs to be replaced. Some dive in and investigate before coming to their own conclusions, and others take reports of widespread dysfunction for fact, which can be disastrous if acted upon out of context.

There are many power dynamics at play within the average hospital’s medical staff organization. When new leaders are brought in from the outside, it can create uncertainty, distrust, and in some situations, it might even bring out some underlying paranoia. I’ve worked with clients like that, who have medical staff members who are convinced that new leadership has been brought in strictly for the purpose of shaking things up and that the new CMO or CMIO is going to try to fire everyone.

Although there are certainly situations where some serious housekeeping needs to take place, for the most part, hospital administrators aren’t looking to completely clean house. There may be a few disruptive physicians who need to be dealt with, but it’s not exactly easy to replace an entire medical staff, especially if the physicians are voluntarily on staff rather than employees. One wouldn’t want to lose the referral base that comes with community-based physicians, especially if the facility has a solid referral network that is tied to an accountable care or other risk-sharing platform.

At times I think about going back to the CMIO trenches, but then I’m reminded of how a new CMIO is sometimes treated. I’ve worked in an organization that had a previous CMIO who I replaced and that can be difficult if your predecessor was well liked or if there was very little boat-rocking. I’ve been around when the CMIO position is newly created and that can have challenges as well. Technology leaders can be nervous that the CMIO will meddle in their affairs and operational leaders can be suspicious as well. Other clinical leaders can be worried about losing control of their departments or service lines, especially if the new CMIO is overly enthusiastic.

In my first CMIO position, I was subjected to senior members of the medical staff who demanded referrals, and sometimes not very subtly. It was implied that I’d need to send business their way if I expected their support in medical staff matters.

I had a close friend who became the first CMIO at a large health system. Since he came from the ambulatory side, the hospital medical leaders didn’t trust him. Other ambulatory physicians didn’t trust the fact that he was a generalist. One particular senior cardiologist continuously harassed the new CMIO, telling everyone that he personally would have been better suited for the job even though he had no informatics experience and didn’t apply for the position. The organization’s leadership didn’t do much to help solve the problem, especially the CIO, who was more interested in how the organization appeared on “best places to work” lists than he was in how the clinical and financial systems were performing and whether the health system was receiving solid return on investment.

I’ve looked at some open CMIO positions and it’s hard to think about uprooting yourself and moving to an environment that might not be quite as advertised. I’ve been on site with clients who put on a great show for visitors, then as you become more familiar and they let their guard down, you learn things that want to make you run shrieking away. Several of the positions require candidates who have completed Epic rollouts from soup to nuts, which puts those of us who come from best-of-breed organizations at a slight disadvantage. I’m not thinking about making a change in the near future, but always like to keep my eye out for interesting opportunities.

Looking for a CMIO, particularly in a warm locale that doesn’t have a tax on Diet Coke? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/11/18

January 11, 2018 Dr. Jayne 1 Comment


It’s been a while since I’ve shared from the reader mailbag. I have to say it’s been hard to keep up lately. I’ve been filling on an “interim” CMIO engagement that feels like it’s never going to end. The hospital hasn’t taken my advice on productive work and process improvement, so every day is an email battle. Couple that with an increase in spam and nonsense press releases landing in my Dr. Jayne account and it’s a recipe for late night eye-crossing.

From Retail Medicine: “Re: CVS-Aetna merger. I agree with your concerns. I envision their community approach to healthcare being short on care and long on profit. How do we work to protect patients who are not aware that they are not receiving the care that they need and deserve? It is clear that those setting the rules have little understanding or empathy of the situation.” The reader attached a copy of the letter they sent to the CEOs of both companies, which brings up many good points. A significant portion of visits to retail clinics may be unnecessary since they are for upper respiratory infections, sprains, and strains – all of which can be self-managed without clinical intervention using common sense remedies such as rest, fluids, and over-the-counter medications. We see this at our urgent care, where patients come in when they have had symptoms for only a few hours and haven’t tried anything to address the symptoms. Nurse triage lines could help, but many patients aren’t aware of the services their insurance plan offer. It remains to be seen whether higher co-pays for emergent and urgent visits will make a difference with these visits. Other points included the need for retail clinics to coordinate with primary care physicians through a comprehensive communication system.


From Vintage: “Re: smart glass in exam rooms. Sounds like big fins on autos in the early 1960s – eye-catching, but useless and phased out in a year or two. Surely the money paid for smart glass could have been allocated to investments with more direct impact on patient care or improvements to the working facilities of care givers. But it looks cool, I guess.” I suspect another way that cost savings could be achieved would be eliminating the large-screen monitors for so-called transparent charting. I’m sure there are plenty of physicians who don’t want their lack of typing skills or difficulty navigating the EHR to be obvious to patients. There are still too many physicians who fall into those subsets. I work regularly with physicians who have been using an EHR for years, but when you watch them, they navigate as if they have never seen the screens. I wonder if there is a biological condition that inhibits formation of muscle memory in a subset of end users? I’m always amazed when physicians who mastered complex medical disciplines struggle with straightforward actions like entering a chronic condition on a problem list.

From The Field: “Re: observations from implementing Epic. My clinical work is entirely divorced from my IT work – I show up, see patients, and head out, electing not to get involved in a multi-layered bureaucracy. No one thought to ask me to jump in on the rollout. As my clinical colleagues struggled with various issues and just blamed the EHR, I found myself slicing the baloney thinner. Some issues were with software. With a little research and overhearing some scuttlebutt, it became apparently that other issues were because certain modules of the software weren’t purchased. Still other issues involved configuration and some were user –dependent, where users upstream in the flow of clinical information weren’t using the EHR in ways that allowed downstream users to have a flow of data. A year and a half later, I realize that we are really still implementing the system, finally getting back around to fixing things. On another aspect, the support teams could be very enthusiastic but counterproductive. I began to dread calling in a bug because of the time it would take to process it while I was trying to see patients.” There are always rude surprises when end users discover they’re missing critical pieces needed for them to be successful. I see this when practices purchase a laboratory interface but fail to spring for the mapping needed to make ordering tests a seamless experience for clinicians. Or when content is missing for key specialties, or when non-visit but high-volume workflows such as care coordination or telephone medicine are weak. I admire a clinical informaticist who can manage scope well enough to avoid being sucked into a black hole that’s not in his or her sphere of ownership. The point about the help desk is well-taken – the best support systems I’ve seen involve having strong local super users who can quickly document the details of an issue and log it on the clinician’s behalf, allowing patient care to continue.

From Weirder than Weird: “Re: do-it-yourself circumcision kits. Did you see this article?” I intended to mention it, but it was lost in the holiday shuffle. There is a similar listing on the US Amazon site, although the item appears to be unavailable. That has left the door open for plenty of interesting questions, answers, and reviews. It made me curious what other medical or quasi-medical offerings were on Amazon. I was surprised to find biopsy forceps, uterine curettes, prostate biopsy transport vials, and ringing in at $1,400, a positioning kit for breast MRIs. While the “Young Scientist” brain dissection kit is unavailable, you can have a porcine heart or a fetal pig shipped for less than $45. From the comments on some of the listings, there are plenty of families gathering around the kitchen table to learn about anatomy. Apparently you really can get it all on Amazon.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/8/18

January 8, 2018 Dr. Jayne 1 Comment

I read with interest the news item last week about the Vermont Health Information Exchange. While that state’s exchange is under the microscope for issues with spending and data quality, there are plenty of other HIEs out there that are struggling with being useful at the point of care. Since my work spans multiple states, I’m able to see what is available to clinicians and how well it integrates with clinical workflows. There are variables whether the exchange is truly an exchange – namely whether data can be pushed or pulled or whether it’s little more than a view-only repository.

In the Vermont situation, 91 percent of interviewed stakeholders think that the state needs an HIE, but only 19 percent of interviewees feel that it is meeting their needs. One of the major barriers cited is Vermont’s opt-in policy, which limits the number of patients whose data is present for sharing. At this point, only about 20 percent of patients have opted in.

I had my own adventure with opt-in in my early days as a CMIO, when we created a private HIE to share data among physicians affiliated with our hospital. Although there wasn’t a specific state law that forced us to be opt-in, there were case law citations that prevented us from assuming all patients gave us permission to share data. We were able to maneuver through it over time by having all participating practices add language to their new patient consent forms that permitted sharing through the HIE. The practices also had to go back and have new consents executed for existing patients, and that took time.

Our vendor was subsidizing the interfaces because we were a beta client for their new HIE platform. Our hospital was picking up the rest of the tab, so there was no cost to the community physicians. My staff and I did countless road shows trying to convince physicians that this was a good thing to be part of, but at the same time, our CIO spent a lot of time trying to kill it simply because it wasn’t his idea and it was being executed by clinical leadership rather than IT leadership.

We ended up being live for quite a few years until our state HIE began to take shape. In all, it was an exciting time, but very different from the environment we’re in now, where interoperability is at least a little bit easier.

Despite having been live for several years, my own state HIE still struggles. It doesn’t communicate with our state immunization registry, which reduces its utility for primary care and urgent care physicians. All the immunizations sent to the HIE are strictly added as read-only data element, and there is no mechanism for resolution of duplicates or for reconciling with the immunization registry. A physician looking to validate immunizations on the HIE also has to go to the registry, and since the registry actually functions as a source of truth, why not just go there in the first place?

Our HIE doesn’t store any diagnostic imaging, only PDF report documents. Sometimes these are useful when an existing finding is well described and can help serve as a comparison, but there are entirely too many radiology reports out there with “clinical correlation recommended,” which means the reading radiologist isn’t going to stick his or her neck out by providing a specific diagnosis. When we find unusual things on an x-ray or CT, we’re hard-pressed to understand whether they’ve changed from previous. Instead of being able to provide the patient with immediate reassurance, we’re left giving him or her a copy of our films on a CD for them to take to their primary physician or the pertinent specialist to get it sorted.

The consultants evaluating the Vermont HIE recommended that it provide quality reports to support data-driven care. Our HIE doesn’t do any kind of reporting either, which to me seems a waste of a good population management tool. We’re in the midst of the worse influenza season we’ve seen in the last decade and yet can’t leverage that data for real-time reporting or surveillance. We have to wait for data to be reported to the state health department, then for it to be parsed and sent back to us in static form.

The Vermont HIE review also revealed concerns about patient matching and the function of its master patient index. We struggle with that in my state as well. Our state HIE’s program for identifying potential duplicate patients and merging them feels like it’s virtually non-existent. Since the matching algorithm appears to use address as one of its criteria, when I search for patients I find records that are clearly the same patient but are treated as unique individuals because they have different addresses, even if the rest of the demographics are the same.

We don’t tolerate that level of records duplication in my current practice, and in my former life at Big Health System, we had aggressive policies in place to identify, validate, and merge duplicate patients in our system on a regular basis. There’s no reason the HIE can’t do the same, especially with subpopulations that are known to be transient, such as college students, migrants, and homeless persons.

Another general concern around HIEs that plays out across the country is the sustainability of their funding models. Many are heavily subsidized with state funds and others are cobbled together with a variety of funding sources.

I worked with a practice recently whose HIE is struggling with funding. Practices are either required to do a full integration with the HIE at a cost of more than $40K and then pay a couple hundred dollars per provider per year to stay connected, or if they don’t want to do a full integration, they can pay a steep annual fee for providers to have web portal access. My client’s practice has a residency program with many rotating providers along with a number of locum tenens providers who fill in at their rural clinics. The fee for portal access is strictly per provider, with no regard to resident, full-time, or part-time status. For residents who are only in clinic for a couple of half days a week during a four- to six-month rotation, it’s too costly. For part-time physicians and those who are functioning in a job share situation, it’s not cost effective. We attempted to negotiate a break with the HIE, but were unsuccessful.

In my own practice, where I’m surrounded by Epic hospitals, I’m waiting for the advertised Share Everywhere functionality to start making an appearance. Although it was to be included in their November release for MyChart, I haven’t been inundated with patients whipping out their phones to give me access codes so I can see their records and send a note pack to their Epic-based care team. I’d be interested to hear from anyone who has seen it in the wild or used it to access patient information.

How satisfied are you with your HIE options? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/4/18

January 4, 2018 Dr. Jayne No Comments


The New Year has started out with a bang and a reminder that for some IT organizations, old habits die hard. I tried to log in to my flexible spending account website to submit a receipt for the contact lenses I put off purchasing until 2018, only to be locked out. I wasn’t able to do an online password reset, so had to call customer service. There I was told that my password (which I just set back in December) was expired and that it has to be changed “every 90 days because of HIPAA.” I guess they missed the memo that HIPAA doesn’t require a specific password expiration interval, and also the one where NIST and other organizations are advising against forcing regular password expiration without reason. HIPAA remains one of the most incorrectly cited regulations I can think of and there’s not much hope for improvement.

I also tangled with a pharmacy that insists on calling our office to request verbal authorization to change prescriptions from capsules to tablets and vice versa, even when our electronic signatures are placed squarely on the “substitution permitted” signature line as required by state regulations. This particular pharmacy is the only one who calls and I can’t imagine that their business is so slow that they don’t have anything else to do than to make unnecessary phone calls to physicians.

I’ve always been a bit annoyed at the fact that most EHRs display a dizzying array of formulations that prescribers have to sort through. For many medications, it doesn’t matter if the dosage form is a tablet or capsule, but we have to select one or the other nevertheless. Of course it matters if it’s a liquid or a chewable when you have a patient who doesn’t swallow pills, but otherwise it’s just one more thing we have to assess when we’re clicking through the day. I had to play bad cop and threatened to report them to the State Board of Pharmacy if they continue harassing us.

I’m looking forward to the day when I have robust clinical decision support in my EHR that takes the diagnosis I just loaded and the drug I’m selecting and only shows me the dosage forms and instructions that are pertinent for the clinical situation given the most current clinical recommendations and local antibiotic resistance. To do that in our current system, we manage order sets that each client has to build and maintain. I know there are more integrated solutions out there, but I don’t think they take the local resistance rates into account. At least not yet.

For the vendor with whom I was on the phone the other day troubleshooting an issue with MIPS calculations, I’m going to recommend a New Year’s Resolution: if you’re going to bother being on a call, make sure you’re paying attention. This call was the culmination of efforts to manage multiple support tickets around several interrelated issues. At first I was impressed by their SWAT approach to getting the right teams on the call to try to solve the issue. My confidence flagged the first time that someone had to be asked a question twice due to “being on mute,” which we all know is a (somewhat illogical) euphemism for “not paying attention.” This happened again not five minutes later, with the second support rep at least admitting that he “was multitasking.” I would question the judgment in play when you multitask while you have a disgruntled client on the phone along with five or six of your peers who all have other (if not better) things to do. I used to work with a guy at Big Health System who would routinely be “on two conference calls at once.” I could never figure out why anyone would think that was a good idea.

I had a bright spot in my week when I was orienting a new physician to our group. He wasn’t aware of Clinical Informatics as a subspecialty, but having been a computer science major, was very interested in hearing more about the path to board certification. He had been doing informatics work at his previous employer but didn’t see himself as much more than a super user. When we talked through some of his work, it was much broader than he thought. It’s always good to see the sparkle in someone’s eye when you discuss something they find exciting rather than thinking that conversations about EHR workflow are a chore. We’ll definitely include him in our clinical champion group and see how much he wants to participate now that he’s with us.

I read with interest the reader comment from Sick Doc about urgent care centers being closed on holidays. Now that my practice is approaching 20 locations, we did some modifications of our holiday hours this year. Normally we are open 365 days of the year, but staffing every holiday in a practice that size was taking its toll on staff morale. We remained open, but not at every location, consolidating operations within a 10-mile radius of identified “core” locations. Signage and directions were placed at closed locations with matching website modifications.

We piloted this approach with Thanksgiving and it was successful, so we continued it into the Christmas and New Year holidays. Overall patient volume was down but only slightly, and I think the decrease was within what you could reasonably attribute to people not wanting to miss out on family gatherings or to venture out into the bitterly cold weather we’ve been experiencing. We’re proud to offer care 16 hours a day, which is the most any urgent care in our area provides. Our staff definitely appreciated the greater odds of being able to spend time with family. They’re running pretty ragged with the spiking volumes due to influenza, which we’re countering by having lunch delivered for the staff every day, at least in the short term.


Urgent care is definitely a growing market segment, with an announcement today that Mercy is partnering with GoHealth Urgent Care for Midwest operations. GoHealth already partners with health systems in New York, Portland, Hartford, and San Francisco. I hadn’t heard of them prior to the announcement, but got a kick out of their website’s picture of innovative facilities “engineered for your comfort and privacy” that appears to show a fishbowl-like exam room with glass walls along with a glassed-in vitals station where everyone in the waiting room can watch you step on the scale and get your blood drawn in the phlebotomy chair.

The press release mentions that these are “smart glass” rooms, which I assume means they become opaque when people are in them. For a profitable urgent care, that should be most of the time, making the technology’s value somewhat questionable. The terrazzo floors look nice, though.

Basic visits at the Bay Area clinic start at $250 (cash price paid in full at the time of service) and are $150 in Portland, $120 in Hartford, and $125 in the Big Apple. I wonder what Mercy’s existing urgent care physicians think about the announcement and whether their clinics will remain open?

According to the release, charting will be transparent on wide screen monitors in each room using Mercy’s Epic EHR. GoHealth didn’t have great reviews on Glassdoor, so I’ll be watching this one closely.

What do you think about smart glass exam rooms? Leave a comment or email me.

Email Dr. Jayne.



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