EPtalk with Dr. Jayne 10/18/18

A reader recently asked how/where I keep my own personal medical records. I may have written about it in the past, but my strategy is always evolving, so I’ll share my answer. From my college and medical school days, I have a few paper documents, mostly pathology reports printed from our hospital’s HIM system, and an original vaccination record from our student health clinic. The vaccinations I also keep as a PDF, which becomes useful when I have to turn in my annual health form to volunteer at a youth summer camp. I always chuckle when I have to transfer that data, because I received my last two non-influenza vaccinations (Hepatitis A and Tdap) only because my staff mistakenly drew up doses that were going to have to go to waste, so I had them “waste” the vaccine into my left deltoid.

Beyond that, I have a thumb drive with my entire OB/GYN medical record, provided to me by my physician when she closed her practice. I’m pretty sure it’s not encrypted, and I’ve summarized the important parts into a Word document. I used to have an account on a commercial patient health record courtesy of my employer, but it was clunky and cumbersome, and frankly just creating my own word document was more useful. My genetic counseling records are all on paper, given to me at the end of my visit by my counselor. Her office does not store records electronically or communicate via patient portal. It’s very old-school. When my local health system began their conversion to Epic last year, I did download all my records from their portal, storing them as PDFs on my OneDrive. That way, I can access them from anywhere should I need them. I also store copies of my living will and healthcare power of attorney on the OneDrive, because I’ve seen too many bad things happen and I trot those documents out as needed.

It’s not an elegant solution, but as a physician I have a pretty good handle on my health status and can quickly put my fingers on the data I need even, if it’s not very well organized or categorized. I’m relatively young and healthy, so I don’t have a lot of records to track. I love the idea of patients having their own curated records that they can share, but that concept still scares a lot of physicians silly. I’ve seen some really good solutions on the market, but there hasn’t really been a lot of traction with patients, even with Apple on the scene. I do have an iBlueButton account with Humetrix, although I haven’t used it in a while. Hopefully I’ll stay healthy with no additional data to add.

Speaking of staying healthy, many of us in clinical informatics pride ourselves on delivering evidence-based care using robust clinical decision support tools. Still, the last mile in making evidence-based care a reality is often the conversation between the clinician, his or her staff, and the patient. During this year’s influenza vaccination season, we’re seeing patients who are resistant to the vaccine because of the perception that it was ineffective last year. This is borne out in a recent survey by Stericycle, which notes that a third of US respondents don’t plan to get a flu shot this year. Last year, influenza killed more than 80,000 people, but the data doesn’t appear to sway these folks. My staff has practiced and role-played various talk-tracks for patients, so we’ll have to see if we can continue to convince our patients that it’s the right thing to do. For certain, we’ll be getting an EHR-delivered score card at the end, so every vaccination counts.

I recently learned about the Neighborhood Navigator tool, released by the EveryONE Project in partnership with the American Academy of Family Physicians. The tool uses more than 100 languages and integrates with Google Maps to help patients find directions and connect with social services for needs such as food, housing, transportation, employment, legal services, and more. There is a set of training videos for physicians to help them understand the tool and how to best refer patients.

My colleagues in the physician lounge often lament the changes in healthcare brought on by the growing presence of the Internet and the rise of social media in everyday life. Data from recent surveys reveals some interesting statistics: 54 percent of millennials (and 42 percent of all adults) have either “friended” their provider on social media or would like to do so; 65 percent of millennials (and 43 percent of all adults) find social media appropriate to use to contact their provider about a health issue; and 32 percent of those surveyed have taken a health-related action as a result of information they read on social media.

I stumbled across the “Shots by AAFP/STFM” app in the Google Play store. It includes full CDC vaccine schedules and footnotes, as well as dosing information, contraindications, and catch-up schedule information for all available vaccines. Content is written by immunization experts at the Society of Teachers of Family Medicine. You can also enter a patient’s age and various parameters to get a recommendation on what vaccinations are needed. I use multiple resources in trying to figure out vaccine schedules for people, so I’m looking forward to giving this a try to see if it will be my new one-stop-shop. It’s also available on iTunes.

My slow day in the clinic allowed for a lot of Web surfing in between studying for boards, and I also stumbled upon ePrognosis from University of California, San Francisco. The site’s goal is “to be a repository of published geriatric prognostic indices where clinicians can go to obtain evidence-based information on patients’ prognosis.” I ran the profiles of my favorite community-living nonagenarians, and it looks like the odds of them continuing to do well are very good indeed.

Working at an urgent care that also provides occupational medicine services, we see a number of patients who come in for drug screens. Many employers require these to be observed drug screens, so that there is no question of an employee substituting someone else’s urine sample. I chuckled when I saw this feature on a Florida convenience store that has had to put up a sign telling users not to microwave urine samples. Even our drug screens that are not observed include taking the temperature of the sample to make sure it’s within a valid physiological range, so if someone were going to try to microwave it, they’d have to get it just right. Still, it makes one think twice about using a public microwave.

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Curbside Consult with Dr. Jayne 10/15/18

As an urgent care physician, I enjoy the satisfaction of being able to make a bad day better for many of my patients. Although I live in a major metropolitan area, there is a relative shortage of primary care physicians (at least ones taking new patients). For those patients who have primary physicians, there’s a shortage of same-day and after-hours appointments that mesh with patients’ busy schedules and their desire for convenience.

I’m happy we can meet our patients’ needs, but I’m often conflicted about the fact that delivering what is essentially primary care in an urgent care setting often contributes to the fragmentation of care. That’s in addition to the cost contribution, because a visit with us typically costs more than a visit to a primary care physician due to negotiated contract rates with payers and higher co-pays for patients.

The fragmentation could potentially be reduced through better technology, particularly better interoperability. Our EHR allegedly has all the interoperability bells and whistles, but local hospitals and their owned physician groups aren’t too keen on sharing data with competitors despite our desire to deliver better patient care. Our state HIE’s provider-centric pricing model makes it cost prohibitive for us to connect, given that the majority of our providers are part time. Even if it were more economical, our HIE is largely read-only, which doesn’t do a lot for the efficiency or accuracy of being able to bring patient data to life in the chart.

A good chunk of our patient volume happens before 9 a.m. and after 5 p.m., which is a testament to the fact that patients want to receive care at a time that is convenient for them, even if it might be more expensive. They also like being able to get care same day and not have to wait for 3-5 days for an appointment for straightforward medical problems. Many of our patients are hourly workers who don’t have paid sick time, and even those who have sick days may be challenged to find two or three hours to visit their primary physician during the work day.

I often think of the reasons behind why people choose to get their care when and where they do, so this Kaiser Health News article caught my attention.

The article covers the idea that millennials are at the forefront of wanting convenience when selecting their care and tend to choose urgent care, telemedicine, and retail clinic options. A poll of 1,200 adults found that younger patients were less likely to have a primary physician, ranging from 45 percent of patients ages 18 to 29 and declining to 12 percent for those age 65 and older. We see that play out in practice, whether it’s strictly due to the convenience angle or whether it’s due to a lack of available primary care capacity.

However, I’m seeing more patients in the Baby Boomer demographic who may have a primary physician, but choose to come to urgent care because they’re busy in their retirement and don’t want their schedules upset by needing to seek medical care.

I have several friends who are dabbling in telemedicine as an adjunct to their regular primary care practices. They report that patients have discussed their desire to handle medical issues at the time and place of their choosing, whether they actually get to interact with the physician face to face or not. Patients are used to transacting the business of their lives online, whether it’s banking or retail, and since healthcare has become a commodity, it’s no different.

One colleague notes that while the patients are glad she’s offering the service, many of them would be just as happy seeing any other physician and not specifically her. We’ve moved into a generation where patients no longer have a primary care physician for life. They may have one for three or four years and then have to change because their employer selected a different network, or they may change due to relocation and the more fluid lives that people tend to live now.

There are concerns that moving away from that continuity where physicians know their patients not only drives up costs, but also leads to inappropriate antibiotic use or misdiagnosis. We see patients who come in specifically because “my primary wouldn’t call me out a Z-pack” and spend a lot of time educating them about viral illnesses. At least we can send them home with medications to help with their symptoms, which makes them feel like they’ve done something to get better even if it’s not an antibiotic. There’s a powerful psychology in that.

We also see patients who have been to their primary care physician and also a subspecialist, but feel like their problem isn’t being addressed so they come to us “for another opinion.” It’s difficult to explain that we’re not experts and if they’ve been to a subspecialist at one of the local academic medical centers and there’s not an answer, that we’re unlikely to find one at the urgent care with our limited testing and radiology capabilities.

I’m particularly interested in the concept of delivering regular primary care via telemedicine, rather than just care for urgent and acute issues. Virtual visits have the power to revolutionize what we do, adding convenience for both patients and providers. In order to be successful, though, we have to get payers and policies aligned to pay for them so that physicians will be more likely to offer them. We also have to get technology aligned, including robust patient portals, the ability for patients to upload their own health data and documents, and better understanding from mid-career physicians that telemedicine isn’t going to suck away their evening and weekend hours.

I think about all the hours that my practice spent trying to track down patients and get them to come in for appointments back when I was in the primary care trenches. I would bet that at least half just disliked the process of going to the doctor and would have been game to do a virtual visit.

I’m excited about projects that pair community health workers with physicians to deliver a combination of in-home contacts with virtual physician visits, particularly in rural areas. A friend of mine recently received a grant in that regard, and I can’t wait to hear how it plays out in real life. I know she is having some challenges figuring out how to actually deliver the services, whether to try to integrate something with her EHR or to use a third-party telemedicine solution. It sounds like the options among vendors vary dramatically, so she is going to keep me posted on her progress.

Are you a physician who regularly incorporates virtual visits into care, or a healthcare IT person who supports one? I’d love to hear from you. Leave a comment or email me.

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EPtalk by Dr. Jayne 10/11/18

I was excited to hear that Atul Gawande, MD has been booked as the opening keynote speaker for HIMSS19. Many of us were initially enthusiastic about the efforts by Amazon, Berkshire Hathaway, and JP Morgan Chase to revolutionize healthcare delivery. That enthusiasm was somewhat tempered by the clarification that they’re really focused on solving the issue for themselves as employers, although it may eventually be extrapolated to the world at large. Regardless, Dr. Gawande has significant street cred in the healthcare trenches, and as a practicing physician, I’d much rather hear from him than from some of the other recent HIMSS headliners.

I was also excited to hear some information coming out of the American Academy of Family Physicians annual meeting this week. The American Board of Family Medicine used the meeting to announce a pilot program starting in January that will “assess the value and feasibility of a longitudinal assessment option to the 10-year secure examination.” Completing educational opportunities on an ongoing basis rather than cramming for an exam every 10 years is much closer to what we do every day in practice and was the preferred choice for recent exam-takers who were surveyed by the University of Florida in conjunction with ABFM’s assessment of the role of the exam. The questions will be administered quarterly and providers can use resources to find the answers, which better demonstrates our ability to manage knowledge rather than memorize.

I’m doubly excited since I have to recertify in 2019, although I already spent nearly $1,000 on a self-study board review course. The proposal still has to be approved by the American Board of Medical Specialties Committee on Continuing Certification in November. There aren’t any details on how large the pilot will be or whether everyone who wants to participate can actually take part, so I might still have to take the exam. I’ll be crossing my fingers, though.

The use of ride-sharing services as an alternative to ambulances for transportation to the hospital is getting some coverage in mainstream media. Data from 2011 shows that the US spent $14 billion on ambulance services, more than a third of which was paid for by Medicare. Inappropriate use is estimated at approximately 30 percent.

Although it sounds like a good idea from a cost perspective, I’ve found that in practice, patients don’t do the best job of determining whether an ambulance is necessary or not. We’ve had patients in the midst of active heart attacks at our urgent care who want to argue with us about an ambulance transport because of the cost. I’d hate to see someone in that situation summoning an Uber to their home because they’re worried about the money.

In order for this lower-cost transportation to be appropriate, patients are going to need education on whether it’s the right option for them. Maybe the ride sharing services need to add some screening questions to the app to not only help patients, but also to protect drivers from unwittingly picking someone up who needs serious medical attention. So far, what I have heard about Uber Health is that it will allow providers to order transportation, but doesn’t necessarily address the issue of patients trying to get rides on their own. I’m still up for some screening questions in the apps themselves.

Last week, the US Senate sent for presidential signature a bipartisan package fighting the opioid epidemic. The bill passed the Senate by a vote of 98 to 1, showing that political adversaries can and actually will cooperate when the circumstances are right. The only opposition was from Senator Mike Lee of Utah. The 600-plus page bill includes relaxation on Medicaid payments for inpatient treatment, increased surveillance on opioids being imported by mail, and allows certain midlevel providers to prescribe buprenorphine treatment. It doesn’t appear to have been signed yet, but I’m keeping my eye out.

The opioid bill is timed nicely with the release of the Surgeon General’s report on “Facing Addiction in America.” Assisting in management of opioid use (not only prescription, but illicit versions) is an area where EHR technology can be expanded for better support of clinicians. It’s not just about making it easy to link the EHR to the state prescription drug monitoring program (assuming the state has one, which one state does not) but in getting those links into the right part in the prescribing workflows and making the connections fast enough that they don’t impede provider workflow. It’s also about providing clinical decision support including morphine equivalents for drugs patients are already taking as well as those providers are considering for a new prescription. These should be relatively simple things to code, but don’t seem to be given much bandwidth on the development calendars of vendors.

It’s National Health IT Week, but I didn’t see a celebration in the physician lounge. Most of my local physician colleagues still see healthcare IT as a threat, not necessarily because of what it offers at face value, but because it’s a proxy for the perceived decline of medical practice as they used to know it. National Coordinator for Health Information Technology Don Rucker, MD blogged on the HIMSS site about how automation in healthcare is transforming medicine. Rucker talks a fair amount about the 21st Century Cures Act and its prohibition on information blocking.

Despite being signed into law in December 2016, it hasn’t done anything to improve information blocking in my region, which is largely due to competing health systems that refuse to share data even though they could do it fairly easily if they wanted to, especially now that all of them are on the same vendor platform. As an urgent care physician, I can’t even get their physician-owned practices to give me a medication list over the phone (despite the fact that it’s permissible under HIPAA for treatment, payment, and operations), let alone gain access to their clinical data repositories to find out what testing has already been done for patients before they arrive in my exam room.

Speaking of automation (or lack thereof), I’m still battling a billing issue with the hospital where I had emergency surgery over a year and a half ago. They sent me a bill last month for which I had no explanation of benefits document, which is unusual since I save every scrap of documentation around my healthcare. I hadn’t yet had time to call my insurance and see what the story was, but in the mean time, the hospital sent me to collections less than 30 days from the date of the statement.

I hopped on the phone to the payer, who had no record of a claim for that date of service, then had to call back to the hospital’s outsourced collections company, which provided me a supposed claim number. I called back to the payer to learn that the provided claim number didn’t even fit the standard format. They dug a bit deeper and found a charge for the same amount, but on a different date of service. It turns out it was paid, no one knows why I didn’t receive an explanation of benefits, and no one can explain why I was billed more than 18 months after the fact or why I was sent to collections less than 30 days after the bill was mailed. I paid my co-insurance online after sorting it all out, so hopefully this adventure is at an end.

What’s the longest running medical bill saga you’ve ever seen or experienced? What are you doing to celebrate National Health IT Week? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 10/8/18

Although the majority of my work is in the CMIO space, I occasionally do some work for vendors. Depending on the vendor and the situation, it could be anything from participating in a focus group to helping design and execute on usability studies.

I’ve worked with vendors who truly get it and are just looking for supplemental input or outside validation for their strategies, but occasionally I work with a vendor that has some significant gaps. This week included successful interactions and one that left me perplexed, so I’ve decided to put together some thoughts for vendors on what to do (or not do) when seeking input from physicians.

First, vendors need to know what they hope to accomplish by interacting with physicians. Do you want an actual practicing physician, and if so, in what specialty or what setting of practice? If not, do you just want someone who “thinks like a physician” and can take you through typical diagnostic or management options? Do you want to work with physicians who understand both the clinical and informatics spheres, so they can provide input on the end user experience but also strategies for solving the problems they may help you identify? Do you want someone who can help with clinical guidelines only and needs no understanding of software and technology?

Working with physicians can be costly since many expect compensation for their time equal to what they would have earned seeing patients during the time they spent with you. It’s important to not only make sure you have the right type of physician, but also that you are prepared to spend your time with him or her wisely.

I worked with a company early in the week that knew exactly what they wanted. They provided a brief synopsis of the project and the assumptions they wanted to test with a physician. They provided that information with enough lead time that I could review it thoughtfully prior to our call. They made sure to let me know that they wanted to interact over video, which let me know that I shouldn’t be in my pajamas or look like I just came off the treadmill, which is occasionally my habit depending on how many calls and meetings I have in a given day.

When I joined the call, it was clear that all internal resources had joined with enough time to be set up and oriented and they were ready to introduce themselves and describe their roles on the project. They also asked me to say a few words about myself and my background, which allowed for adequate level-setting all the way around.

We worked through a product prototype first at a high level, with me giving initial impressions and the team documenting any questions I raised or elements that I didn’t understand. That allowed us to get through the entire workflow without being derailed by details or issues with the mock-ups. Then, we took a second pass through the prototype and addressed the areas where I had questions or didn’t understand where the workflow was going.

I think it was helpful to them that I understood that we were working with some enhanced wireframe designs and not actually software on some of the screens, so that I could phrase my questions around whether what I was seeing was just an artifact of the mock-up or whether it was actually a design element. We then took a third pass through the workflow, with the team allowing me to identify areas where I thought the flow could be enhanced or where functionality could be added to better meet the original design intent.

It was clear that the team was experienced in respecting the time of their audience and also that they had prepped for the call, knowing approximately how much time to allot for the different phases of review. It didn’t feel rushed, we didn’t end with a lot of time left over, and there weren’t too many items that needed additional follow up. They clearly took good notes during the call because they were able to come back to different comments I had given and read them back to me almost verbatim, asking for clarification or expansion on what I was thinking. The whole experience was challenging and fun, and I hope they’ll be interested in my feedback as the project progresses.

The vendor I worked with later in the week provided a polar opposite experience. It was a bit of a different situation to begin with, since the vendor is trying to introduce a new spin on existing workflow and technology rather than moving forward with an innovative product. In my opinion, that makes it challenging since anyone looking at their offering is judging it against their current technology whether consciously or not.

They were asking me to evaluate a new way to do work that I’ve been doing electronically for nearly two decades across half a dozen platforms with numerous upgrades on each. Although one could take the strategy that it would be good to have an experienced clinician who can provide feedback on what other vendors are offering or have tried in the past, the developer kept interrupting the conversation and going on and on about not allowing “the experience” to be hampered by “the technology of today.”

I didn’t realize there were going to be developers on the call. That’s always a tricky one since sometimes when you provide feedback, they can take it personally, and especially since they weren’t introduced when the call began. Having silent parties on a feedback call that suddenly jump in and start a conflict with your research subject usually isn’t an effective strategy.

The product owner tried to calm him down, but it wasn’t working. I tried to explain that unfortunately the workflow they’re trying to address is hampered by a litany of external requirements that they hadn’t addressed, such as governmental and payer regulations. It doesn’t matter what your UI looks like if it is going to force the end user to behave in a way that is going to cause trouble in the case of an audit.

Part of the exercise was for me to work through an alpha version without direction or training to evaluate how intuitive the workflow was. At one point, someone who probably thought he was on mute but wasn’t actually said, “She’s doing it wrong. Why is she clicking there?” When I replied, “I clicked there because every other screen has the ‘save and close’ button in the bottom right corner and that’s where my hand naturally flowed,” there was just a stunned silence. At that point, another member of the team took over the call and we moved forward in the workflow, but I had a hard time thinking of the product vs. whether someone was getting schooled out in the hallway.

The session ended about 30 minutes early. I wasn’t sure whether they were out of material or whether they were just flummoxed. Frankly I was glad for it to be over, because it was stressing me out and my treadmill was calling. I’m happy to help, but there’s a level of dread that they might ask me to work with them again. We’ll have to see how the next sprint cycle unfolds for them. I hope if they’re working with other physicians (they had better be, because when you’ve heard one physician’s opinion, you’ve heard one physician’s opinion) that it’s a more successful experience.

Do you have any advice for software vendors who are seeking physician input? Leave a comment or email me.

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EPtalk by Dr. Jayne 10/4/18

ECRI Institute releases its 2019 list of the Top Ten Technology Health Hazards. The list is created each year by assessing various factors around each potential hazard, including severity, frequency, preventability, and breadth of the hazard. Insidiousness is also considered – whether the problem is difficult to recognize and whether it could lead to downstream errors before the problem is identified.

This year’s list contains some hazards that are clearly healthcare IT issues. but also some problems that healthcare has been grappling with for a long time:

1. Hackers can exploit remote access to systems, disrupting healthcare operations
2. “Clean” mattresses can ooze body fluids onto patients
3. Retained sponges persist as a surgical complication despite manual counts
4. Improperly set ventilator alarms put patients at risk for hypoxic brain injury or death
5. Mishandling flexible endoscopes after disinfection can lead to patient infections
6. Confusing dose rate with flow rate can lead to infusion pump medication errors
7. Improper customization of physiologic monitor alarm settings may result in missed alarms
8. Injury risk from overhead patient lift systems
9. Cleaning fluid seeping into electrical components can lead to equipment damage and fires
10. Flawed battery charging systems and practices can affect device operation.

Most of us are familiar with the need to address cybersecurity concerns, as we see ongoing cases of not only breaches, but ransomware attacks. However, I’m still surprised by the number of organizations that don’t keep their systems current with recommended patches and updates, or that are even on versions of software that are no longer supported by their vendors.

Other items such as alarm settings may be addressed by policy and procedure, which can be harder to institute than technological safeguards unless the organization is truly invested in a culture of safety.

Items 2 and 5 are simply gross and it seems they should be straightforward. Unfortunately, the situation is complicated by some manufactures not providing detailed cleaning recommendations or institutions using harsher cleaners than recommended, which damages the surfaces of equipment and allows absorption or sequestration of contaminants.

Retained surgical sponges are an issue that hospitals and surgery centers have tried to address through technology, including special thread in sponges that shows up on x-rays. Other technologies augment the manual counting process and can be effective if they are used correctly. These vary from special counting racks to radio frequency locator systems.

The Centers for Disease Control’s National Center for Health Statistics recently updated its guidelines regarding hurricanes. These go into effect October 1. The hurricane piece is located on pages 19-20 of the 120-page document, which I’m sure all physicians, coders, and billers will be lining up to read. It mostly addresses the ICD-10 codes for external causes – although they have been in place for years, the guidelines direct physicians how they should be used. The guidelines also address the use of Z codes, which can explain why patients presented for care, including homelessness, inadequate housing, poverty, and lack of availability or inaccessibility of health care facilities.

Speaking of CMS, a recent blog by administrator Seema Verma addressed the topic of “Better Data Will Serve as the Foundation in Modernizing the Medicaid Program.” Essentially, CMS is seeking to demonstrate how the ever-growing Medicaid budget is driving better health outcomes. CMS is also looking for ways to “improve program integrity, performance, and financial management in Medicaid and CHIP.” CMS has identified core sets of quality measures that will be used to monitor outcomes, although reporting is voluntary at this time. It admits that reporting is burdensome and has tried to mitigate the burden through the Meaningful Measures initiative, noting future intent to “leverage existing and more automated data reporting systems to generate these Medicaid measures on behalf of states, thereby reducing reporting burden while also improving data consistency, comparability, and comprehensiveness.”

That’s a buzzword bingo winner right there. Theoretically, isn’t CMS already receiving the data through individual provider reporting as part of Meaningful Use? Wouldn’t that allow CMS to aggregate the data rather than having states submit it? I’m not in the details on Medicaid MU very much any more, but maybe someone who is can shed a little light on this for me. All I know is that as a practicing clinician, fewer of my peers are accepting Medicaid patients and those who are have generally stopped booking new patient visits, leaving a continuing gap in care delivery and pushing patients to the emergency department.

Flu season is officially upon us, with positive cases being reported even though the 2018-19 season is not yet being named on the CDC website. We’re seeing plenty of cases in my practice, along with a particularly nasty influenza-like illness that walks like the flu and talks like the flu but comes out negative in testing.

Our urgent care volumes during last year’s flu season were largely driven by patients who either couldn’t get in to see their primary care physicians or who didn’t want to go to the emergency department due to potential wait times, overcrowding, and perceived lack of service. We’ve hired several new providers and a small army of paramedics and scribes to help us get through the upcoming season. If you haven’t received your vaccine yet, now is the time.

We already knew it in our hearts, but I was saddened to see the Journal of the American Medical Association call out the “Southern diet” as deadly. Its main mechanism is thought to be elevated blood pressure. The study looked at nearly 7,000 people who were part of a larger long-term study of diet and lifestyle. It tracked weight, blood pressure, cholesterol levels, alcohol use, income, and exercise habits along with symptoms of stress and depression. The study notes, “The largest statistical mediator of the difference in hypertension incidence between black and white participants was the Southern dietary pattern, accounting for 51.6 percent of the excess risk among black men and 29.2 percent of the excess risk among black women.” Hispanic and Latino individuals were excluded from the study.

I looked in the full-text article as well as in the references for the link to the “Southern diet score” they used but didn’t find it. I’m curious how my own diet stacks up – I do love a good fish fry with cheesy potatoes and apple cobbler.

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Curbside Consult with Dr. Jayne 10/1/18

I occasionally do a little bit of work for a local personal injury attorney. It’s not the big-time expert opinion work you hear about physicians doing on the side, but more of a translation service. Basically, I take hundreds to thousands of pages of printouts from EHRs and try to reconstruct a coherent timeline of what happened and who documented which data, so that the legal team can understand the facts of a case and determine whether they have something they want to take forward. At least the printouts are virtual, and I’m sifting through PDFs rather than dealing with boxes of documents delivered to my door.

I worked on a case over the weekend from a local hospital where I have never been on staff. The most striking part of the assignment was the poor quality of the records.

The case involved a “routine” outpatient surgical procedure that ended in the patient’s death. The entire episode of care lasted barely more than 24 hours, but there were six different PDFs sent, ranging from 20 pages to 370. Although all the notes and entries were electronically signed by the pertinent physicians, it was quickly apparent that the physicians hadn’t really read the notes before authenticating them. Either that, or they read them and just have a passing familiarity with the idea of matching the pronoun to the gender of the patient or ensuring that the note actually makes sense. Especially since this episode of care contained a profound medical misadventure, one would think that the attending physician (who was going to receive attribution for the case) would have made sure the key portions of the record made sense.

The hospital had numbered the PDFs from one to six, and I quickly realized that the numbering was not at all related to what one would expect in a typical chart. Each file contained a mixture of timelines and care locations (pre-operative area, operating room, intensive care) and was so confusing that I actually thought about printing the whole thing out so I could sort it into chronological order. The admission history and physical was in the middle of the third file, and the discharge summary (also known as the death note) was in the middle of the second. It probably would have been better if the discharge summary was at the end of the last file, because after reading it, I was so aggravated that I had to take a break.

Although the document was clearly identified as a death note, it also contained “Home Instructions for the Patient” and a list of “Medications You Should Continue at Home.” I imagined myself as the widow of this patient reading that and how insensitive it must have seemed to her. She had requested the records personally and provided them to the attorney after she was unable to get answers to her questions from the hospital’s risk management team.

I imagined how confused she must have been by the six files, how disjointed they were, and why she felt she needed to ask the hospital for clarification because the records didn’t make sense. I also put on my EHR hat and thought about how easy it would be to have a separate template for the death note that didn’t have those components that only apply if a patient is actually leaving the hospital.

When I finally made it to the physician notes, I noted how poorly the history of present illness (HPI) was written even though it was either dictated or typed as free text. The patient had been transferred from the operating suite to the intensive care unit after being emergently intubated and placed on a ventilator, which the HPI described as “the patient was difficult to breathe.” The patient was referred to twice as “her” and the rest of the time as “him,” the latter of which was appropriate. Another physician note said that the patient had been “electively intubated for the outpatient procedure” which was incorrect, which somewhat makes one question the accuracy of the documentation in general.

The nursing notes were also interesting, with a nurse documenting that a fall risk assessment was performed and “the patient verbalized understanding” despite the patient being paralyzed, sedated, and on a ventilator, with a documented Glasgow Coma Scale of 3 which basically means the patient was nonverbal and unresponsive to verbal or painful stimuli. One can perhaps blame that one on a macro or shortcut being used, but as a healthcare provider I was embarrassed to see it. The patient also had a “weapons assessment” performed upon arriving to the intensive care unit, although I’m not sure how he could have become armed after being assessed similarly in the pre-anesthesia care unit and having been unconscious most of the time. I understand the value of checklists, but it was just one more thing clogging up the notes that didn’t make sense.

I was heartened to see that the hospital was using a virtual sepsis protocol and remote ICU services from a tertiary care center. My enthusiasm was curbed, however, when I reached the laboratory data section, which displayed the data in an extremely hard-to-read grid (above). I can’t imagine that there was much clinical input on or approval of that document before putting it into the system, and if there was, would love to have a conversation with whoever approved it to go into production. I’m sure users are reading the data on a screen with a scalable display in real time, but it’s still important to be able to have a printout that makes sense.

The attorney who sent me the case felt that there was not likely a valid claim, but had asked me to review to help provide answers to the family. Even in that context, I always review to see if there was an element of negligence or substandard care. I wasn’t pleased to see that the consent for surgery document didn’t have the patient’s name filled out or the surgeon’s name completed in the respective blank spaces. It did have a patient sticker and MRN on it, but not using the blanks as designed just makes it feel like either someone was in a hurry or someone didn’t care, neither of which are great when there has been a poor outcome.

The bright spots of the entire chart were the chaplain’s notes. They were free-text narrative, and although I couldn’t tell whether they were dictated or typed, they were cohesive and actually told the story of what had happened to the patient far better than the physician progress notes (each of which was 8-10 pages long because they contained copy-and-paste content from previous notes). The chaplain’s notes also contained detailed summaries of what was discussed with the family and their responses to the information provided. Those chaplain’s notes were probably the most solid piece of documentation in the chart and they illustrated that the clinical team acted within the standard of care after the initial event.

In the healthcare IT world, we think of projects and timelines and budgets and deliverables, but often we struggle to find the time to think about patients and their families and how those individuals would view our efforts. This family probably doesn’t think very much of the quality of records at this institution and I know the attorney doesn’t either.

As a CMIO, a patient, and a family member of patients, I’m appalled by what I saw. We can do better, and our patients deserve it.

I’d like to throw out a challenge to readers. Take a look at the documentation your systems are producing. Find a death note or a discharge summary with an outcome of “deceased” and see what’s in it. Make sure that you are producing documentation that you would want a patient’s widow or child to see. If you’re a vendor, take a look at your document production code and see if you’re contributing to the problem or helping to solve it. I challenge you to find the development budget to make these issues right if you’re the cause.

Do your users read and correct their notes, or just sign them? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/27/18

The request period for CMS to provide a MIPS Targeted Review is open for less than three weeks. Eligible Providers who participated in the Merit-based Incentive Payment System in 2017 can review their final scores and performance feedback on the QPP website. These scores will determine whether providers receive a positive, negative, or neutral payment adjustment for Medicare-covered services in 2019.

A Targeted Review can be requested if MIPS-eligible clinicians or groups believe that an error has occurred in the payment adjustment calculations. Examples where this applies include data quality issues, eligibility issues (such as being below the low-volume threshold but being assigned a penalty) or not being treated appropriately if qualifying for reweighted scores due to extreme and uncontrollable circumstances. Based on the chatter in the physician lounge, it seems that hardly anyone is reviewing these, so they’ll just be surprised when they find out if they’re getting an incentive or penalty. If you think you should have a review, requests can be made until 8 p.m. ET on October 15.

A group of 29 participants in the CMS Next Generation Accountable Care Organization program is uniting to work with CMS to ensure continuation of the Next Generation ACO program. This is in response to some pushback against the program, which allows organizations to take on greater financial risk in return for expanded flexibility for care coordination and other services. Some organizations feel the promised savings hasn’t appeared as quickly as expected. Participants in the coalition include Dartmouth-Hitchcock Medical Center, Henry Ford Health System, Mission Health, Carillion Clinic, and Trinity Health.

The group members plan to “focus on developing elements of future payment policy, network design, and beneficiary engagement.” They also plan to share best practices and show how risk-bearing arrangements can accelerate transformation in care delivery. Next Generation ACOs were responsible for more than $61 million in savings in 2016, when there were only 18 organizations participating. That number is now up to 51 organizations, which are focusing on chronic care and disease management as well as expansion of primary care services.

Speaking of healthcare savings, a new report from The National Council for Behavioral Health’s Medical Director Institute shows that simply getting patients to take their medications as prescribed could lead to substantial cost savings and improved clinical management. It’s long been quoted that nearly half of people who are prescribed medications don’t take them as instructed. The problem is complex and involves many factors: understanding the need for medication, being able to acquire it (cost or transportation issues), understanding how to take it, and actually taking it at the right time and under the correct circumstances each day.

The institute projects a potential $2 billion yearly savings from reduced hospital costs alone, assuming that a number of its recommendations are adopted over the next five to seven years. Some of the recommendations seem straightforward, such as “better communication between physicians and patients” and improved risk assessments to determine who might not take their medications. However, under our current fractured and stressed system, even something like communication is a challenge, with little time available to actually sit with patients and ensure they understand why they need medication, how to take it, and what to expect.

Of course, technology can help with some of these, such as embedding risk assessments into the EHR or serving them up via a patient portal, but the latter assumes patients have Internet connectivity and a certain degree of health literacy. Data sharing can be used to identify non-adherence – I love the medication history in my EHR that lets me see when patients refill their medications, which can be a proxy for not taking it as directed if the dates aren’t as expected. Other solutions require more cooperation from other parts of the healthcare system, such as expanding use of long-acting injectables as compared to daily oral medications and increasing patient access to pharmacy services.

The institute cites data that one in six Americans take psychiatric drugs and notes the risks to patients not taking medications as directed. I saw this in my practice the other day with a patient who came in for fatigue and lethargy, and it was most likely a medical misadventure with incorrectly administered psychotropic medications. It took me a good 30 minutes to get to the root of the matter, which caused a backup in the clinic and skewed my productivity numbers for the day. Sitting with the family was the right thing to do, but not all clinicians are going to do it (and I doubt my emergency department-trained midlevel providers would have). The patient hasn’t had a psychiatrist for six months due to insurance issues and I ultimately wasn’t able to “fix” the problem, but at least was able to point his family in the right direction.

Most of the news coverage coming out of Washington, DC this week is swirling around the Supreme Court nomination, but I was glad to see that Congress is still at work trying to complete legislation dealing with opioids. A deal reached on Monday includes a measure to allow use of Medicaid funds for inpatient treatment of addiction. The so-called “IMD provision” (Institution for Mental Disease) lifts a ban on using those funds for treatment. The initial ban was put in place because of a concern that scarce funds would be paid to higher-priced inpatient facilities. It’s not like addiction goes away because someone is hospitalized, and since there generally aren’t enough beds to go around already, I don’t think the availability of funds is going to significantly impact utilization. It’s hard to charge for a bed that doesn’t exist. There are also waivers already granted for 15 states with waivers pending for 11 more, but that doesn’t cover everyone which explains why Congress is stepping in.

It’s hard to tell exactly what’s going on in the measure, though, because the final legislative text is not yet publicly available. According to my sources, the Senate bill lifts the ban, and the House version provides for treatment of all addiction, not just restricting it to treatment of opioids and cocaine. There is still some contention around HIPAA and confidentiality rules, with healthcare providers pushing to align the confidentiality rules with HIPAA so that clinicians could share information. It looks like the current law will stay in place, keeping additional protections for records of substance abuse treatment.

The House also blocked changes to the Medicare Part D “donut hole” that were requested by pharma. No one wants to be looking like they’re allowing pharma to benefit while allowing the proposed changes to ride the coat tails of bills targeted at the opioid epidemic. I’m sure we’ll see pharma trying to tack this onto something else as the legislative season continues.

I’ve been struggling this week due to a catastrophic outage at my hosting vendor, whose disaster recovery plan completely unraveled. Apparently it started with a server administrator who was supposed to perform a “file system trim” but mistakenly executed a “block discard” instead. Needless to say, the storage platform immediately dropped all data and crashed everyone. In a serious of unfortunate events preceding that calamity, someone had disabled the snapshot functionality, so there was nothing to use to quickly restore data. Instead, they tried to access the off-site backup server in another state, finding an I/O capacity issue that limited restoration efforts.

I don’t mind my websites being down, but it also took out my email for several days. Although I was able to reach out to key clients and pass along an alternate address, I suspect a number of people think I’m just ignoring them and have no idea what I’ve missed. The outage was long enough that most mail servers would stop trying to redeliver.

Having been on the other side of outages, my heart goes out to the admin who created the problem as well as the company’s leadership who is finding out that “trust but verify” is a lot more important than they thought. As I followed their updates (which were extremely transparent) and the customer forum, I was amazed by the number of fellow customers that had no backup of their sites and no disaster recovery plan of their own. There was talk of how much money they were losing, but no discussion of business continuity insurance or even of disaster planning. There was a lot of screaming in all caps and little realization that flooding the support center with tickets asking them to “FIX THIS MESS NOW!!!!!!” probably wasn’t helpful, especially since they were posting real-time updates to all clients.

It’s a good reminder to make sure that your data is backed up in multiple places (and not just by your vendor, but by you personally) and that also your vendor is testing their backup system and restoration process frequently. Stuff happens, and having a plan makes it a lot less painful, that’s for sure.

When is the last time you tested your disaster recovery plan? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/24/18

Being in the consulting world, I am exposed to a large variety of practices, partnerships, health systems, integrated delivery systems, and more. It’s always challenging when clients and prospects want me to “find someone that looks just like us” before they agree to start working on a project.

I let them know that it’s not just a question of finding someone in my client base that has similar characteristics, but sometimes even finding someone in the healthcare realm that looks like them is challenging to impossible. Explaining this can be difficult, especially after clients have interacted with vendor sales reps who have done their best to convince them that as long as they talk to someone in the same specialty, or as long as they talk to a group of the same size, that they can expect to have comparable experiences.

I see this with both small and large clients, even with large health systems that think that just because XYZ health system on the other side of the country did a certain project a certain way, that they will have similar outcomes. There are so many variables that play into a project’s success, that it often becomes one of those “your mileage may vary” situations.

I ran across this recently with an organization that was looking to understand what size of a team they needed to support their ambulatory EHR needs after migration to a new system. They seemed rather upset that I couldn’t just tell them how many people to hire, without performing some level of discovery around the level of support they planned to provide, what their proposed governance structure would look like, what the organization’s support budget was, and what skill set they expected the team to have.

It’s a complex equation, and I always try to attack the idea of governance – both clinical and application – as the first step in figuring out what makes a group tick and what their needs might be. Organizations that understand the value of governance are like gold to me. They understand that decision-making is important, as is understanding who owns the application and who is responsible for making decisions related to implementation, maintenance, support, and upgrades.

When an organization decides to have tight governance, it can result in not only cost savings due to decreased variation, but also in measurable quality when providers understand that it’s important for people to deliver care in a standardized way. Many organizations do a good job with this during the design and build phases of an implementation, but once the system goes live it’s tempting to fall into bad habits.

Organizations may make customizations to appease a single provider or a small group of providers, which not only consumes resources in the present time, but also in the future, as those customizations have to be constantly evaluated against upgraded software versions. Some organizations I’ve worked with don’t even track their customizations, so they can’t possibly evaluate them. Each upgrade becomes a bit of a surprise as they try to figure out what the “out of the box” software looks like vs. what they have installed in their environments.

My first Lean Sigma project years ago was to work on an EHR upgrade, and I admit that the project itself failed – we ended up not taking the upgrade – but we learned a tremendous amount about the methodology needed to successfully evaluate a new release and get it through the upgrade process. We created an evaluation paradigm that I still use today, across multiple vendors and even outside of EHR applications.

Sometimes the decision to modify the application rests with a clinical committee, but other times it’s the nebulous “IT” that reviews requests and makes the changes. This is unfortunate because technology projects require care and feeding not only by the technical team, but by clinical and operational owners. However, it’s easier to blame “IT” rather than addressing inadequate or absent governance. Other groups may keep their governance structures after go-live, but they become weak over time due to shifting priorities, members’ attention being focused elsewhere, or outright neglect.

It’s great when things are ticking along just fine, but bringing your governance group together quarterly even if there aren’t major decisions to be made isn’t a bad idea. There may be issues that are brought to light or maybe the group just confirms that things are going well, but it’s one of those things that if you don’t ask, you might be missing problems that you didn’t even know existed. If you can’t even get people in the room, that might be a red flag for apathy or end users checking out rather than engaging.

Governance can be tightly linked to management, although it’s best if neither exists in a vacuum. Strong management helps ensure that decisions that are made are carried out in an effective and cost-efficient manner. Effective management is what transforms an organization to being reactive towards the squeaky wheel into one that can proactively look for issues and identify solutions before things turn into problems. It’s often difficult though to have strong management with physician groups, especially when there are numerous competing personalities and where organizational politics becomes a factor.

I’ve seen so many groups take a page out of “Lord of the Flies” rather than be willing to address difficult colleagues or tackle ineffective team members. When I work with them, I present techniques for communication and consensus-building and sometimes it seems like this is the first time they heard that there are “treatments” that can help get them through the rough spots just like there are remedies for medical conditions.

Both governance and management can be tightly linked to culture. I frequently encounter organizations that can’t articulate their culture, and I guarantee that if the leadership can’t even define the concept, they’re not doing a great job of carrying it to the rest of the organization. If leadership is preaching the need for strong governance and effective management,and then doesn’t deliver on those expectations at the highest levels, it becomes not only demoralizing, but often costly for the organization which ends up floundering. The importance of these relatively “soft” disciplines shouldn’t be underestimated.

It’s with all of these factors mind that I approach each organization I work with. One has to understand who they are, where they have been, where they are going, and where they want to be before you can make recommendations to help them. When you’ve seen one organization, you’ve seen one organization, regardless of how similar they may be in size, scope, specialization, etc. It’s tough to determine whether your experiences might be like someone else’s without asking some difficult questions.

I challenge organizations who are in the market as buyers to consider this concept when you are presented with a reference site or a case study that someone is trying to use to convince you to buy, or when you’re trying to determine your implementation or support model. You might find yourself asking some difficult questions of your own organization. Uncomfortable as it might feel, it’s a good thing.

How does your organization approach concepts like governance? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/20/18

This week is Prescription Opioid and Heroin Epidemic Awareness Week. There are several ONC resources available to help clinicians lean what technology is available to them, including prescription drug monitoring programs and electronic prescribing of controlled substances. My practice still hasn’t taken the leap to the latter since we dispense the majority of our controlled substances from our in-house pharmacy, although it’s now mandatory in some states.

AMIA has issued a Call for Participation for its 2019 Clinical Informatics Conference in Atlanta. The CIC meeting has a greater focus on applied clinical informatics, clinical decision support, and health policy compared to the annual fall AMIA meeting. Atlanta is a fun town and I’ve heard the clinically-focused meetings are great, but I’ll miss it due to it conflicting with my annual stint teaching in an outdoor classroom program.

I had some great reader feedback on my recent piece about cultural competency. Readers seem to appreciate the articles that aren’t necessarily pure healthcare IT but touch on issues that many of us face in the workplace.

One reader shared their own experiences with cultural competency training that’s likely to be minimally effective. It’s being delivered as a single mandatory three-hour session and we all know how much information people really absorb after the first hour or so. The reader notes, “Everyone I’ve talked to has been longing for the olden days before text pagers, when you could go to a meeting, set off your own beeper by surreptitiously turning it off and back on again and then acting surprised before rushing out to respond to the ‘emergency,’ never to return to the dreaded mandatory activity.”

The training is also being delivered lecture-style to large groups, which is a shame because group discussion could really bring this topic to life. If care teams or groups of workers attended together, discussion could help them learn more about each other and how to work together effectively as a team as well as with their patients. The reader goes on to describe an institutional push to curb profanity, noting the need to start “whipping out thesauruses looking for allowable substitutes – maybe they should just put Ivory Soap dispensers in the hall to allow cleansing of tongues and improved hand washing in one swoop.” I suggested they consider the Elizabethan Curse Generator, which automates insults in Shakespearian English. Take that, thou distempered fat-kidneyed wagtail!

I was glad that Jenn mentioned the annual Physicians Foundation report on the state of physician practice. The decline of independent practice continues, with barely a third of the 9,000 physicians surveyed using that term to describe themselves. Although Jenn covered some of the highlights, including that 80 percent of physicians feel they have experienced burnout, I found some additional statistics that were thought-provoking:

• US physicians handle over 1 billion patient encounters each year across all settings of care
• 12 percent of physicians are planning to find a non-clinical position
• 61 percent favor either a single-payer health system or a single-payer system with a private insurance option; 27 percent favor a market-driven system; and only 4 percent think we should maintain the current system
• 22 percent of physicians either do not see Medicare patients or limit the number they see
• 32 percent of physicians either do not see Medicaid patients or limit the number they see
• 47 percent of physicians are compensated based on quality/value, but only 18 percent believe that these payments will improve care or reduce costs
• On average, each office-based physician supports about 17 jobs and pays a total of $1.4 million in wages and benefits.
• 49 percent of physicians would not recommend medicine as a career to their children or other young people
• 27 percent of physicians would not choose to be a physician if they had their career to do over
• More than 68 percent of physicians do not believe that Maintenance of Certification processes accurately assess their clinical abilities
• Physicians work an average of 51 hours per week

The report includes a listing of questions and responses aggregated by various demographic factors including age, employment status, gender, and specialty. It also includes direct comments from respondents, which start on page 50 if you’re interested.

One of the mechanisms that physicians use to combat burnout and reduce the amount of time spent interacting with the EHR is the medical scribe. JAMA Internal Medicine ran an article  this week titled “Association of Medical Scribes in Primary Care With Physician Workflow and Patient Experience.” The question posed was whether using scribes decreases documentation burden, improves productivity, improves patient communication, and enhances job satisfaction among primary care physicians. Not surprisingly, the study (although limited at 18 primary care physicians) showed that using scribes was linked to reductions in documentation time and improvements in productivity and job satisfaction.

I’ve been in a practice that uses scribes for the last three years, although I don’t always have a scribe during every shift. We deploy them based on volume of patients seen at our various locations, so if you are scheduled for a lower-volume location you may be on your own. When it gets busy and five or six patients walk in at the same time, you definitely wish you had a scribe. Although I’m fast with the EHR and have tons of personalized templates, macros, and order sets, it’s still not as fast or as accurate as working with a scribe who can document while you’re doing the exam and speaking with the patient.

Unfortunately, many of our scribes are pre-meds or post-baccalaureate students trying to gain admission to medical school or a physician assistant program. This means that once the admissions letters come out, we have to hire a fresh crop of scribes and attempt to turn them into Olympic athletes before influenza season hits.

The new Medicare cards continue to roll out, with more than 35 million mailed to date. Medicare is processing claims and eligibility requests using the new Medicare Beneficiary Identifier and it seems to be going smoothly for the regions where the new cards have arrived. Cards should be mailed to all Medicare participants by April 2019. I polled a couple of colleagues on the revenue cycle side and haven’t heard of any major hiccups, but would be interested to hear from readers who are knee deep in it (especially any readers who are Medicare beneficiaries themselves.)

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/17/18

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/13/18

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 9/10/18

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/6/18

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/3/18

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

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

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

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

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

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EPtalk by Dr. Jayne 8/30/18

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/27/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/23/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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