Curbside Consult with Dr. Jayne 1/7/19

The government shutdown has impacted some electronic media, including the National Zoo’s Giant Panda Cam and the National Park Service website. It hasn’t slowed CMS, which continues to send regular emails about the recent final rule redesigning the Medicare Accountable Care Organization (ACO) program. Referred to as “Pathways to Success,” it is designed to advance five goals: accountability, competition, engagement, integrity, and quality. The program modifies the participation options available to push ACOs toward taking on real financial risk faster than they had been under the previous programs.

I have been under the weather and tried to use my illness-imposed downtime to read my way through various fact sheets and documents around the program, but have had trouble making sense of some of it. The CMS press releases reference different announcements and rules that have been put out, including the Calendar Year 2019 Physician Fee Schedule (aka the November 2018 final rule). According to the release, the Pathways to Success final rule also takes a step back in time, finalizing policies for extreme or uncontrollable circumstances for performance year 2017, which were initially established via an interim final rule in December 2017. I had to read that part of the announcement several times since I’m not exactly sure how that works to modify a program year that ended 370 days ago. I thought maybe it was confusing because I was reading it while I was hopped up on cold medicine, but I eventually decided that it’s just confusing.

In trying to distill the communications, my assessment is this. Medicare has figured out that the majority of ACOs are participating in Track 1 for the maximum time allowable and some of them are generating losses. Track 1 is a one-sided model with sharing of savings without the ACO having to take on risk, therefore Medicare absorbs any losses. The original idea was for organizations to use Track 1 as a way to get their feet wet with shared savings in hopes that they’d quickly move to more risk-bearing agreements. That hasn’t happened, so now the proverbial stick has to come out.

The other existing ACO varieties (Track 2 and Track 2) are two-sided. Eligible ACOs share a larger portion of any savings, but in exchange they’re required to share losses if spending exceeds benchmarks. These programs have been shown to generate savings for Medicare and are improving quality, so Medicare wants to further those types of arrangements.

Medicare has also figured out that so-called low-revenue ACOs (mainly made up of physician practices or rural hospitals) are outperforming high-revenue ACOs, which typically include hospitals. There are challenges for the low-revenue ACOs to move to a more risk-bearing arrangement because those organizations may have less control over how their assigned beneficiaries use services and therefore spend money. Medicare piloted the “Track 1+ ACO Model” during 2018, with the goal of proving that a two-sided model with lower risk would be attractive. Its success influenced the construction of the new redesigned program, according to CMS.

The redesigned program offers two tracks, named BASIC and ENHANCED, which are open for five-year agreement periods starting July 1, 2019. The BASIC track lets ACOs start under a one-sided model and gradually accept higher risks as they move through five levels A, B, C, D, and E. Once they reach the highest level, they’d be recognized as an Advanced Alternative Payment Model (APM) under the Medicare Quality Payment Program. The ENHANCED track is based on the existing Track 3 and allows flexibility for ACOs willing to take on the highest levels of risk. The existing Track 1 and Track 2 programs will be discontinued, as will new application cycles for Track 1+. CMS feels those options would be redundant to the new program.

CMS aims to move BASIC organizations through the alphabetical levels (which they refer to as the “glide path”) by automatically advancing them at the start of a new performance year. Organizations would also be able to jump to a higher level faster if desired. The ultimate goal is to move all ACOs to the ENHANCED track, with high revenue ACOs being required to transition more quickly. There are also stratifications based on whether ACOs are identified as experienced or inexperienced with performance-based risk but to be honest I skimmed over those particulars in my pharmaceutical-induced fog.

The final rule updates the mechanisms for repayment when ACOs have shared losses. Both new tracks may start with lower repayment amounts based on a percentage of Medicare Part A and Part B revenues, with the amounts recalculated annually based on changes in the ACO participant list. Benchmarks will also be recalibrated, incorporating data from ACO experience and regional performance measures. The rule also aims to reduce “opportunities for gaming” by holding terminated ACOs accountable for pro-rated shared losses. ACOs are also able to choose between different beneficiary assignment methodologies and to change their selections for subsequent performance years. Starting in January 2020, eligible ACO providers will be able to receive payment for telehealth services for certain beneficiaries in certain situations. There are also changes to expand the Skilled Nursing Facility (SNF) 3-day rule waiver.

The redesign also allows ACOs under certain two-sided models to operate a beneficiary incentive program, which may allow for incentive payments of up to $20 to assigned beneficiaries who receive certain qualifying primary care services from ACO members. It also clarifies that under existing program regulations, vouchers and gift cards can be provided to beneficiaries assuming they meet other program requirements such as being connected to the beneficiaries’ medical care. There are a few other tidbits in the rule including updates to beneficiary notification requirements. Beneficiaries have to be notified of the opportunity to opt-out of claims data sharing along with how to change their assigned primary clinician. CMS is developing templates for these notices in an effort to reduce the burden to participating practices.

I’m only marginally involved in the ACO realm, so I’m sure those who are deeper in the process might have additional insights. I’ll be looking to read digests and summaries in the coming days until I’m on the mend. Until then, my next reading list involves chicken soup.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/3/19

I mentioned being tired from seeing patients the day after Christmas. Now that we’ve done our month-end close, I know why. We broke our own record and saw nearly 1,300 patients that day, 70-something of which were on my schedule. It truly takes a village to be able to care for that many patients and I’m grateful that my practice’s leadership believes in systems-based care and building teams so that they can run like well-oiled machines. The Centers for Disease Control lists nine states as having high flu activity and another 11 with widespread activity, so it might be a long winter.

This article in the Journal of the American Medical Informatics Association caught my eye with its title: “Cranky comments: detecting clinical decision support malfunctions through free-text override reasons.” I’ve done my share of chart reviews where providers have entered interesting comments when faced with an alert, so I was eager to read more. The authors looked at their database to identify those clinical decision support rules that had at least 10 override comments. The comments were classified into three categories based on whether the user felt the rule was “broken,” “not broken, but could be improved,” or “not broken.” They also looked at the comment frequency and a “cranky word list heuristic” to rank the rules based on the override comments.

Parsing the comments uncovered malfunctions in more than a quarter of all the active rules in the system, which was higher than expected. The authors recommend that “even for low-resource organizations, reviewing comments identified by the cranky word list heuristic may be an effective and feasible way of finding broken alerts.”

For those who are curious, representative override comments included items such as “you are stupid,” “stupid EPIC (sic) reminder,” and comments with many exclamation points. Other cranky words include: dumb; idiot; please stop; why; misfire error, epic, and wrong. The authors note that “swear words were originally included but are omitted from this list because they did not yield comments. Other organizations may wish to include them.”

I’ve heard a fair amount of chatter among physicians regarding the new rule that starting this month in which all US hospitals must publish their price lists online in a downloadable format. Nearly everyone I’ve heard from agrees that having the charges isn’t terribly helpful. What one would really need to know is the negotiated rate between the insurer and the hospital. Alternatively, knowing the hospital’s self-pay discount might be helpful.

Hospital lobbying organizations are concerned that patients might forego care if they see prices that are too high, not understanding that most services are discounted. Of course, there’s nothing stopping hospitals from publishing that data, but we’re not likely to see it soon. I poked around on the websites of the local health systems and within their patient portals but haven’t been able to find anything. I’d be interested to hear from readers who may have actually downloaded one.

On the flip side, CMS has put forward a proposal to require pharmaceutical companies to publish Medicare and Medicaid prices for drugs featured in TV ads. Physicians I’ve talked to are supportive of that idea, and many would like to see TV advertising of drugs eliminated completely. I don’t usually watch broadcast TV, but was exposed to it over the holidays at relatives’ houses. There certainly are a lot of drug ads out there and some of them aren’t even clear on what condition the drug is designed to treat or which patient population is being targeted. Print ads aren’t much better, and even some of the ads in physician trade publications are confusing.

At the beginning of every year, I do some general office housekeeping tasks, including updating my filing and accounting systems for the year and making sure all my recurring calendar appointments are in order. As I was paging through the weeks, I realized that HIMSS is just around the corner and I’m feeling like the next month is really going to be a crunch. I have some serious shoe shopping to do before then, along with breaking in any new purchases. My favorite pair of “trade show shoes” met its demise last year and finding just the right kicks to get me through hours and hours of the exhibit hall will be a challenge. Advance registration discounts end January 14, so if you’re planning to go but haven’t registered yet, you can still save a few bucks.

Working in healthcare IT has been a great way to meet people who work non-traditional hours. Some people make their employment choices based on their enjoyment of overnight shifts because it suits their personalities as “night owls.” Telemedicine and teleradiology have opened up additional options, which has led to the need for support personnel covering the physicians who are staffing those shifts.

I spent some time working at an observatory and know that I do well on the night shift, but only when I can completely tweak my schedule to support it long-term. The occasional night shift kills me. The New York Times recently ran a piece about businesses that are encouraging their employees to work at periods of maximal wakefulness as a way to boost productivity and to help avoid safety incidents due to fatigue.

The US Navy recently migrated the traditional 18-hour submarine schedule to a 24-hour one, and other companies are allowing employees to select day or night shifts based on their preferences. Working remotely can help as well. I know I’m more productive when I work in focused blocks of time outside of the office and having even a 20-minute nap in the afternoon makes a huge difference for me. That’s supported by the “window of circadian low,” which forecasts a midafternoon dip in wakefulness for most people, as mentioned in the article.

The piece mentions strategies employed by pharmaceutical manufacturer AbbVie, where employees go through a nine-hour program to identify their best times for creativity vs. low-energy tasks. Employees are encouraged to mesh their work and professional lives to harness those periods as well as to work around family commitments, leading to a dramatic increase in employee satisfaction with work-life balance. I’ve worked in several clock-punching organizations where even salaried employees were expected to put on a show of being at their desk at certain times regardless of whether they were actually doing anything productive.

Has your employer done any investigation into harnessing people’s most productive periods during the day? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/27/18

The holidays tend to bring out the best (or the worst) in people, depending on whether you work in the customer service sector and how harried your clientele might be. Healthcare has become less of a vocation and more of a transactional situation, where the customer is always right and ratings drive salaries as much or more than clinical outcomes might.

Our urgent care practice is open 365 days per year, although some of the locations close on Thanksgiving, Christmas, and New Year’s Day if they’re within five miles of another site that is open. We used to have every location open on those holidays, but it wasn’t an employee satisfier and closing a portion of the locations made a huge difference for our teams and their families. For those who do work on the holidays, we have catered meals delivered the day before so that staff can at least reheat something for lunch or dinner that might be marginally more interesting than a brown-bag from home.

My holiday rotation put me on Black Friday this year and also the day after Christmas. I knew I was in for a wild ride this morning when there were 10 people waiting outside my door before I even arrived. The situation must have been even worse at other locations, because my scribe was immediately redeployed to another site to work as a patient care tech and another tech was pulled to a third location. Several of our sites broke the records for most patient visits in a day.

I’m always glad that we’re there to help patients, but the unpredictability of surge volumes can wear out a staff pretty quickly. We had some patients who weren’t happy about the wait time and a couple who stormed out of the office because of it. Those are always difficult situations and the team took them in stride, although it always leaves a lump in your stomach when you know someone was unhappy.

The holidays also brought out some examples of the challenges we face in trying to coordinate care based on the way that healthcare is financed in the US. I saw one gentleman who had a work-related injury that occurred last Saturday. He wasn’t able to be seen because we have a worker’s compensation contract with his company and no one was there to authorize the visit. The practice couldn’t see him on his personal health insurance because he had already declared it to be work related and it would therefore be denied.

He wasn’t willing to pay out of pocket, so he went back to work. He couldn’t reach anyone in the authorization department on Sunday or Monday and the office was closed on Tuesday, so today was the first day he could be seen. Although he had tried to treat himself the best way he could, I suspect that he’s going to have a poor outcome because appropriate care was delayed.

I had a patient who required some specific follow up and I wanted to contact his physician through the after-hours exchange. Usually to accomplish this I ask a staffer to call the practice, listen to the after-hours message and get the exchange number, then have them put out a page for the physician to call my cell phone. It can take an hour or more for this process to happen, and in today’s care coordination non-event, it didn’t happen at all.

When my assistant called the practice, they hadn’t switched their phone system over from the usual “we are unable to take your call” message to the “we’re closed, please call the exchange at the following number” message. There was no voice mail available and the patient said he had driven past the office and found it closed. Without an exchange number, we weren’t able to reach his physician or another covering provider.

I had flashbacks from my days as a solo physician when I was the person who had to make sure the phones were switched over. I would call the office before I left to confirm it worked. I sent a task in the EHR to have tomorrow’s team try to do the follow up, but I’m sure that physician’s office is going to be slammed with calls tomorrow and I don’t envy my colleague in trying to take care of it.

We also had a patient come in late in the evening for a preoperative clearance visit, only to find out that her surgery was scheduled for the morning. Good thing that all of her labs were normal and her medical history didn’t have any concerning elements or that surgeon would have had a surprise on his schedule tomorrow. His office was working today, however, because they had called the patient and let her know that they hadn’t received her labs and x-rays, which prompted her visit to us.

We did see some genuine emergencies, including a patient who fell carrying a glass ornament that caused a fairly serious laceration when it broke and a patient with dehydration due to foodborne illness. We also saw some self-inflicted damage, including someone who was seriously ill after trying to “cleanse toxins” with a recipe she saw on the Internet. What she did was to partially cleanse her body of electrolytes, which we were happy to replete. Another gentleman had a raging fever, shaking chills, and poor oxygenation after failing to adequately treat his bacterial pneumonia with a vitamin B12 infusion given at a local spa.

We had two family members who were waiting with patients and decided to be seen “while we’re here.” They didn’t have urgent issues, but figured that since they were waiting already, why not? Neither of them had tried any over the counter or home remedies and both had minor problems that could have been treated for less than $10 at the drugstore. Convenience is king, however, and they both left with prescriptions so that insurance would cover it rather than spending the money out of pocket. They’ll also generate multi-hundred dollar urgent care bills.

It’s moments like that which become a bit depressing, when you are silently screaming that there is a patient in the room next door with an ornament shard stuck in their body, and instead of dealing with it, you’re writing scripts for athlete’s foot and cold sores. We also had patients themselves adding on medical problems after check-in, including one who wanted refills on all her maintenance medications while she was there for an ice-skating related fracture. The reason: “My doctor went on vacation the week before Christmas and never responded to the refill request.”

I felt sad for the nonagenarian who hasn’t felt good in a decade and whose chief complaint was, “I used to climb 14,000- foot mountains and now I’ve felt crummy for a couple of years” and who was brought in by his daughter. There’s not a lot we can do about that at the urgent care other than to offer sympathy, rule out any life-threatening issues, and arrange follow up care. I was grateful for the occasional strep throat visit or sinus infection and even the fractures since they didn’t involve family disharmony or complex psychosocial issues. I’m privileged to have elders in my own family who are generally in good health, and based on what I see at work, I don’t take it for granted.

There’s virtually no consulting work between Christmas and New Year’s, so I’ll be back in the trenches again tomorrow and then over the weekend. Let’s hope for primary care docs who have their phones set up, offices that are open, and sidewalks that aren’t slippery. My New Year’s wish is that the folks who concocted the influenza vaccine nailed it and that everyone has a happy and safe 2019.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/20/18

Big Data continues to be a buzzword and I enjoy hearing about novel applications. The Journal of the American Medical Informatics Association recently published an article covering a system that uses online Yelp restaurant reviews to identify foodborne illness. The system is currently in use by the New York City Department of Health and Mental Hygiene to monitor for foodborne illness complaints. It classifies review based on whether they indicate illness, and if so, whether multiple people are involved. It has identified 10 outbreaks and over 8,500 complaints.

Missouri is the only state in the US that doesn’t have a Prescription Drug Monitoring Program, and Governor Mike Parson has indicated he’d like to sign legislation that is “long overdue.” Parson, a cattle farmer by background, came into office following the resignation of the former governor following a scandal. He’s keenly aware that the state is the only one without it, although friends practicing in the state tell me that St. Louis County launched its own database that aggregates data for a large portion of the state. Maybe they can harness the existing system rather than re-create the wheel.

My state’s PDMP has helped me in the clinic more times than I can count, so I feel for those who don’t have access to the tool. Missouri also recently approved marijuana for medical use. When I called my former classmate to ask her about the PDMP situation, she noted that her office received 20 phone calls about it the day after the election. Good luck to those of you in the Show-Me State.

Speaking of controlled substances, a US Food and Drug Administration panel recommended this week that physicians who prescribe opioid drugs should also prescribe the overdose reversal drug naloxone. This would lend itself nicely to order set and clinical decision support functionality, although there’s quite a bit of debate as to its necessity and the amount it would add to overall healthcare spending.

There’s also debate about patients getting naloxone added to their pharmacy profiles since that data can be used for other purposes, such as life insurance underwriting. NPR recently reported on a nurse who was denied coverage because she carries the drug as a healthcare provider who is willing and able to use it should she come across a patient experiencing an overdose. The issue highlights the dilemmas faced by many of us in healthcare, where even the best-intentioned ideas can have numerous downstream consequences.

Users, beware: SplashData has published its annual list of the 100 worst passwords of the year, based on five million leaked passwords found on the internet. The worst offenders continue to include “123456” and “password.” Other new entries on the list include “donald” (which debuted at number 23 and may be inspired by our Commander in Chief), “sunshine,” “princess,” “charlie,” and “!@#$%^&*.” The old standbys of “admin,” “welcome,” and “iloveyou” remained on the list, although I’ve never been enamored of my computer or my job enough to consider the latter option.

Dr. Jayne’s inbox has been flooded with announcements from various companies who plan to participate in the JP Morgan Healthcare Conference in San Francisco. There are usually some interesting keynotes at the conference, whose attendees are clients of JP Morgan. It looks like there are several hundred presenters from startups to the usual big players. Another round of press releases will follow the actual conference, including transcripts and sometimes recordings of the presentations, so I have that to look forward to. I’d be interested to hear from anyone who has attended including what they thought of it and if they learned anything that they couldn’t glean otherwise.

A shout-out to Jenn over at HIStalk Practice and her coverage of medical-themed holiday decorations at her local hospital. If you’re not including HIStalk Practice in your regular news roundup, you’re missing out.

Workplace-themed trees aren’t unique to healthcare, such as this one made of used pointe shoes at the English National Ballet.

Jenn also clued me in to the rise of private equity funding in the medical apparel space, with recent funding of scrub manufacturer Jaanuu. The company has raised $25 million to date. The Nordstrom family also participated in the recent funding round. Although making scrubs and lab wear more fashionable is a goal, they’re also working to use odor-eliminating, water-repellent, and antimicrobial-treated fabrics to increase functionality. Company founder Sethi Young notes that medical professionals “need a ‘uniform’ that’s not uniform at all – no one style, fit, or fabric is going to be what you need to do your best each day, every day.”

It seems to me that perhaps there’s a disconnect between the company’s vision and the realities of work within a hospital, medical office, or other clinical setting. Workers don’t necessarily get to choose what they’re going to do each day, but rather need clothing that can handle anything that’s thrown at them in an often-unpredictable environment. I don’t wake up envisioning, “I’m going to have to suture a lot of lacerations today, better wear the stain-fighting pants in case I drip Betadine on myself” or wanting to be glammed-up by my scrubs. The initial thought that there’s a disconnect was reinforced when I read of their desire to become a “lifestyle brand.”

I’m going to stick with my sub-$40 lab coats and the durable scrubs that I know I can just about boil. I’ve been wearing scrubs for the better part of two decades and have had hospital-issued ones, personally-purchased ones, high-performance designs, extra-cheap designs, and one double-breasted scrub top I had to wear during a transplant team trip that made me think I was in a sci fi movie. I guess I’ve been lucky that I never felt that they had a “negative psychological impact” while I went about doing my job.

The only problem I’ve ever witnessed with ill-fitting scrubs was during an emergency C-section, when the pregnant obstetrician had her overly large scrubs pulled up above her belly. When she ran down the hall, they slid down, almost making her trip. Since they were hospital-issued, OR-mandated scrubs, it’s not like she could have strolled in wearing fashion maternity scrubs.

What do you think about lifestyle brands in the healthcare space or the concept of lifestyle brands in general? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/17/18

I recently had an invitation to attend a webinar on artificial intelligence in medical imaging. There was a recent article on the same topic that’s still sitting in my “to skim” pile, so I thought it might be good to go ahead and take a peek.

I have to read diagnostic images as part of my day job. It’s one of the more challenging parts of my practice, primarily because I didn’t do it for a decade and was out of practice. Most of the images we encounter are x-rays we’ve ordered on our own patients, which seem easier to read because we have the whole clinical picture and know what we’re looking for on the images. For quality purposes, we also over-read the studies ordered by other physicians at different locations, which can be challenging because you don’t always have the whole clinical picture.

The most challenging images however are the CT scans. We’re not doing the primary readings on those, but due to some quality issues with our virtual radiologists, we’ve been asked to review all of our images. Given that my formal radiology training was a two-week rotation more than two decades ago, I’ve been seeking out educational resources to help improve my skills.

Still, each time I come across an image that has questionable findings — whether it’s a CT or a regular x-ray image — I can’t help but think that having some computerized support would be beneficial. Most of the articles I’ve seen on the topic are specifically directed at the incorporation of AI into radiology workflows. I haven’t found very much research looking specifically at AI within primary care radiology workflows.

In getting AI technology approved, studies look at whether the technology can identify the correct findings at least as well as the radiologists, who are usually residency trained and board certified. I’m sure there’s a preponderance of academic medical center radiologists reflected in the studies, and I would suspect that outcomes might be different in those institutions where radiology is highly specialized compared to community hospitals, where radiologists may be more generalists. There may be even different outcomes in accuracy of readings when you throw emergency physicians, internists, pediatricians, and family physicians into the mix as they read films in their offices and various outpatient settings.

Several of the potential solutions being evaluated in radiology involve support prioritizing the radiologist’s work list. Some algorithms analyze screening tests where the majority of studies are negative and highlight those images where an abnormality may be present. This is being done for studies like mammograms, where imaging technology is moving from 2D to 3D images, creating additional image volume and requiring additional time to read each study. The goal is to prioritize those that are the most high-risk so that they are addressed quickly and carefully. Other solutions are looking at areas where an abnormal study poses a high risk, such as post-trauma head CT scans.

Even though they’re not studying readings by primary care providers, there’s some exciting work being done with chest x-rays. One effort looked at 1.2 million images working to create an algorithm that would assist in “low-resource settings” without radiologists, which would certainly apply to my practice. Once the system was trained to identify specific findings — such as heart enlargement, calcification, presence of fluid, and opacity — it was tested against a panel of radiologists looking at a set of 2,000 x-rays. The system reliably identified the findings roughly 90 percent of the time. I wonder how it would score against non-radiologists looking at the same images.

There are particular types of x-rays that I still struggle with, because they can be difficult to read just because of the body part you’re looking at. Rib x-rays are an example and are challenging because the ribs sit on top of dense parts of the body (the heart, the spine, and major blood vessels) and because they curve and angle, which causes overlap when you’re trying to figure out what you’re looking at. They’re also tricky when you’re dealing with larger patients, who have more tissue for the radiation to penetrate.

I had a patient with some trauma who came in sounding like he had a broken rib. Normally, I’d prefer to order a CT scan because it gives you much better pictures of ribs without overlap. However, I was working at one of our outlying locations that doesn’t have CT, so I went with the plain film. There were indeed some rib fractures. I identified what I thought were two separate issues, but my partner doing the over-read didn’t agree — she thought there was only one. Regardless, the one looked strange enough that I felt a CT was indicated to fully define what was going on and transferred him for the study.

Within 20 minutes we had a radiologist on the phone telling us he had three fractures and also a collapsed lung, which neither of the initial reading physicians picked up on the x-ray. In hindsight you can see it, but it’s a really subtle finding and the border of the lung overlaps with the edge of a rib, right at the top of the chest where there’s a lot going on in the film. It’s likely that both of us were focused on the indication of “rule out rib fracture” and even though we did assess for lung issues, we didn’t see it.

That’s the problem with human brains and how we process information. We’re constantly prioritizing what we’re working on and rapid switching is a factor when we’re addressing multiple tasks (I had eight assigned patients I was covering at the time I was looking at the films). As a physician, you feel terrible when something like this happens, but it does happen.

I’m grateful that the only issue here was a brief delay in diagnosis. The patient’s condition had not deteriorated in the time it took to get the CT can and he had normal vital signs and oxygenation the entire time we were evaluating him. The biggest challenge I had was finding a hospital to accept his transfer, since his preferred hospital suggested that I send him elsewhere because “our folks don’t like to take care of that.” Not exactly a ringing endorsement, but the closest Level 1 Trauma Center was more than happy to accept him.

I look forward to the day when I have some AI helping me out in the trenches. Hopefully we’ll get to that point before it’s time for me to retire.

What do you think of AI in diagnostic imaging? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/13/18

CMS announced an upcoming outage of the Open Payments system, in advance of the data submission for Program Year 2018. The system will be down January 3-6 and then again January 14-26. CMS notes that the outages “coincide with enhancements which will enable a better user experience,” but I suspect that they won’t be revolutionary enough to justify 17 days of downtime.

I felt like a fish out of water in my practice this week, as my state’s Prescription Drug Monitoring Program database had some technical glitches. Apparently, connectivity issues impacted the accuracy of the dispensing data for the past week, leaving physicians wondering whether their patients had actually picked up controlled substances more than the website showed. It can be amazing how dependent we become on technology and how much we miss it when it’s not working.

On the other hand, we rolled out some new technology that isn’t working quite as planned and it led to a great deal of aggravation. We switched online check-in platforms and it’s been difficult for both patients and staff to adjust. Our old platform was pretty basic, allowing a patient to provide demographic and insurance information along with a brief history. It also added the patients to a queue so we could bring them into the EHR when they arrived.

The new platform promised much more functionality, including an “appointment time” so that patients can wait at home, avoiding other sick patients and remaining comfortable. However, we’re still trying to see patients quickly as they arrive and aren’t set up to hold an exam room for a patient with a pending appointment time. Despite the wording on the online check-in page, patients have been arriving at the office with the expectation that they’ll be seen at their appointment times. This has led to some friction at the front desks and to a couple of outright confrontations. We’ve been working with the vendor to see if we can change the nomenclature to something like “estimated visit time” or “estimated treatment time” rather than an “appointment time” but it doesn’t look like it can be done.

Our leadership is contemplating going back to the “virtual line” product, which happens to be integrated with our EHR. One of my partners asked about using a system like restaurants use, where a patient can leave the office and be paged when it’s their turn. I have mixed feelings about that approach for patients with infectious conditions. If they’re sick enough to be seen, they don’t need to be moving around the community or visiting retail locations adjacent to our offices.

They’re also contemplating telehealth options, which could help to reduce congestion in the office. I’m personally excited about that option, as flu season makes me dread the inevitable upper respiratory infection I’ll get regardless of how much handwashing I do, and would reduce the number of sick people traveling around the community.

A friend who works at a software vendor clued me in to a recent New York Times piece about our collective obsession with innovation. I was pulled in by its tagline that “some of our best ideas are in the rearview mirror.” It further hooked me with this:

We are told that innovation is the most important force in our economy, the one thing we must get right or be left behind. But the rear of missing out has led us to foolishly embrace the false trappings of innovation over truly innovative ideas that may be simpler and ultimately more effective. This mind-set equates innovation exclusively with invention and implies that if you just buy the new thing, voila! You have innovated. Each year businesses, institutions, and individuals run around like broken toy robots, trying to figure out their strategy for the latest buzzword promising salvation.

That seems to sum up a good portion of the healthcare IT market, especially in the lead-up to HIMSS. There’s a lot of “shiny object syndrome” going on, and by looking for the next buzzword-enriched solution, we may be missing what the article describes as true innovation:

It is a continuing process of gradual improvement and assessment that every institution and business experiences in some way. Often that actually means adopting ideas and tools that already exist but make sense in a new context, or even returning to methods that worked in the past. Adapted to the challenges of today, these rearview innovations have proved to be as transformative as novel technologies.

How many new technologies have hospitals partially implemented that might be revisited to ensure they deliver their additional promise or might be pushed to provide additional benefit for users? Can we glean additional return on our investment or find new uses for it? Are there ideas where some old-school thinking might be of benefit?

The article mentions swings of the pendulum in urban planning and the return of previously marginalized solutions such as farmers’ markets. It mentions the rise of craft beer, heirloom vegetables, and artisan baking as ways that we are moving forward by looking back.

There are plenty of problems that we can solve in healthcare that don’t require technology, and many organizations aren’t even thinking about them. At one large multi-state integrated delivery network, physicians aren’t allowed to delegate refill authority to trained staff even for routine maintenance medications for blood pressure or high cholesterol. Although there are some great systems out there to help with refills (healthfinch, anyone?) an organization first needs to decide that physicians should have support completing those types of routine tasks. Until they arrive at that point, it doesn’t matter what technology is available.

The intersection of technology and policy made me want to scream this week. One of my clients recently changed their password security requirements. I’m wondering if I missed a new release from NIST because some of the requirements are directly contrary to what had been released earlier in 2018. This hospital has adopted some particularly onerous guidelines. Not only must the password include upper- and lower-case letters, it must also include numbers and special characters. They’ve also reinstituted time-based changes every 90 days. Passwords can’t be reused for at least a year. Worst of all, at least five of the eight required characters must be changed for every new password.

NIST has said previously that requiring periodic changes and arbitrary complexity isn’t helpful for security and that it just frustrates users. On the flipside, the helpful people at LL Bean recommended that I write down both my password and the answers to my security questions. If you’re a hacker looking to score some durable polo shirts or “wicked good” boots, have at it.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/10/18

The physician lounge was abuzz on Friday due to a piece on CNN claiming that Australian researchers have developed a “10-minute cancer test.” Supposedly it “can detect the presence of cancer cells anywhere in the human body” and stems from research looking at the structure of cancer DNA when placed in water. Physicians were mostly grumbling about having to respond to patient questions about such a sensational announcement when the ink on the publication was barely dry. Patients tend to take hold of these kinds of announcements, especially if they have a particular concern about cancers for which there aren’t good screening tests, such as ovarian cancer.

There’s always more to the story when these announcements are made. Despite author Matt Trau’s statements that the study “led to the creation of inexpensive and portable detection devices that could eventually be used as a diagnostic tool, possibly with a mobile phone,” in this case, the test hasn’t even been used on humans. People tend to hear the part about diagnosing cancer with their phones and miss the part about animal studies. The authors are excited and with good reason, but it’s a long way from where they are with this test to having it available at the primary care office.

The test mentioned in the publication, which was released this week in “Nature Communications,” has only been used to detect lymphoma, along with cancers of the breast, prostate, and bowel. It’s also only been used on around 200 samples, although it did have 90 percent accuracy. Researchers using high-resolution microscopy noted differences between the structure of cancerous DNA fragments and non-cancerous fragments when the DNA was placed in water. The test uses colloidal gold particles to bind to cancerous DNA, creating an electrochemical reaction that can be quantified.

One of the urologists around the table was particularly vocal about suggesting that this test could be used for prostate cancer since there has already been a fair amount of controversy about prostate cancer screening. We’ve seen the Prostate-Specific Antigen (PSA) fall in and out of favor – first approved by the FDA in 1986 to monitor prostate cancer progression, it was approved in 1994 to be used along with a digital rectal exam for screening of asymptomatic patients. Over the next two decades, we saw patients with “abnormal” tests who underwent procedures that may have been overly aggressive given the slow-moving nature of prostate cancer, not to mention the non-cancerous conditions that can cause PSA elevation. Over time, we learned that the test was being relatively overused certain populations without definitive evidence that it drives outcomes in a beneficial way, leading to recommendations that we don’t just order it, but rather have a risk/benefit decision between the patient and the physician before deciding to test.

As we consider new technology and new tests, we need to heed the lessons of the past and proceed with caution, guarding against “shiny object syndrome” and the assumption that just because we can theoretically use a smart phone to do a test that it’s a good idea. CNN ran a similar piece back in January, covering a test developed at Johns Hopkins University that screens blood samples for eight common cancers by detecting cancer proteins and gene mutations. That test, called CancerSEEK, is still being studied to determine its applicability in clinical medicine and whether it can be widely used to screen patients who aren’t experiencing symptoms. CancerSEEK was evaluated in a much larger study that included humans with almost 2,000 patients participating. The test was 70 percent sensitive among the eight cancers, but the range of accuracy for individual cancers ranged from 33 percent in breast cancer to 98 percent in ovarian cancer. The Hopkins team also used an algorithm to evaluate the source of the cancer for positive tests, but the ability to pinpoint a source was only 63 percent.

It will take a tremendous amount of money to bring either of these technologies to the point of care, and unfortunately with medical research, the money doesn’t always follow the hype. Even when tests are promising, they have to be shown to be effective and to be able to make a difference across large patient populations before payers will cover them, which often the main barrier to patients receiving new tests and treatments. EHR and other healthcare vendors follow these discoveries closely since they need to stay ahead of the curve for supplying appropriate clinical decision support information and including new discoveries into order sets and EHR content.

Those changes don’t happen overnight. I work with one EHR vendor that still hasn’t incorporated standard-of-care screenings that were recommended by the United States Preventive Services Task Force (USPSTF) back in 2007. It’s understandable that providers are frustrated when it takes more than a decade to update the EHR.

The conversation about detecting cancer DNA quickly segued into one about the recent “gene-edited baby” announcement coming out of China. A scientist claims to have used the hot new CRISPR gene-editing technology to alter two human embryos to be resistant to HIV. The babies have now been born and the news led to significant outrage from the international scientific community. The processes of announcing the research has broken with the standards of research, with the information being revealed via YouTube rather than through rigorously-reviewed scientific channels. That’s not surprising in the era of social media, but should be viewed with caution. There are many other concerns with the research, including lack of appropriate Institutional Review Board protection for the participants, lack of documentation of the work actually done, and the lead researcher owning patents around the techniques used in the process. It wouldn’t fly in the US or in many other nations.

The conversation came full circle when one of family medicine docs at the table spoke up. She said she felt sad that everyone was excited about these media sound bites around research whose practical use was years away, but she has difficulty getting medical professionals engaged around her work with school-based clinics and mobile outreach to our city’s homeless population. I mentioned working with providers who struggle with EHR adoption and the challenges of trying to get them to use the guideline prompts and alerts that are already in the system for tests that are proven to be clinically effective as well as cost effective. It’s certainly something to think about in this world where we’re used to getting our information 200 characters at a time and the deeper discussions sometimes elude us. Physicians don’t have the time to pull the original articles and read the primary source data, so it’s unlikely that patients asking about these new advances are going to have done so either.

Given our work in healthcare information technology and the seemingly relentless push for innovation, we often become skeptical (if not cynical) about developments. We’ve seen plenty of creative new technologies fizzle and watch the industry continue to search for the next big thing. And we understand how hard it is to take technology from the idea stage to practical use at the patient bedside whether physical or virtual. It will be interesting to look back on these developments in a year, or five or 10, and see where we have landed.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/6/18

Following the ONC annual meeting at the end of November, I received an email that the slides and webcast would be “made available in the near future.” This always aggravates me after conferences, because by the time they make the content available, people have moved onto other things and momentum is lost. Especially with a relatively small (two-day) meeting, it shouldn’t be that hard to get the materials together since presumably people had to submit their slides in advance for review and approval. Webcasts also aren’t that hard to get online, especially if they’re not edited. Making the materials available quickly would help engage those who couldn’t be there and allow them to be part of the discussion.

I finally had some time to dig into the draft “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs” document that ONC issued last week. It offers three goals for reducing clinician burden, including reducing time and effort to record information, reducing time and effort for reporting requirements, and improving EHR functionality and ease of use. I’m not sure whether or not I should read something into how those goals were constructed, since fixing the third goal would likely solve a big portion of the first one. When you dig deeper into the document, it becomes apparent that the first item refers not only to documentation effort, but the fact that the documentation required for billing is a burden above the documentation required for clinical care.

The usability discussion specifically addresses poor design of clinical decision support tools, including pop-ups that require “excessive interaction.” It also mentions poor implementation of electronic summary of care documents, lack of standardization around the presentation of clinical content, and the need for improvements to configuration and implementation processes that should “proactively engage the end user.”

One of the problems here is the fact that EHR vendors simply don’t want to spend as much money as would be needed to make EHR systems substantially better. I worked with one vendor that had a limited development budget, which essentially meant that the only work they could afford to do was that which was mandatory – either required for them to maintain certification or to address severe patient safety defects. Even minor patient safety defects were put into the deferred maintenance bucket to sit until more development hours became available, which often meant that they didn’t get fixed. When there’s not enough money to fix patient safety issues, that means that the “nice to have” and usability enhancements logged by customers over the years rarely made it to the requirement stage.

They also go in-depth about reporting issues and the fact that “regulatory requirements and timelines are often misaligned across programs and subject to frequent updates, which require significant investments from clinicians to ensure annual compliance. Government requirements are also poorly aligned with the reporting requirements across many of the federal payer programs in which clinicians may participate …” How about this — let’s put a freeze on federal reporting requirements until the federal payers can get their own houses in order. Present us with a unified set of reporting requirements that make sense clinically and actually allow us to drive the needle for clinical quality rather than just make us report for reporting’s sake.

While we’re at it, here are my other suggestions to solve the issues (although I’m sure they’d never be accepted): First, allow physicians to bill office visits based on time. Not the current “greater than 50 percent of this visit was spent in counseling and coordination of care” nonsense, but actually billing on time like a lot of businesses do, including attorneys, accountants, auto mechanics, and the guy who does my hair. If you’re more complex and take more time, allow us to be compensated for what we do. If you’re a quick visit, let us see you and get you on your way. One might say this may lead to abuses, so let’s put reasonable caps on it, such as a maximum of 16 hours a day. It can’t be any worse than our current system that doesn’t even detect fraudulent physicians that are billing many more procedures than they could possibly do in a day.

Second, let’s also address the usability issue by requiring vendors to issue standardized reports to their clients on how much development time is spent on regulatory requirements, remediation of software defects, patient safety issues, usability, new content, and the like. I know vendors hate this idea because they’re afraid the information will wind up in the public eye, but it’s important for customers to understand whether their vendor is really putting their money where their mouth is. This is hard for publicly traded companies, since actually spending money on development eats into the profit margin. Still, there has to be some kind of accountability for where the millions of R&D dollars are being spent.

While we’re at it, let’s also think about adding some requirements that will just make everyone’s lives easier. Let’s standardize to LOINC for laboratory orders and results. It’s there, it works, and it would save time for hospitals and healthcare organizations. Not just in the EHR, but with the laboratories – I’m tired of federal mandates that put the onus on the physicians, but don’t do anything to make lab vendors comply. I can’t even count the number of practices I’ve worked with whose vendors aren’t sending LOINC codes with results, but the practices have to have the codes mapped in the EHR, so much manual mapping occurs. Why not just fix the problem at the source? The strategy does allude to this a bit with standardization of medication information, order entry content, and results display conventions, but it’s shameful that we’re still talking about this a decade after the start of Meaningful Use.

What about patient matching and interoperability issues? There’s no federal funding for a universal identifier, but what if the vendors came together and created a voluntary one? Let patients opt in or opt out, but if they want to opt in, let’s give them a unique ID they can carry around to their providers that can be used to assist with matching. It’s clear that it’s never going to be a federal priority even if they blockages in front of it are cleared.

I ended up having to stop reading the document, because what I thought was going to be a quick blurb about it has rapidly turned into a semi-angry rant about the state of things. I’ll have to refine my thoughts before I enter my formal comments, which I will certainly do before the January 28, 2019 deadline. ONC plans to post all the public comments that are received, which should make for some entertaining reading in front of a nice fire on a snowy evening.

If you were in charge of all things healthcare IT, how would you fix these problems? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/3/18

My former employers at Big Hospital System recently reached out to me, requesting some assistance with practices they’ve acquired. In the years since I left, they’ve consolidated their empire onto a single EHR platform and have streamlined a number of IT departments including the EHR implementation team that I used to manage. The current implementation team is relatively green, having been hired with job descriptions that only allow them to address the new EHR, and not to think critically about or assist with any other systems. They’re also a relatively small team and their time is spoken for over the next 120 days. Whoever made the decisions to restructure the team this way apparently didn’t talk to the business owners of the employed physician group, which has continued to acquire independent practices at a rapid pace. These practices are then left in limbo because they can’t get a deployment slot on the new EHR for months and months, but they still have to try to run a practice either on their legacy system (if they owned rights to it and can keep it) or possibly even on paper.

The acquired physicians are frustrated and rightfully so. Being added to the main health system EHR platform was part of the decision-making for employment for many of these struggling independent practices, allowing them access to a repository of information about their patients along with professional referrals and communications. Several of them were already frustrated with their existing EHRs, and the idea of having to stay on broken systems for another six months is unacceptable. Unfortunately, they either didn’t understand or overlooked the contractual agreement regarding EHR migration, which clearly gives the health system control of the timeline for retirement of their current systems and movement to the mother ship’s platform.

I was asked to do some contract work with these practices, trying to reduce the frustration factor on their existing EHRs while they wait for migration. The health system also asked me to look at the installations from a support perspective, to determine the best strategy to handle upgrades and issues with the systems in the interim. I asked myself why this wasn’t done during the courtship process, and of course it has to do with money and convenience for the employer. That’s the way many physician contracts are these days, unless the contracting practice reads them with a careful eye and is willing to walk away if they don’t get an acceptable outcome. There’s also the factor of the physician group’s leadership assuming that the health system’s IT team would be willing and available to support the new practices and failure to gain an understanding of existing migration and implementation resources before setting a verbal (and unenforceable) timeline in front of the practices they were wooing.

I was happy to take on the work, not only because it was local and would keep me from having to travel much during the holiday season, but also because I know some of the impacted physicians personally, either on a professional basis or through community organizations. The work has been a flashback to my early days as a medical director for informatics, as I’d go out with recently-implemented physicians and try to optimize their day-to-day workflows. It’s always gratifying when you find quick wins that can impact physicians in a positive way – maybe they’re not using medication favorites or order sets. Those findings are common among small practices that may not have had dedicated EHR super users or that may not have spent the money and time needed for advanced training.

I’ve also had some flashbacks about working with systems that don’t seem to have a lot of clinical oversight. When I saw some of the workflows, they made me wonder whether a physician at the EHR vendor performed user acceptance testing before the content went out the door. One of the more obnoxious “features” I saw was part of a lab interface, where the ordering user has to handle those pesky but necessary “ask at order entry” (AOE) questions. For many tests, there should be a 1:1 relationship between the test code being ordered and the specimen type. For example, if you’re ordering “Stool for Ova and Parasites” the specimen type is “stool” and it should only have to be entered once. In one system I worked with, the ordering user (the provider in this case) had to enter “stool” as the specimen type twice for the same test. Since she was a GI doc and was ordering three different stool panels, she had to enter a specimen type of “stool” no less than seven times, even though each test was prefixed with “stool.”

I thought maybe it was just a configuration issue since there are situations where there still needs to be a more specific specimen type entered even though there is specimen information in the test name. For example, urine cultures – even though “urine” is in the test name, one has to specify whether it’s a clean-catch or catheterized specimen, etc. It was clear that it was a design issue, however, when we got to the blood tests, when the user had to select “venous draw” for all seven tests in the basic metabolic panel. That’s pushing absurdity, and no wonder the providers are frustrated since the BMP characteristically is performed using a single blood tube, not seven different samples.

I also ran into some examples of management absurdity. One practice has been performing weekly backups from their server, which resides in a data closet in the office. I asked them if they ever restore from the backups, and they said no. We talked a little bit about the need to practice downtime procedures and to make sure the backups are working properly. They agreed to do some downtime testing, and we restored the most recent backup to their test environment. I thought it was a bit weird that their test environment was hosted outside the practice but their production server was still in the closet. When we restored the backup, the most recent data entry was from June 2013. This led to some detective work, and after burning through some billable hours I was able to determine that they had been migrated from their self-hosted server to a cloud-based platform in the summer of that year. No one must have understood the significance of the migration, because the practice had been paying a third-party IT resource to perform regular backups of a server that was no longer being written to and had spent tens of thousands of dollars over the last five years for no reason. They were grateful that I figured out that they could stop with the backups, but were fairly aggravated about the whole situation.

I’m glad I can help some local physicians, but I hope they realize this is just the beginning of their relationship with Big Hospital System. The grass may have seemed greener on the corporate side of the fence, but now they’re just a handful of physicians among thousands. Despite what they may have been told during negotiations, they’re going to have to wait their turn for everything including migration to the shiny new EHR. In the meantime, I have a feeling we’re all going to get to know each other rather well as I spend some time on the helping side of the help desk.

How does your health system handle practice acquisitions? Are they live on the communal EHR day one? Leave a comment or email me.

EPtalk by Dr. Jayne 11/29/18

Recent data from Case Western Reserve University shows that hospitals meeting EHR Meaningful Use standards had average patient stays that were shorter than their non-MU-compliant counterparts. Digging deeper into the data, they looked at four years of information and found that the length of stay was about four hours shorter. In various industry publications, there are plenty of quotes floating around from hospital administrator types talking about how MU-compliant EHRs improve compliance with treatment pathways and improve communication. As a physician, I’m wondering whether that four-hour length of stay is clinically significant. I’m also questioning the quotes from people talking about it generating “significant savings” for large health systems. To do that analysis, you can’t just look at the length of stay – you’d have to look at all the costs and factors contributing to that length of stay, including the cost of the EHR and the payroll costs associated with all the clicks mandated for Meaningful Use; as well as the costs to purchase, implement, and maintain the EHR at the MU-ready level above and beyond clinically-necessary EHR functionality. Nurses and staff can move faster caring for patients when they’re not performing clinically-irrelevant screenings or documenting unnecessary data.

The study, published in the Journal of Operations Management, only looked at hospitals in California and categorized hospitals three ways – those who had “meaningful assimilation” of EHRs, those with full adoption, and those with partial adoption. Comments from the authors note that “results from this study indicate that meaningful assimilation of technology is likely to help free-up clinicians and other valuable resources – this approach is preferable to making additional investments in facilities or hiring additional employees as more people seek hospital services.” This oversimplifies a complex problem. Speaking from experience, length of stay can also be shortened by having more care coordinators with smaller patient loads and greater ability to orchestrate hospital discharges in an efficient manner, making sure the family, the patient, the hospital, home health, and any receiving facilities are all on the same page. That requires hiring human beings, which cost money.

My last hospital stay was four hours longer than it needed to be because the surgeon’s PA rounded over lunch rather than before office hours, and there had to be a physical exam documented prior to discharge despite the fact that I had met all discharge criteria and practically had a car running in the parking lot trying to get out of there. Still, we had to check the boxes for people to get paid, prolonging the stay. The study also doesn’t show causation, merely correlation. It’s likely that hospitals that are fully compliant with Meaningful Use are also participating in other initiatives such as quality improvement projects, promotion of clinical best practices, etc. on a higher level than other hospitals. In order for the study to truly show causation, the authors would have needed to control for those factors as well.

Atlanta-based Sharecare was named to the Deloitte Technology Fast 500 for the second consecutive year. Sharecare promotes itself as a “digital health company that helps people manage all their health in one place,” including helping them calculate and track their “real age” versus their actual chronological one. These kinds of rankings are based on revenue growth rather than clinical or quality factors, although health plans are engaging with Sharecare so there must be clinical data in there somewhere. I’m skeptical about their involvement with Dr. Oz and also their website lead-ins on taking “the first step to growing younger.” We would be better served as a society if we promoted people getting the best health at any given point in time rather than focusing on being younger, etc. There’s something to be said for growing old with grace and not trying to fight the clock with various surgeries, injections, and products. They have a whole section on their site for advertisers titled “Drive measurable results for brands,” including talk of “precision targeting fueled by the largest database of first-party, self-reported health information” including the ability to drive “awareness, engagement, and proven conversion for brand partners.” That kind of calls into question their other motivations, at least in my book.

On that same note, in the news earlier this week, Mr. H asked about private equity in healthcare – specifically, whether the “slash-and-burn, flip-focused” methods were appropriate in healthcare. The Washington Post story he references looks specifically about PE in a nursing home situation. I’ve not personally experienced that, but I have seen plenty of private practices sell to PE organizations, particularly in dermatology and ophthalmology. Providers in those specialties have remained independent for a long time while their lower-paid primary care counterparts have already given up independence for the security of hospital employment. Still, running a practice is daunting, and with the changes in reimbursement and contracting and managing people it’s enticing to want to sell to someone who promises to take care of all the perceived hassles.

However, nearly everyone I’ve encountered who has sold their practices has very quickly found that it becomes all about profitability. The fact that the PE firms are only going after high-profit practices should have been a tip-off – they’re not snapping up general internal medicine or family medicine practices. Physicians gave up having to make human resources decisions only to find their staffs slashed and longstanding employees laid off. Administrators with MBAs but little healthcare experience are making decisions about patient care including what services to offer and whether providers can see uninsured patients. Not all the decisions are correct about profitability in the healthcare context – a colleague recently was forced to institute a policy where uninsured patients were turned away, because his PE overseer didn’t realize that self-pay patients can be profitable due to low billing costs. The 24 year-old administrator saw “uninsured” and thought “indigent,” causing the loss of some longstanding patients who had always paid their bills at the time of check-out. The physician would love to leave, but a 30-mile non-compete radius has him trapped unless he truly wants to start from scratch.

What are your thoughts about private equity organizations in the healthcare space? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/26/18

While many people were out doing their Black Friday shopping, I was getting clobbered at urgent care. We saw over 1,000 patients across our locations, which is similar to the patient counts that we see during the height of influenza season.

Many of the patients were coming in for fairly low-acuity problems because their primary care physicians’ offices were closed and they were concerned that their conditions would worsen over the weekend. A portion of the patients had issues that had gotten worse over the holiday, while others had holiday-related injuries.

I saw some Thanksgiving-related injuries, including a patient who was injured by a frozen turkey that fell on her, allowing me to use the ICD codes W61.42 “Struck by turkey” and Y93.G1 “Activity, food preparation and clean up.” Another injured her finger “spiralizing” a sweet potato. I couldn’t find a better code for that other than the usual wound codes, but the turkey incident was a challenge for my scribe.

It’s rough enough seeing that large volume of patients (more than 70 of them were on my schedule) but it was made more difficult by an EHR that behaved erratically. I’m pretty sure my EHR has the world’s most user-unfriendly error codes, such as, “The length argument value must be greater or equal to X” and “Error attempting to push run time parameters onto the stack.” Both of those gems allowed the user to click through without incident and allowed return of normal function, so it’s not clear why we were even seeing them. Although I’ve been in the healthcare IT world for a long time and have come to terms with just clicking through and not getting too worked up, some of my staff members were very frustrated by messages that had no meaning.

Due to increasing co-pays and concerns about crowding at the emergency room, we had multiple patients who ultimately needed transfer to a higher level of care, which can be stressful for the staff. Most of the team I worked with have been in the urgent care space a long time, so they weren’t nervous about handling patients with stroke or chest pain symptoms until emergency medical services arrived to transport them to the hospital.

It’s still challenging, though, especially when your schedule gets backed up while you’re caring for a truly sick patient while other patients are popping out to the clinical station because they feel that they’ve been waiting too long. The consumer-style expectations of our patient population continue to rise, and on a busy day full of lacerations and hospital transfers, it’s definitely harder to meet those expectations. Patients are already frustrated because their primary care physicians’ officers are closed, assuming that they have a primary physician, which many do not.

We also had an uptick in patients who were presenting to us for care after being seen at a retail clinic. They had seen a nurse practitioner only to be told that their condition was outside the scope of practice permitted at the retail clinic and that they would need to be seen by a physician for laboratory work, chest x-rays, etc.

We’re happy to take those referrals, but the patients aren’t thrilled to pay an urgent care co-pay on top of whatever was spent at the retail clinic, not to mention the time involved in leaving one facility and traveling to another. The local retail clinics vary dramatically in how they screen patients for scope of practice. Some seem to do the screening upfront and refer the patient prior to any exam, where others see the patient and then refer. The latter doesn’t make for very happy patients.

One of the more challenging parts of my day was caring for a patient who came in with what appeared to be a viral illness but that turned out to be a life-altering diagnosis. In the urgent care trenches, we’re often accused of practicing defensive medicine or ordering too many tests, but when your CT scan detects a serious cancer that the patient had no idea was present, it’s sobering. I’m sure when Monday rolls around we’ll have to deal with the retroactive authorization for the test, but it will be worth it.

I hate having to tell patients about those discoveries. It would be so much better to have a physician who knows the patient give them the news. Patients are generally glad that they have a diagnosis and a plan to move forward, even if the news is not what they expected. I’ve had several situations like this over the last several weeks and I wish there was a way to follow along with the patient’s care. In our region, though, the big health systems aren’t about to share data with an independent urgent care even though their systems are allegedly interoperable.

Today was a much easier schedule and I had a couple of hours where patients only trickled through the door, so I was able to work on some informatics projects. We’ve been faced with shortages of some of our common medications, so I worked on an analysis of diagnosis patterns and volumes to estimate how long we can stretch our supplies. It’s still baffling that we have shortages of key medications in the US, including antibiotics and especially generics. We’re also low on influenza vaccine, so I worked on a strategy to predict demand and redistribute what we had. Not exactly high-powered informatics or big data analysis, but the run-of-the-mill data needs that are common for practices.

I also spent some time with one of our training scribes to talk about proposed changes to our scribe program since we have had to ramp up quickly to prepare for the opening of several new locations. We don’t want to shortchange any of the training, but want to make it as efficient as possible since scribes are the lifeblood of our high-volume days during flu season.

I had some time to play around with data around influenza and was glad to see that our influenza activity is paralleling the CDCs data at around 2 percent of the visit volume. It’s days like today that I’m glad to have an EHR and can extract data for useful purposes. In the coming weeks I’ll be extracting data for more challenging purposes, including our annual analysis of whether we should continue to opt out of the federal incentive programs. That’s a much bigger project, including analysis of provider workflow, documentation time, and click counts on top of the analysis of payer mix, CPT codes, quality measures, and more. It’s not exactly something I look forward to every year, but it’s rewarding to be able to analyze, interpret, and package the data so that informed decisions can be made.

We also had a tornado warning issued while seeing patients, which put our disaster planning skills to the test. There’s not a lot of patient privacy when you have people huddled in the central core of the office, away from the windows that are present in all the exam rooms. People seemed to take it in stride, though, especially since we’re looking at high winds through the evening and snow into the morning. I may be grumbling during the commute, but at least I’m not in Chicago at RSNA where there is still a blizzard warning in effect. Wherever you may be, I hope your weather allows you to stay safe.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/19/18

Thanksgiving is upon us, a quintessential US holiday. A friend sent me some seasonally appropriate ICD codes, including the W61.43 category “Pecked by Turkey” and W60 “Contact with Sharp Leaves.” There’s also Z63.1 “Problems in Relationship with In-Laws” for those of you with challenging holiday kinship arrangements.

All kidding aside, in some areas, Thanksgiving marks the beginning of increased healthcare utilization, which stresses the system in a variety of ways. People who have reached their deductibles for the year may be trying to schedule elective procedures at the same time providers and staff are trying to take time off with their families. There tends to be a bit of overeating in the US, which can lead to an increase in gallbladder disease, gout attacks, and elevated blood sugars. Family and personal stress levels increase. Just when things start to settle down, influenza and other viral illnesses will begin to peak.

Just in time for the holiday magic, the United States Preventive Services Task Force released a final recommendation statement regarding screening for unhealthy alcohol use in adolescents and adults. Adults 18 and over should be screened in the primary care setting and in addition to screening and practices should also be providing brief behavioral health counseling interventions to reduce unhealthy alcohol use. However, current information is insufficient to recommend screening in adolescents aged 12 to 17. EHR vendors, get ready to update your clinical guidelines packages.

To further dampen our holiday spirits, the Department of Health and Human Services has released its new Physical Activity Guidelines for Adults that emphasize the fact that roughly 80 percent of US adults and adolescents are not sufficiently active. HHS recommends that adults complete at least 150-300 minutes of moderate intensity activity each week, or 75-150 minutes of vigorous intensity activity each week. We should also be doing muscle-strengthening activities twice weekly. There are other specific recommendations for older adults and pregnant / postpartum women. The bottom line is “sit less, move more,” and even if you’re already moving, you’re probably not moving enough.

As we move toward the end of the calendar year, the healthcare IT space is in the doldrums, with vendors marking time until HIMSS, when they’ll try to make a big splash (among the dozens of other vendors trying to do the same thing) with various product releases and enhancements. The user group season is winding down with hospitals and health systems having exhausted their travel budgets for the year. Even those facilities that have cash to spend might be waiting until the beginning of the calendar year to start dispersing it unless they’ve aligned their fiscal years to the federal calendar and their year started in October. Nothing big usually happens between now and HIMSS unless it’s scandalous or completely revolutionary and unexpected.

It’s a good time to reflect on the year that has been and to think about what we might like to accomplish in the year ahead. I’m encouraging my team to think about their priorities, both professional and personal. Are there new skills that they’d like to learn, or a different area of the healthcare IT world in which they’d like to be more knowledgeable? Are they satisfied with their work-life balance and travel schedule, or do they want opportunities to slow down (or speed up?)

I work with several people who have recently become relatively empty nesters and they’re interested in potentially picking up extra work opportunities to fund things like retirement catch-up savings or creating college savings accounts for grandchildren. I had incorrectly assumed they were interested in slowing down, and without a structured conversation about priorities, I might have missed out on extra capacity with some outstanding resources. Another member of my team will be leaving at the beginning of summer, having decided to purse a public health masters’ program. Sometimes these goals align across personal and professional domains and sometimes they’re at cross purposes, but I appreciate the opportunity to try to help people meet their goals.

I have several good friends who have had it pretty rough this year with layoffs, family illness, natural disasters, and other unexpected surprises. I’m continually impressed by their resilience and their ability to look at the world through a glass-half-full lens (even if it is occasionally tinted with a hint of desperation). It helps put things in perspective and reminds me of how important it is to support the people around you from an emotional standpoint. It has taught me that time is short and success can be fleeting. I’ve made it a point to schedule quarterly meetings with friends and colleagues I had previously lost touch with, even if it’s to meet to walk a couple of miles at the park during a child’s soccer practice rather than sip wine as we might have liked to do in the past. If we don’t make those relationships a priority, it’s too easy to lose touch.

I’d like to challenge our readers to make a list of things they’d like to do in the coming year that will bring them either closer to friends and family or to help them explore a part of themselves that they’ve allowed to be put by the wayside. Maybe it’s a larger commitment such as a new hobby, or maybe it’s something as small as taking yourself to a local museum. I’d love to hear from readers about what they find satisfying and what they’d like to accomplish in the coming year. In the meantime, I’m going to try to find my pre-Thanksgiving bliss with some pastry therapy. Caramel apple pecan pie, in case you’re curious.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/15/18

I’m always on the lookout for interesting startups and young vendors and have been following Diasyst for a while. Looks like they’re hitting their stride as Piedmont Healthcare plans to implement their solution in both diabetes specialty and primary care clinics along with independent Piedmont-affiliated practices and the residency programs at Piedmont Columbus Regional.

Diasyst uses a patient-facing app to gather blood glucose readings and other information, then analyzes the data against best practices and current clinical guidelines. Clinicians can use an intuitive dashboard to make adjustments to patient treatment regimens and communicate those treatment plans directly to the patients, who can review them and indicate acceptance.

I had a chance to see a demo a while ago. The screens are intuitive and the data is backed by research collaboration with institutions like Emory University, Georgia Tech, Grady Memorial Hospital, and the Atlanta VA Medical Center. It’s a great way for physicians to leverage other members of the care team in managing diabetes. I also like that they’re not just engaging with physicians – they’re looking to work with employer-based clinics and payers as well.

Although Mr. H and Jenn have weighed in on the Athenahealth acquisition, I haven’t had a chance to put in my two cents. I agree with the sentiment that it seems like the end of an era, especially since the company has been highly visible in its campaigns for disruption, although at times it feels like they were leading what surely had to be a bubble.

It’s definitely causing some anxiety for clients. I had drinks with my favorite OB this week and they just switched to Athenahealth after some disastrous interactions with a previous vendor. They were hoping for stability, but now feel uncertain about what the changes might mean. Athenahealth has been doing a nice job transitioning from the “more disruption please” era to continue looking at important factors, such as physician burnout.

They just released some new data from their research that showed that physicians feel well supported when they have effective communication and strong communication. Isolation is a predictor of burnout and is exacerbated by administrative burdens, time pressure, and limited referral options.

As industry watchers, we miss Jonathan Bush and his antics (wrestling at MGMA and HIStalkapalooza at the New Orleans Rock’n’Bowl are two of my favorite memories), but seeing what happens next will surely hold our interest.

Back to the story of the demise of my OB colleague’s relationship with her EHR vendor. They had been in negotiations for some time around some serious customer service and financial issues. The discussions stalled and the vendor issued an ultimatum that sounded like it was going to block access to their charts, leading to the decision to make a hasty switch. They’re still sorting through some data migration issues, but are at least up and running.

I’ve seen the emails and notices from the vendor and the best way I can describe them is a cross between a high-pressure timeshare pitch and a blackmail letter, with a side note of pleading. Several emails conflicted each other and different company reps threatened different termination dates and processes while begging them to stay. I was embarrassed for our industry as I read them. We can do better, folks.

Speaking of doing better, NextGen Healthcare hosted its annual User Group Meeting in Nashville this week with the theme “Better Never Stops.” A reader shared this photo of CEO Rusty Frantz on the dance floor.

I always joke that some year I’d like to hit the EHR vendor user group circuit, attending all the major get-togethers as part of a road trip to end all road trips. The budget for that adventure is beyond my reach, but I was more than happy to attend a regional summit hosted by Slalom in St. Louis along with partners AWS, Salesforce, and Tableau. For those of you who haven’t had the pleasure of visiting that Midwest city, you’re missing out on a delightful intersection of barbecue, hot chicken, and Italian food (including something called a toasted ravioli, which is a wonder by itself). Crashing with a med school colleague definitely left more room in the budget for culinary delights, along with the fact that the registration fee for the meeting was a requested donation to the United Way.

It was a different kind of conference, focused on the goal of “reimagining healthcare for the local community” with afternoon breakout sessions where participants worked together to design solutions to problems like price transparency, managing complex care, and battling healthcare inequality. I enjoyed the hands-on approach and hearing directly from people in the trenches rather than being a passive listener. A white-board artist captured comments from a panel discussion as well as from keynote speaker Allison Massari, who spoke about an intense personal trauma and the value of compassion and connection as part of healthcare. My favorite quote was from a speaker who asked, “Is there a way to not essentially make the patient a victim in their own care?” Those are powerful words.

The Slalom team did an excellent job pulling everything together and facilitating the breakouts. I may have to start checking out more regional conferences, especially those in cities where I can find a sofa to sleep on.

At the conference, I also got to prep for HIMSS with some shoe watching. The AWS rep had snazzy trainers and company socks. One of the panelists had some seriously kicky boots, but I couldn’t figure out how to get a picture of them without being too obvious. I’ll have to practice my covert shoe capture skills before February rolls around.

One of my intrepid readers noticed that I didn’t make my usual mention of Veterans Day in Monday’s Curbside Consult. It wasn’t an intentional slight, but rather an issue with my writing timeline ahead of some other commitments, including celebrating a family milestone with my favorite veterans. Many of my physician co-workers trained in the military and their wealth of experience is an ongoing reflection of the years they dedicated to protecting our nation.

The one hundredth anniversary of the armistice ending WWI was an historic event, but also shows that history continues to repeat itself because the “war to end all wars” has been followed by conflict after conflict. I’m angry when I see people lacking respect for our veterans, but I am heartened by images such as this one of Cub Scouts presenting a wreath at the Tomb of the Unknowns in Arlington National Cemetery. For those who don’t recognize the yellow neckerchief, it means these girls are second graders. Thank you to our youngest generation and let’s hope they Never Forget. (Photo credit: National Capital Area Council, BSA)

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/12/18

I was intrigued by the results of Mr. H’s recent poll results regarding reader attendance plans for HIMSS19. Only 28 percent of respondents will be going, although the sample size is pretty small at 216 readers. Most of the people I’ve asked recently about their HIMSS plans are under substantial budget constraints, with some employers limiting even high-level IT staffers to only one conference per year. Those with limits seem to generally choose their EHR vendor’s user group meeting, or otherwise a meeting that is more specific to projects that they’re going to be working on in coming months.

Since HIMSS released the educational sessions schedule this week, I decided to do a bit of a deep dive to see what is on the calendar that might be interesting to potential attendees or might bring value to their efforts to persuade their employer to send them.

The first place I landed was the subset of Views From the Top sessions, where attendees can “be inspired by compelling stories from high-ranking leaders in a variety of industries.” The first session that popped up was one presented by Jason Cheah, who is CEO of the Agency of Integrated Care in Singapore. I do enjoy the international sessions, often there are some progressive approaches to healthcare IT problems, although it can be tricky to find nuggets that can be applied back home since the healthcare delivery systems might be significantly different from what we have to work with in the US. I recently spent some time with some physicians from Canada and learned that although some of the issues are the same, there’s enough of a different spin on payment and prioritization of initiatives that some of the best ideas I heard would be difficult to apply at my own hospital.

Wednesday’s session titled “Transparency in Prescription Drug Costs to Help Patients Save Money” will certainly address a US-centric topic, given that the presenters are CVS Health Chief Medical Officer Troy Brennan, MD and Surescripts Chief Executive Officer Tom Skelton. They’re slated to talk about drug cost and benefit plan information transparency and how to better expose that information to patients, prescribers, and pharmacies. Price shopping is a big deal for the patients I currently serve – many are using sites like GoodRx to help make medications more affordable. It’s still a patchwork of coverage, though, as one of my patients found out when a local Walmart refused to honor the $15 price listed in the app, telling the patient it would be $50. The patient didn’t fill it at our office due to a $40 price tag in the first place, and with the drive and the confusion ended up in a situation where our office was closed so they couldn’t get it from us for less, so they didn’t fill it at all. Not good news for the teenager with bronchitis and asthma who really would have benefitted from access to an inhaler overnight.

Another Views From the Top session is titled “Defeat Nation State Actors Stalking the Health Care Sector” and covers cybersecurity best practices and risk exposure management. It sounds interesting, but likely more suited to the technical side of the house as opposed to the average clinical informaticist.

Next, I went to the section titled Reactions from the Field, which is designed to feature “market suppliers ‘in the field’ working closely with healthcare organizations to address common issues in cybersecurity, innovation, life science / pharma, or artificial intelligence.” It goes on to note that there will be four sessions with three panelists each, but no details are published. I’ll have to check back in a month or two to see what that’s all about. The Industry Solutions Sessions are also not listed in detail yet but are slated to include vendor-sponsored case studies presented in hour-long sessions.

The HIMSS Davies Award Sessions are listed and include a number of bread-and-butter type sessions covering issues we deal with on a regular basis: improvement of quality scores; reducing urinary tract infections due to catheter use; decreasing falls; improving pediatric asthma outcomes; sepsis management through clinical decision support and virtual care; clinical risk systems; and achieving the Triple Aim. Although some of the session descriptions clearly stated which organization was presenting, others used acronyms or abbreviations that left me guessing. There also were no presenter names included.

The Government Sessions header also failed to include a list of actual sessions, although it promises to help attendees “get answers to your pressing questions surrounding the Trump Administration and its impact on health and health information technology.” I assume the usual players will be making an appearance, but again will have to check back.

From there it was on to the General Education sessions, where a brand-new Blockchain Forum has been added. There are three specific sessions listed out for those of you looking to get the most current information on everyone’s favorite buzzword. I found a couple of interesting sessions interspersed among various forums, including one on counterfeit pharmaceuticals in the supply chain and another on data interoperability across non-hospital care venues such as long-term / post-acute care facilities.

There do appear to be a couple of new formats and venues for sessions. The SPARK Session (Session Providing Actionable and Rapid Knowledge) is designed to be 20 minutes of quick insights. Sessions are also being grouped into “content streams” aligned with the Quadruple Aim and allowing attendees to focus on domains of technology, information, organizational efficiency, care, environment, and societal challenges. There will also be a Learning Lounge with on-demand viewing of live-streamed sessions. I hope the room is large and the chairs plentiful because it might become the hip place to be for those with tired feet and aching backs.

From a consultant standpoint, I’m hoping there will be some good sessions in the Federal Health Community Forum, although no sessions were listed yet. I’m helping clients through a number of governmental initiatives including the Comprehensive Primary Care Plus (CPC+) program and of course MIPS, so if there’s any easier ways to navigate or advise, I’m hoping to pick up some tips. As with other areas, the details aren’t quite posted yet.

In the email announcing the session listings, HIMSS promised over 400 sessions and there certainly isn’t anywhere near that number posted yet for our consideration. It just goes to show that I should probably go back to planning my HIMSS session attendance like I have for the last several years – at the last minute on the plane while sipping a cocktail and hoping I packed the right shoes. At least by then HIMSS should have all the sessions listed and maybe some presenters.

What’s your strategy for planning your trip to HIMSS? Are the sessions important, or is it more about the exhibit hall, building new relationships, and catching up with colleagues? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/8/18

There was some chatter in the physician lounge this week about a study published in JAMA Network Open looking at the accuracy of EHR medication lists vs. the substances actually found in patients’ blood. Researchers looked at 1,350 patients and found that while a majority of medications were detected in the blood as listed in the EHR, there were many more medications detected that were not reflected in the EHR. Such incomplete documentation prevents systems from performing drug-allergy and drug-drug checking, placing patients at risk.

As much as some clinicians don’t like it, I prefer when patients bring in all their medications and supplements, even if it takes extra time going through a brown bag, shoebox, or tote. That way we can keep the EHR updated and also physically impound medications that patients shouldn’t be taking, if warranted.

There was also a fair amount of conversation around Tuesday’s elections, and the various positions held by candidates regarding healthcare. Kaiser Health News published a great piece looking at the various terms being thrown around during the election, including single-payer, universal healthcare, and Medicare for all. Gubernatorial candidates in California, Massachusetts, and Florida were pushing for state-run single-payer systems, where others were calling for less specific “universal coverage” or “public option” provisions. Like those mentioned in the article, the physicians around my lunch table didn’t fully understand the different models or what they might mean not only to their practices, but to their families.

There was zero chatter around the announcement by CMS that access to Quality and Resource User Reports and PQRS Feedback Reports will be sunset at the end of December. Since 2016 was the last performance period for those programs and 2018 was the final payment adjustment year, there isn’t much of a need for the reports to remain online. Physicians or their authorized representatives can download them until December 31, but it’s unclear how many providers reviewed the data in the first place or whether they tried to use it to drive practice-level improvements. Reports will be available eon the CMS portal for those of you looking for a little bedtime reading.

As I was getting ready to leave, one of my colleagues asked me what I thought of Atul Gawande’s recent New Yorker essay on “Why Doctors Hate Their Computers.” He takes readers through Partners HealthCare’s journey from homegrown EHR to Epic, and all of the physicians around the table were familiar with that 16 hours of training he leads with. (In our case, it was 17, and let me tell you everyone was counting.)

Having run more than a handful of EHR implementation projects, I loved Gawande’s description of his trainer, “younger than any of us, maybe a few years out of college, with an early-Justin Bieber wave cut” whose technique incorporated “the driver’s ed approach: You don’t want to be here; I don’t want to be here; let’s just make the best of it.”

Gawande walks us through his own thoughts about the rise of computers, including the once-coveted Commodore 64, which brings back memories for some of us who have been on the cutting edge. Having been the second person I knew with a modem (the first being the guy from whom my brother bought the used card from), I felt a little bit of his pride and optimism as he readied himself for training. The last three years have quashed that optimism, however, and he has “come to feel that a system that promised to increase my mastery over my work has, instead, increased work’s mastery over me.”

I appreciated his discussion of “the Revenge of the Ancillaries,” where design choices were considered by constituents from various parts of the organization. He makes a point that was telling: “The design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes… Now the staff had a say (and sometimes the doctors didn’t even show.)”

I’ve seen that happen during several build decision projects, and it sounds like there may not have been adequate checks and balances in the governance process. For example, requiring stakeholder signoff in addition to participation in the working groups. Requiring user acceptance testing of critical workflows would also have caught some of the issues he cited, such as hard stops and required fields, prior to the go-live. He also highlights issues with the maintenance of patient problem lists that are exacerbated by governance issues, with duplications and lack of specificity in entries. Cut and paste is also an issue, one that could be addressed by governance and consensus among users about the best way to use the EHR.

Gawande does discuss the phenomenon of governance, noting that, “As a program adapts and serves more people and more functions, it naturally requires tighter regulation. Software systems govern how we interact as groups, and that makes them unavoidably bureaucratic in nature. There will always be those who want to maintain the system and those who want to push the system’s boundaries.”

I’m in agreement, but it’s still a challenge to figure out why organizations don’t spend the time needed up front to define some of these goals. What is the vision for the new system? How does it support the mission? What are the expected outcomes? How do we define success? Instead it’s often a race against a timeline, which may or may not reflect organizational tolerance for a particular speed of change. The best implementation I ever worked on had a motto of “go slow to go fast.” We may have spent more months in the design and build phase than other organizations, but when we went live, we hit the ground running and there were very few changes needed to the system in the first few months.

Mr. H has already commented on the Gawande piece, and one reader shared their thoughts on the physician mentioned who admittedly ignores messages in her inbox and deletes them without reading them. I hope there aren’t any patients reading The New Yorker who might have a concern about their care in her practice, because if she is ever called into court about a missed diagnosis, things aren’t going to end well for her. I can’t imagine publicly admitting that I don’t review results and I doubt that the medical staff administration is going to think too kindly of it.

Reading the piece from the perspective of a clinical informaticist, there’s a lot to unpack, and also a lot of opportunity to potentially improve things for the impacted physicians. I’m not sure what I think about it from a patient perspective or a non-IT perspective, since it oversimplifies and under-explains some of the complexities that have brought us to where we are. That’s what I told my colleague, and I ended with a reminder that the one of the EHR subcommittees still has some openings, so if he wants to be part of the solution, there’s a venue available.

I don’t frequently call out companies for wacky marketing, but this one is baffling. The subject line of the email advertises a profitability webinar with “cybersecurity strategies you can use,” but the email itself discusses patient experience and how to “cultivate a loyal base.” Oh yeah, and there’s the part where they sent the invitation out less than 24 hours in advance for a webinar that is in the middle of the work day. For mass marketing emails, I’d recommend peer review at a minimum before sending them out. Get it together, folks.

[UPDATE] Greenway Health was quick to read Dr. Jayne’s comment and apologize that their email preview line displayed incorrect wording (the subject line itself was correct). They also note that this was the third in a three-email series, so those who wanted to sign up had ample time well before this email. They also say their surveys and best practices indicate that 2:00 p.m. ET works best for providers.

Do cold emails entice you to join webinars in the middle of the day? How many do you register for that you end up not attending? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/5/18

A reader recently asked for Mr. H’s prediction on what to expect from Medicare’s “Patients Over Paperwork” initiative. Mr. H asked me to chime in, along with readers, with my thoughts on the proposed changes to E&M codes, office visit documentation, and other paperwork.

He noted that, “It’s hard to separate meaningful HHS/CMS announcements from the political rhetoric spouted by its campaigner-appointees, so I’ve quit trying.” I agree that it’s a quite a challenge to figure out what is going on with CMS lately, since there seem to be many announcements talking about how great things are going to be, but with little change for the people actually doing the boots-on-the-ground work.

I’ve been shocked by the level of rhetoric in CMS announcements under the new administration. Everything seems to have been cranked up a notch and things that need not be political are being politicized. Healthcare finance and payment for providers is complicated and divisive enough and doesn’t need red vs. blue overtones applied on top of it all.

As to the initial question, I think that some of the details in finalizing the 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) rules show that the current CMS/HHS leadership might have bitten off more than they can chew. Physicians were initially excited about a potential move to overhaul Evaluation and Management (E&M) coding, creating fewer “blended” codes that were purported to more accurately reflect the work being done by physicians during office visit encounters. Although there was some positive excitement, the majority of the 15,000 comments that CMS received were negative, according to multiple reports (for those of us who didn’t read all of them). On November 1, CMS responded to that dichotomous excitement by delaying changes to those visit codes until 2021.

It’s important to remember that even though CMS ostensibly only makes the coding rules applicable to Medicare patient visits, because of how things work, they’re pretty much applicable to everyone, including commercial insurance payers and Medicaid. Self-pay patients are impacted somewhat, depending on how practices handle those patients.

The overall sentiment cited in the announcement of the delay was concern by physicians that the planned blending would reduce payments to physicians caring for Medicare patients with complex health conditions and/or multiple chronic conditions. CMS will now plan to consolidate the codes from eight to three instead of the originally-proposed two, preserving the “level 5” code used for the most complex (and most time-consuming) office visits. Another two years are needed to work out the details, apparently. CMS Administrator Seema Verma is quoted as saying, “We know this is going to have a tremendous impact on many physicians in America. We want to get it right.”

I take issue with that comment. If you knew it was going to have such a huge impact, why did you think it was OK to go ahead and put it in the most recent proposed rule? Wouldn’t it have been better to put together some working groups or task forces, etc. including actual working physicians rather than cobbling together something internally and then having to take it back? To an in the trenches physician, this back and forth makes one feel like CMS doesn’t understand us and that it has become reactionary rather than proactively addressing the issues that all of us face. If the wheel was less squeaky, would this have moved along?

The American Medical Association and the Medical Group Management Association are in support of the delay, noting in various press releases and on-the-record comments that the plan was flawed. MGMA SVP of Governmental Affairs Anders Gilberg stated, “Blending payments rates in 2021 won’t necessarily reduce burden, especially with CMS’ newly required add-on codes.” More than 150 various medical societies signed on to a letter opposing the new structure prior to the announcement of the delay.

CMS claims that proposed changes will simplify the way physicians bill for visits, and along with other modifications, are expected to save clinicians $87 million in administrative costs in 2019, ultimately yielding a net savings if $843 million over the coming decade and 21 million hours by 2021.

You know what would also save money and reduce physician angst, possibly slowing the retirement and exodus of much-needed clinicians? Stop harassing physicians with coding audits. Practices constantly receive requests from their Medicare intermediaries asking for documentation to justify the various codes. The practices I work with have gotten responding to these down to a fine science, trying to waste as little of their time as possible. Most of them have a 95 percent or greater success rate in justifying their codes.

I agree that means that five percent of the time they are overcoding or undercoding, but does catching that justify the millions of hours spent dealing with the audits? How about targeting the most egregious offenders and letting the rest of the physician base spend their staff resources managing patients rather than printing and mailing/faxing records to auditors? Burden isn’t just a financial problem – it’s a psychological one and is closely associated with clinician burnout.

Notwithstanding the delay in the E&M codes, CMS is moving forward with other elements of the Rule (and other proposed rules) that are supposed to reduce burden or save money. Physicians can focus on documentation of the interval history since the previous visit, rather than re-documenting previously documented information just for the sake of documentation. Physicians will not have to re-document the chief complaint and history of present illness already documented by their staff or by the patient himself/herself, just because the rules require it. Wholesale acquisition costs for Medicare Part B drugs are supposed to be lowered with the savings passed on to consumers. The so-called “Meaningful Measures” plan should simplify quality reporting for various federal programs that often do not align. Telehealth services and remote monitoring under home health should save money.

As I try to put my thoughts together on this complex topic, my blood pressure is definitely rising. I struggle with the conundrums that we’re facing in healthcare today, at least in the way that I have boiled them down so that I can attempt to understand them:

• We don’t want universal healthcare, but we want universal control over how physicians and facilities bill and how they are paid.
• We want to set up complex rules to control payments, but then we get upset when organizations figure out how to game the system (RIP, provider-based billing).
• We don’t want higher-quality physicians to be able to charge more for their services on the front end, but want to spend loads of administrative money trying to incent them (or penalize others) on the back end.
• We don’t want to require payers and employers to cover a universally agreed-upon subset of preventive services and money-saving interventions such as birth control, but we want to reduce disease burden and lower the rate of poverty.
• We want the most high tech services in the world regardless of whether they’re indicated, but we don’t want limits on those services based on ability to pay or overall financial burden to society.

There are many other elements I could cite, but I’d like to preserve some good spirits for the rest of the day and a charity project I’m about to go work on. I wonder, though, as policy-makers debate the solutions they propose for all of this, if they really think about both sides of the various equations or whether we’ve gotten to such a position of polarization that they can only see their own perspective.

What do you think about the Patients Over Paperwork initiative? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/1/18

November is Home Care & Hospice Month, so let’s give a shout-out to members of the healthcare informatics community who work in those environments. From my time at Big Health System, it seems like hospital projects get all the recognition and the lion’s share of the budget, while ancillaries like home health and hospice are struggling to even get support.

There are a number of challenges faced by these disciplines that make their work tricky – connectivity issues, mobile documentation, chart fragmentation, lack of coordination among prescribers and referring physicians, and more. Plus, there are the challenges inherent with going into people’s homes and dealing with unpredictable (and sometimes dangerous) situations.

Our occupational health clinic works with a home care group and I’ve heard stories about home care teams that go the extra mile bringing food and personal care items to patients who are struggling to stay out of the hospital. Hats off to these vital members of the healthcare team and the informatics personnel who support them.

Whether it’s related to the month of recognition or not, CMS released a rule finalizing changes to the Home Health Prospective Payment System. Claiming it will “strengthen and modernize Medicare,” it made changes to coverage for remote patient monitoring, added home infusion therapy benefits, and updated payments for home health with a new case-mix system. Burden is also supposed to be reduced through fewer reporting measures for certifying physicians. The changes begin in calendar year 2020.

Building on the legacy of EMRAM, HIMSS Analytics releases a new Infrastructure Adoption Model called INFRAM. Along with AMAM and CCMM, the models are designed to measure organizational efforts to improve processes and outcomes through technology implementation and adoption. INFRAM is designed to assess technical infrastructure within health systems, benchmarking prior to go live on EMR (as HIMSS still calls them) systems. Subdomains assessed as part of the model include security, collaboration, wireless capabilities, data center, and transport.

The American Medical Association is providing $15 million in grants over five years to fund innovations in residency training. The Reimagining Residency Initiative aims to transform residency training to better prepare graduates for the healthcare system of the future. Depending on the specialty, graduating residents are often unprepared to operate in the “non-system” that we have going in the US – they may not have been trained on value-based care, coding in such a way that one can actually be paid, and working collaboratively with other physicians and members of the healthcare team.

AMA did this previously in a $12 million program with medical schools, leading to development of a “Health Systems Science” textbook and curriculum to teach physicians to work with emerging technology and how to participate in patient safety, quality improvement, and team care projects. The Request for Proposal will be distributed on January 3, 2019 with letters of intent due February 1. Medical schools, health systems, and medical specialty societies are invited to participate along with graduate medical education sponsors. Awards will be announced in June 2019.

NCQA announces availability of various datasets to help us with our analytics endeavors. The Quality Compass 2018 dataset includes HEDIS and CAHPS data, aiding benchmarking. The current set includes data for commercial, Medicare, and Medicaid submissions. Separate data is also available for CAHPS 5 OH Adult survey results for commercial and Medicaid payers. Also, there is a CAHPS Booklet includes benchmark data for Adult and Child CAHPS surveys. Last, the Health Insurance Plan Ratings 2018-2019 results include scores similar to the Medicare Five-Star Quality Rating System.

The American Medical Informatics Association announces its Inaugural Class of Fellows for the newly established FAMIA Applied Informatics Recognition Program. The program is designed “to recognize AMIA members who apply informatics skills and knowledge within their professional setting, who have demonstrated professional achievement and leadership, and who have contributed to the betterment of the organization.” The recognition is open to physicians, nurses, pharmacists, and others within clinical informatics. Formal recognition will occur at the AMIA 2019 Clinical Informatics Conference in Atlanta, April 30-May 2, 2019. Some of my favorite people are on the list – congratulations to all!

As I’ve worked with youth in various community organizations over the last decade, I’ve seen the expansion of smartphones, with both positive and negative impacts on youth knowledge, exploration, and relationships. Time magazine reviews recent research on the impact of technology on young people’s mental health, noting increased rates of diagnosis for depression and anxiety in those using screen-based devices for more than seven hours per day. The data is from a 2016 study looking at more than 40,000 children ages 2 to 17.

When doing a sanity check on the data, I originally balked at the seven-hour figure as an outlier, but the study notes that around 20 percent of youth aged 14 to 17 spend this amount of time on screens each day. Youth in this use category were also more easily distracted, had emotional lability, and had difficulty finishing tasks compared to those who spent only an hour a day on screens. Adolescents were more likely to have issues than younger children.

Every time I’m in an airport and see toddlers and young children glued to a phone or tablet while their parents are also glued to a phone, I want to scream. Maybe I’m turning into the local curmudgeon, but childhood is a time for wonder and explanation. I want to tell them to take their children over to the window and look together at what is going on around the airplane. Watch the baggage handlers and look for your bags. See how the plane gets refueled. Talk about the jobs people do and how everyone plays a part in getting you to your vacation or grandma’s house or wherever.

Those behaviors in young childhood influence how individuals will use phones and devices as teens, and we know from numerous pieces of research that social media use is linked to low well being in teens and adolescents. There’s nothing funnier than watching a group of teens stand in a circle and “group chat” instead of actually chatting face-to-face with each other. Funny, but sad. I’m glad that one of the organizations I work with is a no-phone zone for the most part, forcing young people to interact with each other and also with the adults supporting their adventures.

Weird news of the day: Having one’s appendix removed has been linked to a nearly 20 percent lower risk of developing Parkinson’s disease. Researchers noted that the appendix holds alpha-synuclein, which is thought to influence Parkinson’s development. One working hypothesis is that the appendix participates in immune surveillance “contributes to Parkinson’s through inflammation and microbiome alterations.” It’s not compelling enough to run out and have surgery, but I’ll be interested to see where the data takes us.

What is your organization doing to celebrate Home Care & Hospice Month? Leave a comment or email me.

Email Dr. Jayne.