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Curbside Consult with Dr. Jayne 9/11/17

September 11, 2017 Dr. Jayne 2 Comments

Over the last several years, I have worked with a number of organizations that are trying to improve their corporate cultures. I have to give them full credit first for realizing that they had cultural issues, and being willing to reach out for help. I do most of my work in this area as a subcontractor for another consulting firm, which likes to bring me in because I can not only do the work but I have the MD behind my name. There are a lot of physicians who need coaching (and sometimes coaxing) who respond better to a peer with the same degree, regardless of their understanding of your level of experience behind the credentials. Some of their clients are large health systems and some are smaller, but everyone is facing similar stresses brought on by the pace of change in healthcare.

Many of the issues that we deal with are “light” cultural issues – basically having a set of rules, whether written or not, about how teams work together and how meetings are run. These are some of the low hanging fruit-type items, such as making sure meetings have agendas, that we work on scheduling policies and procedures, and that we work on managing meeting dynamics. Often, people are resistant to change for the sake of resisting change, or because they’re stressed about getting their work done. Having agendas and scheduling protocols can help reduce the overall burden of meetings. Once workers start to see that following the rules of engagement helps get them out of meetings and back to other activities, they begin to buy in to some of the larger changes that we need to make.

We typically have to get people to that place where they know they’re not going to be undergoing “death by meeting” as much as they’re used to, before we introduce some of the more challenging concepts such as device-free meetings. One has to move carefully towards that goal, especially with organizations that have been through layoffs or reorganizations. In these cases, teams may be understaffed and employees figure they’re running a hundred miles an hour and can’t keep up. They multitask during meetings, working on email and texts either overtly or under the table. Eventually we need to get rid of those distractions, but you’ve got to have some breathing room first. When people know the meeting will finish on time or early and they will have time to check email, get something to drink, and hit the restroom, they’re more likely to play along with other changes you need to make.

The goal is to get everyone to focus on the meeting at hand – not on their next meeting, or all the other things they have to do when this one is over. In other words, to be fully present and attentive to what is in front of them. It’s difficult enough to do when people are so used to multitasking or being instantly accessible to others, but it’s even more difficult to do when you try to do that kind of a transformation without a plan. I worked on an HIE project a few years ago with an organization that handed out custom challenge coins with the phrase “Be Present” to every employee without any kind of background or lead up to the initiative. The first thing that people speculated on was how much money the organization had spent on it, especially when staff hadn’t had a pay increase in several years and people had been downsized.

A couple of weeks later, when the actual initiative was rolled out, it was regarded as a joke. I would be on conference calls where people were blatantly ignoring what was going on, and rather than even try to cover with an “excuse me, can you repeat that” or “I missed the question” they’d actually say, “I’m sorry, I wasn’t fully present” as if that absolved them from being disrespectful. The first time I heard it, I was just grateful that I was also on the phone and that I wasn’t in a room full of people who could see my expression of horror. I encouraged management to address the comment directly with the employee in question, but they didn’t want to “ruffle feathers.” Since there were no repercussions, others felt emboldened to do the same thing, and the idea of “not being fully present” actually started to work its way into the corporate culture. I was glad to be working on the HIE project and that I wasn’t wearing my change leadership hat for that one. Watching their efforts implode was painful but taught me a great deal about what not to do when working on cultural transformation projects.

I hear similar tales of woe from some of my physician colleagues whose practices have been acquired by larger organizations. A couple of them are part of an organization that is focusing cultural transformation around the idea of assuming positive intent. There are plenty of leadership experts that support this philosophy as a way to help move organizations forward through difficult times. When you’re being asked to change, assuming that it is for the better can smooth the way. Groups trying to change rapidly may not have time to explain the full who, what, where, when, why, and how, so the phrase aims to encourage people to trust those that are leading them and working with them so that everyone can advance. It can be a great productivity booster as people free themselves from worrying about the ulterior motives of others.

Depending on who you talk to or whose materials you read, however, there’s another piece to the phrase: Assume positive intent until proven otherwise. This means that when negative intent is identified, people who are creating chaos need to be dealt with so that they no longer have the ability to disrupt or harm others. It’s hard to do that tough work though, and none of us particularly enjoy dealing with disruptive people. I’m hearing more and more about organizations that seem to be looking the other way or that are unwilling to deal with difficult people, asking their co-workers to just go along with it for the sake of assuming positive intent. I’ve heard stories about other organizations who have used the concept as a way to counter poorly-led or hastily-planned initiatives. Asking your employees to assume positive intent when you don’t have your leadership act together is not the way to build trust or move towards success. Changing corporate culture is incredibly difficult and it’s best when coming from both the top and bottom.

Is your organization working on corporate culture? Has your team asked you to assume positive intent? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/7/17

September 7, 2017 Dr. Jayne 2 Comments


I was interested to hear of Cerner’s formation of an Advisory Group “to provide insights and recommendations in support of Cerner’s work” on the VA EHR program. Although it’s “comprised of distinguished former government, military, and private sector leaders sharing a common interest in Veterans health and wellness,” it’s lacking any “regular” veterans. My former hospital was very progressive in having patients represented on a variety of steering committees and project teams – sitting right alongside the CEO, hospital board members, department chairs, service line directors, and other stakeholders as we made a variety of decisions that impacted patient care. I didn’t fully understand the gravity of having patients (and their caregivers) on those committees until I experienced it myself. Staring a patient in the face while making difficult decisions about EHRs and the management of patient data is very different than making the decision in a room of IT experts. Even though there are distinguished veterans in the group, I would submit that the electronic health needs of the “average” veteran are different from one who is a former Senator/Governor; even though Senator Kerrey does have experience receiving care in the VA system. My local VA is seriously challenged with leadership turnovers, staffing issues, and poor patient care experiences that our veterans do not deserve. Let’s get some patients in the room and see what a difference it makes as Cerner works to move their care forward.


Speaking of patients, just a reminder that all of us will be patients at one time or another. Let’s avoid being patients with influenza – the vaccination season has already started. The CDC website has information on projected strains – my employer requires all staff members to receive a vaccination by the end of next week. The best part of being vaccinated during my last patient care shift was watching my staff decide who was going to get the short straw and have to play “pin the vaccine on the physician.” The worst part was realizing several hours later that my band-aid had fallen off and I had bled through my scrubs and white coat, probably causing patients to wonder what was going on with my arm (although no one mentioned it). The paramedic who administered my vaccine was horrified, but accepted my explanation that it was much more likely due to the daily aspirin I’m taking rather than her technique.

CMS released a new fact sheet that covers mass immunization events and so-called roster billing. Most of my experience has been with traditional office-based immunizations, but I always enjoy learning something new. Definitely something to think about for organizations who provide mass-immunizations and whose practice management or billing systems will support that type of billing.

We’re struggling a little at the office with physician coverage, as several of our physicians recently relocated with spouses that were finishing medical school or residency and moving on to fellowships or other training programs. We’ve always done our own recruiting, but are thinking about using a firm to broaden our reach. Since primary care physicians are in high demand, I often receive recruiting materials and had to bring in a post card from one recruiter as an example of why we shouldn’t consider using them. Rather than lead with the usual comments about patient volume, procedures, availability of scribe coverage, and hospitalist use, it started with “features two private lakes in a wealthy suburb.” Sure, I’d love to relax by the lake between patients, but I’m thinking it’s more likely that some copy editing is in order.


If you’re on the hospital side, CMS will offer a webinar on September 12 covering the Fiscal Year 2018 Inpatient Prospective Payment System (IPPS) Final Rule. This includes clinical quality measures for the Inpatient Quality Reporting (IQR) Program and Medicare/Medicaid EHR Incentive Programs for eligible hospitals and critical access hospitals. It’s difficult to keep up with all the changes to these programs, so having someone help digest the content might be helpful.

If you’re on the vendor side, CMS has opened the self-nomination process for vendors who might want to be recognized as a Qualified Clinical Data Registry (QCDR) or as a Qualified Registry. The window closes November 1, 2017 for the 2018 MIPS performance period. Candidates have to not only submit a self-nomination but also must email CMS when their application is ready for review. There is quite an array of registries out there, and I’ll be interested to see what new organizations come to the table and whether they’re offering anything truly unique.

Things are starting to pick up in the healthcare IT world, and the user conference season is in full swing. Allscripts hosted its clients in Chicago August 8-10, followed by Aprima, which welcomed its customers August 18-20 in Dallas. Epic will host its clients on-campus September 25-28 with a theme of “World of Wizards.” The EClinicalWorks national conference will be held October 6-9 in Dallas; following that, DocuTAP will hold its User Summit in Nashville October 10-12, overlapping Cerner, which will hold its annual conference October 9-12 in Kansas City. NextGen rounds out the season with its annual user group meeting November 5-8 in Las Vegas.


Some year I would love to take a sabbatical from consulting and just go from conference to conference to conference. Pulling off that kind of a feat would require a lot of wardrobe planning and a serious amount of shoes. The other alternative would be to work with my friends at Heelusions to accessorize a pair or two and give them unique looks for the different vendors and events. I’m impressed by their Cerner-specific creation and wonder if anyone will be sporting them in Kansas City. Brand is everything, and this would certainly let employees embrace the company from head to toe (not to mention, it’s rare to see vendor-logo footwear.) HIMSS is coming, so if you’re looking to take your shoes to the next level, you might want to check them out.

What’s your favorite vendor-logo item? What’s the worst you’ve seen? Email me (and of course send pictures)!

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/31/17

August 31, 2017 Dr. Jayne No Comments

I’ve received quite a bit of correspondence lately, so it’s time to open the reader mailbag.

From Coastal but not Coasting: “Re: great article. It came at the perfect time for my practice. We just received PCMH recognition, level 3, so we are currently beaming! But it has not been easy. There have been many challenges, including staff burn-out and frustration over all of the change. We had to get them to buy in to it without always knowing WHY the change needed to occur. Sometimes the WHY is very involved and time-consuming and we were trying to fast track recognition.” I agree that sometimes sorting out the “why” and the “what’s in it for me” can be challenging, especially when trying to work through things quickly or when trying to meet specific regulations that don’t always mesh 100 percent with how the organization has been running. There are times when I’m working with clients where I just want to say, “Because I said so, and your boss is paying lots of money for my expertise,” but that would rarely go well. There’s an art to balancing buy-in vs. top-down rulemaking and I applaud organizations that have figured out how to do it well.

From Back to School: “Re: huddles. Have you ever met anyone that runs a family huddle? Thinking about my family and children and the chaos of school around the corner made me pause to consider if we might benefit from a more set time / agenda to nail down logistics. We communicate well, but sometimes it’s frequent and distracting with our own work days.” Why yes, I do! One of my good friends from Big Health System takes her process improvement work home with her. They have a family huddle during dinner where they run through the activities for the next day and outline what equipment, supplies, and transportation are needed. Thinking back to the one I witnessed, it’s a lot like a practice huddle. They also maintain a family Google calendar so everyone can see it from their phones. Time management is an important skill that many of the client employees I work with struggle to master. Developing those skills during the adolescent and young adult years would definitely serve one well in the working world.

From John Showalter: “Re: staying sane. I thought you might be interested in learning more about a book I helped write. I think focusing on shared outcomes helps keep everyone sane. I totally agree with you about the meeting skills.” Several of the topics covered in the book caught my interest. What motivates physicians, why a lack of education about revenue cycle and population health impedes their ability to see how improving administrative processes positively impacts the patient, and approaches to creating actionable knowledge that will enable increased collaboration. I struggle regularly with providers that aren’t in tune with the business side of healthcare and don’t fully understand how their world will be impacted by big data. May be a good read for my next book club.

From Cowtown: “Re: private equity in physician practices. Interesting that you notice this pattern. I have had in mind that health systems buying up doctors seemed to be getting fairly smug fairly quickly. It kind of feels like the hospital leadership thinks, we’ve got 300 head of PCP out grazing in the North Region. This attitude belies the fact that doctors (non-competes notwithstanding) hold their own licenses and can take their acts elsewhere. Perhaps there seems to be little will to break away amongst the traumatized mid-career types and the debt-ridden youngsters. Nonetheless, the ongoing evolution of IT, along with the availability of capital as you note, make it entirely comprehensible.

It is a shame, though perhaps expected, that the first forays you’re seeing are aggressive, hubristic moves that misunderstand power – market and otherwise. I believe that successful ventures for primary care will center around:

  • Building physician culture, with an eye towards work-life balance.
  • Operational excellence, with an emphasis on IT and measurement through data.
  • Patient satisfaction, leading toward the basics of customer experience – business hours, asynchronous communication, basic physical plant and services.

Oh, and did I mention, I think these should be primary-care only entities? The specialists can build out their own models, with operational excellence centered on procedures with bundled payments – it’s a different business. PE is the flavor of the day because of the tax advantages for the fund partners. It is usually looking for an exit, which if it is selling out to the hospital, likely becomes a destruction of value event. I hope that capital remains available to physicians, especially PCPs who want to do this the right way.” In many markets, physicians at all levels feel trapped, not just those with debt or feel beaten down. Although they can theoretically take their panels and licenses and go elsewhere, sometimes the choice is between bad and worse. My region has several major health systems; although some used to have distinguishing features (such as the willingness to enter into joint ventures with physician groups for surgery centers or diagnostic imaging) they’ve become fairly homogenized with their relative unwillingness to negotiate with physicians. Narrow networks are making physicians nervous about losing market share, so I see them staying in situations they wouldn’t have tolerated several years ago. The hospital-owned medical groups definitely don’t seem interested in building physician culture or work-life balance although they are trumpeting “operational excellence” through statistics pulled from their EHRs. They’re also treating subspecialists the same as primary care physicians (albeit with larger paychecks) which is adding to the negativity as the procedural subspecialists get a taste of what the rest of the physician base has been experiencing all along.

As a result, we’re starting to see increasing numbers of physicians headed to the direct primary care model. Those who are remaining in traditional physician groups are starting to opt out of Medicare in an attempt to regain autonomy. I’ve heard people talk about it for years but it seems to be actually happening, which will be interesting with the aging patient base in our community. I don’t make it to the hospital physician lounge very often but when I do, the conversations are always lively.

Has private equity shown interest in your practice? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/24/17

August 24, 2017 Dr. Jayne No Comments

In keeping up with Physician Compare and Hospital Compare, CMS has launched the Hospice Compare website for those looking to evaluate end-of-life care options. I’m fortunate to live in a community with some very well-regarded hospice organizations, but I recognize that there are people out there who prey upon families during a highly vulnerable time. In addition to showing quality metrics for pain management and treatment of other symptoms such as shortness of breath, it also displays whether a hospice is for-profit or not and when they were certified.


I had the privilege of being in the path of totality for this week’s total eclipse. Although I wasn’t able to get any photos on my own (this one is courtesy of NASA) it truly was spectacular. I’ve seen a partial eclipse before (back in 1979 with a trusty cereal box pinhole viewer) but I have to say, seeing it through filtering glasses was a very different experience. I did make a pinhole projector and showed it off to a couple of kids who needed a dose of low-tech magic. Even with some pre-eclipse reading, I saw things I didn’t expect to look the way they actually did, such as the crescent shadows through the trees and the shadow bands right before totality. The coolest pinhole projector I saw was a colander, which projected dozens of mini-eclipses on the ground.

I do completely understand how people damage their eyes, because as the eclipse progressed past the totality phase, I wanted to keep looking at the corona. The brightness made that idea a short-lived one and I went back to my viewing glasses after taking another good look at the shadow bands on the ground as they appeared again on the eclipse’s way out. I’m not ready to become an eclipse chaser, but if you have the opportunity to see a total eclipse, I definitely wouldn’t miss it. An ophthalmologist friend from residency practices in the eclipse pathway and had several patients call his office Monday evening and Tuesday morning wondering about retinal injury. Fortunately, he didn’t see any significant damage.

Tuesday, it was back to the grind, working with a client in the advertising space. I’ve worked with advertising and PR firms before, usually in the context of helping a healthcare organization rebuild their brand, but a couple of times with product launches. This is the first time that the marketing firm has been my client. They engaged me because their efforts to build a healthcare business line have stalled. It seemed like an interesting challenge and they were referred to me by a solid client who convinced them that they needed some tough love from someone in the healthcare trenches. Initially I thought that they just didn’t understand the healthcare business, but as I began to shadow them on calls with their clients, I realized that the root cause may be that they don’t understand marketing.

My past experiences with marketing and advertising firms have followed a fairly predictable course. They begin to understand the client’s business and the client’s goals, then take a survey of the current state. Was the client working with another agency? Were they trying to do their own marketing? What kinds of media were used? What was successful? What flopped? As part of understanding the client’s business, they interviewed stakeholders to understand how the business saw itself, then used that information to build a marketing plan for the organization.

My advertising client is working with a practice that is trying to launch an ambulatory surgery center (ASC), but the project has been one barrier after another and they’re challenged by some occupancy and rezoning issues. Regardless, they want to move forward with a plan to get their name and brand more visible in the community so they can bring providers on board and then launch the services to the community. I thought it should be pretty straightforward, and had no idea what I was about to hear on the call.

My client didn’t go into any of the background about why the practice wants to move into the ASC space and what they hope to achieve. They also didn’t ask what the organization is doing for marketing and what has been successful in the past. They launched straight into a checklist of “what date do you want to start running ads in the newspaper” type items that were completely ineffective.

It was clear that the practice was frustrated since they’re not marketers and that’s why they hired someone to assist. It was clear that the marketing firm had done no research on the client’s current web and social media presence. When the client balked at the checklist approach, my client effectively scolded their own client for their lack of understanding of the process.

They then proceeded to go through a patronizing explanation of the marketing process that was so full of jargon that it was making my head hurt. The practice had no idea what to make of statements like, “You need to give us information that will prime the pump” and “we need you to give us content that will hit the sweet spot.” I was in continuous contact with my client via instant messenger and tried to steer the conversation to keep the practice from hanging up on them, hoping that they could take a step back and get the client talking about why this expansion was important to them.

One of the marketing team actually asked, “What does ambulatory mean?” and I think I laughed out loud. If the practice wasn’t confident about their choice before, I’m sure this sealed the deal. (Pro tip: Google is your friend. Do some prep work.) I struggled through the rest of the hour making plenty of notes for my post-meeting discussion with the marketers. Although they were going to get an earful, I wish I could have given some coaching to the practice as well. First off, I wondered if they even checked references on this marketing firm or whether they went with the cheapest offer, or how they came to work with my client. My client currently has zero referenceable clients, which is why they hired me, and although it’s possible they could have fabricated something, I doubt it.

One of the reasons I went into consulting was to help small to mid-sized practices that were struggling with technology and working with vendors and who wanted outside advice on the best ways to move forward. I’m rarely surprised by lack of business savvy among healthcare providers because it’s not something they typically learn during their training. But I continue to be amazed by the cluelessness of the many vendors that are trying to find the pot of gold at the end of the healthcare rainbow.

How does your organization handle marketing? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/21/17

August 21, 2017 Dr. Jayne No Comments

My practice values service to the community and often does workshops for scout groups. Sometimes we’re teaching essentials of CPR and sometimes it’s first aid.

This weekend, I had the chance to help one of my partners put on a workshop for the Medicine merit badge for his son’s Boy Scout troop. He’s an official merit badge counselor and asked me to help a couple of months ago. My brother is an Eagle Scout, so I remembered seeing the merit badge booklets around the house and thinking that they had all kinds of interesting information. Apparently now they’re full color and you can also get electronic copies, so I was glad to see that scouting is keeping up with the times.

There are also a host of unofficial sources for information. My partner steered me to a website that had a PDF workbook for the items that the boys were expected to cover. I grabbed a copy of the actual book from the library, but ended up procrastinating the actual preparation until a couple of days ago, thinking I could just do my parts of the presentation off the top of my head

When I finally hit the merit badge website Thursday night to prepare and cracked open the paper booklet, I noticed that the last update to the book was 2002 (although the website mentioned that the requirements were updated in 2005). I figured I’d be in for some entertainment as I read about how medicine was portrayed to scouts 15 years ago. I was surprised, though, with how well the materials have held up. The healthcare professionals portrayed in the booklet represent a diverse workforce and are filling a variety of roles in medicine. I realized as I was reading that much of the information provided should be required reading for people entering medical fields or for people who want to better understand the medical people they work with.

Game time came too quickly for someone who had procrastinated their preparation. I found myself Saturday morning in our break room in front of a group of teenagers eager to show their knowledge medicine. During the first part of the requirements, the scout has to do a great deal of research on historical medical figures – individuals like Hippocrates, Florence Nightingale, Louis Pasteur, Jonas Salk, Marie Curie, and more. I was impressed by the boys’ ability not only to throw out interesting facts about their subjects, but to talk about why those contributions are important to healthcare even today. (A note to the Boy Scouts: if you consider updating this, let’s think about throwing in Larry Weed for his contributions to patient care and healthcare IT).

We next moved into my part of the morning, which was to teach the boys how to take a pulse and perform a blood pressure measurement. I was quickly cast aside by an older scout who asked if he could teach the group because he had volunteered at a blood pressure screening. I’m not sure why I was even there (other than to prevent them from doing goofy things with the blood pressure cuffs, which may or may not have happened) because the scout did a great job using the EDGE method, which includes explaining, demonstrating, guiding the student, and enabling their success. Since I spend a great deal of my time dealing with processes that have gone wrong, it was so gratifying to see a teenager taking charge and getting things done. Frankly, he was a better teacher / trainer than some of the folks I work with on a daily basis. I suspect that he is going to have a great future regardless of the field he chooses.

I was also tasked with talking to them about the instruments we use in the office, including EKG machines, pulse oximeters, spirometers, and more. We talked a little about electronic health records and how information sharing works in healthcare today, and I gave a little plug for careers in healthcare IT. I don’t think any of them had ever been exposed to a clinical informaticist before (not that I would expect them to have been) and I could see a couple of the boys perk up when we started talking about the technology. They perked up the most when we talked about defibrillating people and what that process actually entails. The drama of shouting “clear” and shooting electricity through someone’s body is well-portrayed on TV and they were definitely interested in learning more about it.

Another requirement is for the boys to discuss what makes a good screening test and why tests aren’t always perfect. Listening to them tell me about specificity and sensitivity and how patients had to be informed consumers so they didn’t spend a lot of money on tests that wouldn’t do them any good truly warmed my heart. These kids are clearly growing up in a world where being an informed patient is going to be critical to staying healthy and they were embracing it.

They branched off into a little discussion on the Affordable Care Act and how people didn’t understand that it was the same thing as Obamacare and why it was a mess. I knew these kids would be informed (one of the other requirements is to research the healthcare delivery systems in Sweden and China and compare them to the United States health system) but I was impressed. I know some of them have been working with my partner individually on the requirements, but they’ve clearly done their research.

The badge also requires the scout to discuss the roles of medical societies, the government, and the insurance industry in how they influence the practice of medicine in the US. From the presentation one of the scouts gave, I suspected we had a ringer in the group who had a physician in the family. It turns out that his mom is a family medicine physician, and he talked about how much his mom’s group struggles with Meaningful Use and other programs. That was an eye-opener for some of the other boys, whose only exposure to healthcare may have been at their own doctor’s office or through what they had read in the merit badge booklet and at our workshop.

They also have to explain how their state monitors healthcare quality and how it provides care to patients who don’t have insurance. These are pretty deep subjects for the average adult, let alone for a 12-18 year old boy, and I was impressed by the fact that the badge dug into it. The boys also had to present on different types of healthcare providers along with their training and educational requirements, as well as different subspecialties and what it takes to become a physician in those disciplines. It was entertaining to hear what the boys thought some of the specialties do vs. what we actually do – paperwork and charting were never mentioned in any of their synopses.

The scouts also had to research the Hippocratic Oath and explain it, along with comparing the original to a more modern version. They had to “discuss to whom those subscribing to the original version of the oath owe the greatest allegiance” (for those of you who haven’t read it lately, it’s not the patient). That led to a discussion of the patient-physician relationship and how it’s important in delivering quality care.

We also discussed the role of patient confidentiality and HIPAA. A couple of the boys in the group are 17 and will be adults soon, so I was able to talk to them a little about deciding whether to include their patients to be able to receive information when they go to the doctor and who they would want to make decisions for them in the event that they couldn’t. These are topics that most parents don’t cover with their young adults before they head off to college. It was a little bit outside of requirements, but it was a valuable discussion.

The scouts also have to volunteer at a health-related event in the community that they’ve had approved by my partner. Some of them have already done their volunteer work and it was interesting to hear what they did – handing out health flyers at a community event, volunteering at a free clinic, and working as a teen aide at the hospital. A couple more are planning to work at an upcoming blood drive and then they’ll be able to earn their badges. Looking at the information they had to explain, discuss, and tell about during the workshop (more than an hour and a half of discussion for each scout) plus the additional research to prepare for their presentations and the documentation they all brought, it seems like this might be one of the more intense merit badges the boys are exposed to. According to my partner, the Public Health merit badge has even more requirements.

It was exciting to see the leaders of tomorrow motivated to learn about our field and willing to spend time serving their community. It gives me hope that even as complicated as healthcare is, we have bright young people eager to try to figure out the best ways to serve patients in the coming decades.

Have you talked to young people about your career in healthcare IT? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/17/17

August 17, 2017 Dr. Jayne 1 Comment


The Office of the National Coordinator continues to advocate for strengthening the health IT workforce. The September 6 webinar will review workforce training materials that were available to the more than 9,000 people who participated in recent programs on population health, care coordination, interoperability, and analytics. Registration is open, and as a participant in one of the educational programs, I’d say it’s worth a look.

In other government news, the Medicare Quality Payment Program hardship application for the 2017 year is now available. Applications must be submitted by October 1, 2017 to avoid payment adjustments in 2018. I continue to run across providers that aren’t sure if they qualify for a hardship exception or not, so if you’re in the practice management or operations space, do your docs a favor and make sure they understand.

Physicians who are in the know have been very happy with the CMS final rule that makes the use of 2015 Edition certified EHRs optional for Medicaid Meaningful Use in 2018. Depending on vendor status, many practices were looking at having to upgrade their EHRs prior to January 1 so they could complete full-year reporting on a 2015 Edition system. The requirement now calls for a 90-day reporting period for Meaningful Use measures. Although Clinical Quality Measure reporting is still full-year, providers can now use 2014 Edition, 2015 Edition, or a combination of Certified EHR Technologies. It’s a welcome reprieve for organizations that are suffering from change fatigue and who may lack the resources to manage an upgrade along with other clinical and business initiatives. Although that change was documented in a final rule, unpublished guidance seems to indicate that practices that are part of the Next Generation ACO program can use either 2014 Edition or 2015 Edition CEHRT.

It’s been a relatively busy time in governmental circles, with the Department of Veterans Affairs also announcing their new telehealth project, “Anywhere to Anywhere VA Health Care,” which will permit VA providers to treat patients across state lines using telehealth technology. Providers can practice across the country within their designated specialty scope of practice. They also released their new VA Video Connect app. Veterans can use their mobile devices to access 250+ VA providers at nearly 70 sites across the country. Although solutions like the app have the potential to reduce travel hardships for veterans, they assume adequate capacity. If providers don’t have adequate time for patient care, simply shifting away from in-person encounters isn’t going to be a solution.

There’s also been action in the Senate to authorize a CMS Innovation Center project to boost use of certified EHRs in the behavioral health space. Psychiatric hospitals, community behavioral health centers, clinical psychologists, and social workers would be encouraged to expand EHR use along with residential and outpatient mental health and substance abuse treatment facilities. The 2009 HITECH Act didn’t apply to many mental health treatment organizations, which may help explain low rates of information sharing between behavioral health and other providers. A parallel bill has already been introduced in the House. Hopefully both will begin to work their way through the House and Senate committees soon.

One of the exciting parts of being in the healthcare information technology space is watching researchers come up with innovative solutions to difficult problems. Laboratory medicine is a big part of clinical informatics, so I was glad to hear about a new technology for Zika virus testing in the field. Researchers from Washington University in St. Louis are using nanorods to develop a test that can provide results without electricity or refrigeration. Proteins attached to the nanorods change color when exposed to Zika virus-containing blood. Although the initial study was very small, it shows a great deal of promise. I was also glad to see the varied affiliations of the authors – mechanical engineering, anesthesiology, and biochemistry/molecular biophysics. The engineering and biophysics fields are expanding rapidly and make great areas of emphasis for premedical students who aren’t sure about their future in patient care.

Speaking of laboratory medicine, LOINC is looking for experts to join four new special topics workgroups. The groups will meet monthly and provide recommendations to the LOINC Committee. Workgroup topics include: Document Ontology, which looks at the framework for displaying clinical results; LOINC ShortName for addressing situations where LOINC codes need to be stored or exchanged but the ShortName is not appropriate; Cell Marker Naming for review of ambiguous terms; and High-Sensitivity Troponin, which will look at the best way to model cardiac assays in LOINC. Workgroups start August 30 and more information can be found on the LOINC website.


I haven’t been able to attend the MGMA conference in years, the last time being when it was in San Antonio. For those who can’t make it to Anaheim for MGMA17, there is an opportunity to attend remotely via MGMA 2017 Monday Live. Registration is $350 for MGMA members and includes access to the general session and several breakouts. Advertising collateral mentions the opportunity to not only listen to sessions but to “network with your peers,” which might be a little challenging given the virtual environment.

Virtual environments are less of a barrier for the one-on-one contact of telehealth. Employers are gravitating toward inclusion of telemedicine services in employee benefits plans. The Large Employers’ 2018 Health Care Strategy and Plan Design Survey estimates that nearly 96 percent of employers will offer telemedicine services in states where it is permitted, with more than 50 percent including behavioral health as part of the offering. More employers are also offering on-site health centers. My local school district is piloting an on-site employee clinic that received a fair amount of traffic in its first year. They haven’t made a decision to expand, but will continue to pilot during this academic year.

Do you have access to an employer-based health center? Have you had the occasion to use it? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/14/17

August 14, 2017 Dr. Jayne No Comments

I work all over the country, so I see both national and regional trends. For a while now, we’ve seen private equity firms sinking money into larger practices, particularly in the profitable subspecialties such as dermatology and oncology. In these larger organizations, the private equity involvement usually starts around capital expenditures, such as opening surgery centers, infusion centers, or purchasing equipment. The organizations themselves are already fairly well developed and may be looking to expand or merge with another practice, but they’re typically pretty savvy about running a business and how to interact with financial backers. Recently though, I’ve seen a couple of scenarios play out where smaller organizations have gotten themselves involved in with private equity money and the practices are clearly in over their heads.

The first organization I saw this with was a primary care group that had a decent number of physicians, but at 50 or so providers, was in no way a large group. They were located in Texas and had delusions of expanding their group statewide and had gotten some backing to do so. I was working with them peripherally through a consulting subcontract with their laboratory vendor, so was able to watch it play out from the sidelines. I watched the practice administrator threaten leadership from their EHR vendor, using phrases around their plan to “triple in size” and to become “a force to be reckoned with.”

First off, even if they tripled in size, that would put them in the 150-physician range, which their vendor doesn’t even remotely see as a “large” client. The practice had failed to realize this before making their demands for free services and free software in preparation for their growth. They also failed to understand that primary care practices rarely have the footprint or financial ability to become a force as they envisioned unless they are very large or have very tight ties to key subspecialties.

The practice administrator had sold her physicians a bill of goods and they were all buying into the illusion that someday they would be the pre-eminent primary care practice in Texas, and by bringing in some PE financing, they were on their way. The physicians didn’t understand that once you bring PE into the mix, you lose a fair amount of control because you’re spending someone else’s money. I never had the opportunity to read the agreement, but it was clear that either they gave away more rights than they understood or that the PE group was taking advantage of them.

The administrator, who is from Detroit, and the PE leader, who hailed from New York, also failed to understand Texas culture. They never could quite figure out why small practices and independent providers weren’t interested in merging with them. Having spent several years living there and dissecting the culture as a relative outsider, I could have given them some pointers.

First off, although Texas is legally a single state, when you travel around it and meet lifelong residents, you quickly realize that it might as well be multiple states. I know people who live in Dallas and Fort Worth who have never been to the other city despite them being only about 30 miles apart. For those folks, crossing that gap might as well be a trip to the moon, which is a shame when you consider what each of the cities has to offer.

When you look at the cities that are farther apart physically, the differences are even more striking. The drive from Brownsville in the South to Texline in the north is almost 900 miles and you cross through multiple cultural traditions on the way. Parts of Texas think they’re in the old south, parts of it think they’re in the Old West, parts of it think they are in old Mexico, parts of it think they’re “big cities,” parts of it ooze small-town charm, and parts of it are just weird (Austin, you know I love you). Oh yeah, and then there’s the Gulf Coast.

To think that you’re going to be able to understand and accomplish expanding to physician practices across that broad of a spectrum within 12 months seems like a long shot. Some of us can’t even get physicians to agree across county lines, let alone across cultural divides and geographic barriers. I’m not saying it can’t be done, but it’s going to be expensive and psychologically exhausting as you try to address the distrust that people have of each other when they’re coming from different perspectives.

Eventually, the practice burned through a lot of money trying to figure out the expansion and the PE group became frustrated. In the end, they were snapped up by a hospital system that they had previously shunned.

Another group I worked with more recently was a procedural subspecialty practice in the Midwest. They had been wooed by a PE firm promising market dominance and expansion, which resonated with the practice’s leadership. Although they’re just trying to achieve regional expansion and grow from their 30-physician size, they didn’t understand that the face they were presenting to the market they were trying to conquer wasn’t a nice one.

My first exposure to them was a meeting where the head of the practice opened with expletives and started shouting at the vendor in front of the PE team. Never a good sign. This guy would go out to practices they were looking at “merging” with (code for acquiring) and behave inappropriately. I once watched him threaten prospective partners and promise that they would be sorry if they didn’t align with his group. I felt like I was in a 1920s-era gangster movie and expected to see Robert De Niro walking around the room with a bat.

I was somewhat gratified to see both his administrative and IT teams begin to ally themselves with the PE team against him. This continued for weeks and he never had a clue that the axe was going to fall until they walked him out the door. In the aftermath, the physicians feel hoodwinked, and frankly I don’t think they wanted to expand that much at all but were relatively powerless to block the actions of the administrator because of their previous corporate setup. They clearly didn’t want to give up as much autonomy as they did for the promise of being the top dogs. If they thought their schedules were oppressive before, they are certainly not enjoying the MBA-level micromanagement that is now going on behind the scenes. I don’t doubt that the practice will eventually grow, but the PE managers have a vested interest in tightening the collective belt so that they spend as little of their own money as possible.

Anyone who doubts that medicine has become a business needs only to look at these types of examples to understand what is going on. Medical schools have done a great job adding courses in patient engagement and complimentary / alternative medicine to their curricula. Now they need to add solid business courses. If they don’t, then physicians need to seek this knowledge on their own just like they would learn a new procedure or therapeutic regimen. There are plenty of smooth-talking individuals looking to work with physician groups and all too easy for them to be on higher ground.

How does your group learn about trends in practice management? Have you had private equity interest? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/10/17

August 10, 2017 Dr. Jayne 1 Comment


My HIMSS planning is officially underway and I’m happy to report securing my preferred hotel for my preferred dates for the first time in several years. The shifted schedule (Monday through Friday) always throws me off when we’re in Las Vegas. The updated schedule now shows Magic Johnson as the closing keynote speaker on Friday, but I’m sure that quite a few of us will be departing before then.

Much of the agenda is similar to years past, but I did note the addition of a fee-based session for Thursday. “Rock Stars of Emerging Healthcare Technologies” is a $295 additional charge and purports to cover disruptive and innovative technologies. I’d be interested to see who is in the lineup, but I’m not eager to spend that much money.

I’ve been catching up on medical reading and continuing education. Many of our readers would be happy to know of a new report linking moderate drinking to cognitive health in old age, at least for some demographic groups. Although it found that patients who consumed a moderate amount of alcohol on a regular basis were more likely to live to age 85 without cognitive impairments or dementia, it’s hard to know the exact nature of correlation vs. causation. The study ran for 29 years and used the standardized Mini Mental Status Examination to gauge cognitive health. Adults with “moderate to heavy” alcohol intake five to seven days a week were twice as likely to stay cognitively intact than those with little alcohol intake. Wine-drinking tends to correlate with higher income and education levels that are accompanied by reduced rates of smoking and greater access to healthcare. The majority of study participants were Caucasian and from a middle-class suburb of San Diego.

The Agency for Healthcare Research and Quality (AHRQ) is seeking nominations for public members of its National Advisory Council. The Council advises the AHRQ Director, the Secretary of Health and Human Services, and other bodies on national health services priorities. Nominees must be willing to serve a three-year term, meeting in Washington, DC three times per year. Desired qualifications include medical practice, other health professional experience, researchers, healthcare quality experts, and health economists, attorneys, or ethicists. Additional information is available in the Federal Register.

There has been a lot of chatter in the physician lounge about Anthem’s recent statements that they will not cover non-emergency conditions when patients seek care in the emergency department. Primary care physicians who have a large number of Anthem patients are starting to worry about capacity and creating plans to care for an influx of patients. Retail clinics and urgent cares are eager to accept the overage. Anthem has piloted this in several states and is in the progress of expanding it to others.

We already see plenty of patients in the urgent care setting who could be easily treated with over-the-counter remedies, so it will be interesting to see how this impacts the patient mix in states where it is a factor. In my area, a visit to the local pharmacy’s clinic runs 40 percent less than a comparable physician office visit and about a quarter of what is charged in the urgent care setting. All are significantly less than the $800-900 typically charged for a basic visit in the emergency department.

Wearing both my family medicine and urgent care hats, the missing piece is education and triage. It’s one thing to simply tell a patient that their bill won’t be covered unless it’s a true emergency, but it would be even better if the payer spent a little bit of the anticipated cost savings educating patients and providing after-hours nurse lines where patients could seek advice. Lots of people surf the Internet for information or get their advice from Dr. Google, but education is still a great value in the long run. My insurance carrier has serious limitations on emergency visits, but offers nothing in the way of other support to triage patients to the appropriate care setting. At our urgent care, we sometimes see patients who started at the retail clinic but couldn’t be treated there due to limited scope-of-practice agreements, which leads to an additional and more costly visit with us.

There has also been a fair amount of chatter around the recent JAMA research letter about Maintenance of Certification (MOC) and Board Recertification fees. Although the medical specialty boards are supposed to be non-profits, they’re taking in significant amounts of money from examinees and those required to demonstrate participation in MOC activities. According to the research, the amount of income from exam fees is out of proportion to the amount it actually costs to administer the exams.

For those of us who are board certified in multiple subspecialties, the expenses can add up. Even for those of us board certified in clinical informatics, we are required to maintain a primary specialty board certification. This seems rather unfair to the large number of clinical informaticists who no longer see patients and might be inclined to allow their primary certifications to lapse. Current policies also exclude a number of clinical informaticists who had already discontinued their primary certifications before the clinical informatics certification became a reality.

I’m due to retake my primary boards in 2019 and figure I’ll have to take them at least twice more before I retire unless something changes. I’m not looking forward to the time commitment or to studying information that has no bearing on my practice, such as obstetrics. I failed to buy a lottery ticket for this week’s Powerball, so it looks like I’ll be in the trenches for the foreseeable future.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/7/17

August 7, 2017 Dr. Jayne 2 Comments

I’ve been working on a project involving laboratory interfaces for a mid-sized multispecialty practice that is trying to integrate with multiple local hospitals. They’re valiantly trying to stay independent, which is quite a challenge given the rampant consolidation that is going on in nearly every healthcare market.

The practice’s leadership figures that if they interface with the hospitals in addition to the reference labs they already send to, it will make it easier to manage patients regardless of where they are admitted. As they were putting together this plan, however, they didn’t understand the complexity of working with organizations that aren’t entirely focused on earning the practice’s laboratory business like the national reference labs are.

Since the practice’s previous interface projects took 30 to 45 days, they assumed that working with the hospital would be the same. They also assumed that the hospital laboratory representatives who regularly come to the practice to tell them about new tests would be able to assist them in navigating the entire process, not realizing that those reps were more sales agents than true account managers.

The first surprise came when Hospital One told them it would be a minimum of three months before they could even talk about a timeline for starting a lab interface project, so they would have to stay on paper for the foreseeable future. It would be a fairly straightforward process to create a printable laboratory requisition so we could move the practice away from the hospital’s carbon-paper form and into EHR-based ordering. However, the lack of an interface had already created a significant amount of extra work for the nursing staff who was expected to manually key all lab results that were related to reportable clinical quality measures.

Even though we couldn’t fix the interface problem, I helped them create a new workflow for keying the results, which involved their medical records staff in addition to the nursing staff, so the workload could be better distributed. Cross-training is always a good thing, and assuming adequate training and quality assurance review, there was no reason why the medical records staff couldn’t be part of the workflow. Still, given the nature of the one-off workflow to key results, compared to the interfaces with the reference labs, I didn’t foresee the practice sending any more orders to Hospital One than they had been with handwritten orders.

Hospital Two was a significantly more accommodating, probably in part due to the fact that the practice hadn’t been sending business to its lab previously. Although they didn’t have available staff to assist with a bi-directional interface project, they were willing to set up a results-only interface that would at least allow discrete results to come into the patient chart without the staff needing to be involved.

Unfortunately, the client’s EHR handles this type of situation by creating two orders in the patient chart — one for the actual order and one that is created when the unsolicited result hits the system. This leads to extra work because someone has to reconcile the orders and match them up, and it would leave the practice with the same amount of extra work as the first hospital. When I mentioned the inconvenience and asked if they were willing to help us implement a workaround that would function as a semi-solicited interface, they were eager to hear about what it would take.

Having done it with other clients, I knew the hospital’s lab system was capable of holding the client’s internal accession number, and that keying it on each order would solve the problem. Usually only about half the hospitals I interact with are willing to do this, often citing the risk of error or the magnitude of the extra work for their lab staff. However, this facility jumped at the chance to see if they could make it work in order to obtain a piece of the practice’s business.

They were so eager to move the project forward that they agreed to send someone to the practice to key in the orders for testing so that the practice didn’t have to hardly expend any resources. Once the orders were keyed, they resulted them promptly, faster than almost any hospital lab I’ve ever worked with. The entire testing phase took barely more than a week and they resolved any issues that were found by the end of the next business day. I have to admit, it was a dream project and the entire thing was done in less than four weeks.

Many of us in healthcare are a tiny bit superstitious (never say the word “quiet” in the emergency department) so I knew that given the success of the project with Hospital Two that the next project was likely to be a nightmare. My vague suspicion grew into actual worry when I met the IT project manager the hospital had assigned to the interface project. I could sense the rarified air around him as soon as I walked in the room and had to suffer through his overly complicated explanation of what an interface project entails. I think he assumed that as a physician I didn’t know anything and he totally missed the part where the practice administrator explained that I was their consultant and had assisted multiple clients with interface projects.

He went on for a good 20 or 30 minutes that seemed like a lifetime, talking about all the important work the hospital IT team would be doing to make the interface happen and how little the lab and practice teams would impact the process. When I finally was able to jump in and explain my experience and the practice’s goals and objectives, I was treated to a rainbow of colors on his face as he went from angry red to bilious green to white. I think it had honestly never occurred to him that anyone on the practice side could have a clue how things should be done.

Since he claimed he didn’t have a sample project plan to review with us, I provided him with my own, which produced an outstanding level of pallor as he realized he wasn’t going to be able to put one over on us. We asked him to review the proposed timeline and comment on it and he said he would be able to get back with us in the next couple of weeks. That’s never a good sign, but I couldn’t tell if he was actually backlogged or just being passive aggressive. As time went on and he haggled about everything from the selection of components for the test scripts to the way in which labs would be resulted, I knew it was the latter. The project has been stalled in every imaginable way, with various resources being unavailable or on vacation at various times despite the hospital having agreed to a project plan and timeline.

The practice’s pleas to hospital leadership have fallen on deaf ears. This week I’ll have to have a serious discussion about halting the project. We’ve been using too many resources with little return, and if this is how a hospital acts when a practice wants to send them their business, I doubt they’ll be responsive if there are issues. The other hospital’s semi-solicited interface has been working like a dream, and to the end users, it functions just like the reference labs’ bi-directional interfaces. There are a couple of kinks for the practice’s IT staff every now and then, but overall, it’s been a big success. There simply isn’t much reason to continue working with a competitor hospital that just puts roadblocks in the way.

It will be interesting to see whether the first hospital ever circles back to us or whether a halted project will bring the third one in line. I suppose some hospitals are simply so big that they forget about their base, or maybe leadership just lets certain constituencies run amok. I can’t say that healthcare IT will ever be dull and am grateful that organizations like this create job security for people like me.

How does your hospital earn business from independent practices? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/3/17

August 3, 2017 Dr. Jayne No Comments


The Food and Drug Administration releases guidance allowing Institutional Review Boards to waive informed consent requirements for clinical studies that have minimal risk. This is a major win for researchers trying to use big data to look at populations as well as those working on precision medicine investigations. Informed consent has been in issue when you’re looking at large banks of biological specimens and the clinical data that goes with them, or just large volumes of clinical data that are needed to identify trends and other areas for potential research. The FDA reserves the right to modify its guidance as needed, but this is a good thing for many of us.


In other government news, CMS announces that it has changed the name of the Social Security Number Removal Initiative (SSNRI) to “New Medicare Card.” Seems like something that should have been an obvious solution from the beginning, but who wants to miss out on another non-pronounceable cluster of letters?

CMS also recently released the 2016 Open Payments data. A couple of my colleagues are apparently raking it in, but most of the folks I work with all had less than $100 in annual payments. Looking at the local landscape, Novo Nordisk and Pfizer were the cheapest lunch players, followed by GlaxoSmithKline. Salix Pharmaceuticals led the pack with an average lunch cost of $24. I’m sure their mealtime presentations on their diarrhea and constipation drugs was a real showstopper.

I know I’m a card-carrying member of the Grammar Police force, but I want to again stress the need for people to be proficient in writing. I’ve been doing a little CMIO augmentation work and was presented with some documentation from a recent consulting engagement. Not only were there font and spacing issues in the document (to the point of being distracting), but there were basic grammar issues that never should have seen the light of day. There is a difference between “it’s” and “its” and also between “there,” “their”, and “they’re.” If you’re only doing spell check and not a grammar check, you’re missing out. And if you embed Excel cells into a Word document, you’re going to miss out there as well.

These are small errors, but frankly they reduce the credibility of your work. I know I’m guilty of sometimes letting a blog get out the door with some errors, but I don’t have the luxury of peer review and am usually writing from a plane, train, or automobile if I’m not writing from a half-crashed state in a hotel room. If you are charging $300 per hour for your work, you had better read it carefully and consider having a friend look it over before you send it to a CMIO. I can’t take you seriously when your work looks like it was styled by a middle school student.

The CMIO whose shoes I am filling passed away unexpectedly and at a young age. It’s been a heartbreaking assignment, because she was clearly loved and respected. Despite the depressing circumstances, people have been extremely accommodating as I begin to get up to speed and work through my plans to sort through the projects that urgently need my attention.

A search process is in full swing, but I suspect they will have challenges trying to fill the position based on how it is funded. It’s cobbled together with 40 percent administrative funding, 40 percent IT funding, and 20 percent clinical funding. The ideal candidate needs to not only have experience and knowledge, but be willing to try to serve three different masters whose needs are sometimes at cross purposes. I’m just covering the administrative and IT functions and that’s been hard enough.

We have some interviews scheduled over the next several weeks, so I am interested to see if they find someone who is up to the challenge (and also wants to relocate to a mid-sized market and to a role that does not have an associated academic appointment). If you’re on my interview schedule, may the odds be ever in your favor.

At HIMSS17, I was invited to join a virtual book club with a great bunch of women from across the country. Every month we read something and then get together on a conference call to talk about the selection. It’s a diverse group of people, with several from the healthcare IT space, one from engineering, a couple of entrepreneurs, and a retired educator. One of them mentioned that she just started reading the most recent MACRA offering in the Federal Register. She said she was thinking of making it her book club selection and giving everyone a section to read and provide a cheat sheet and their interpretation. I’m pretty she just subconsciously wants to be ousted from her book club president role, but I know most of us who have had to read it wish we could have assigned it to someone else. This month we’re discussing the book I picked, so I hope it hit the mark and they don’t vote me off the virtual book club island.

I spend an insane amount of time on the road, so I keep my eye out for services or products that can make my life easier. I have to say I am seriously intrigued by DUFL, a service that stores your business wardrobe and then ships it to your destination. As you depart, you ship it back to them for laundering so it’s ready to go again. The DUFL app displays photos of your catalogued clothes so you can pack your virtual bag for shipping. They charge $99 per trip to pack, ship, retrieve, and launder your clothes and $9.95 per month for storage. Depending on whether you’re going to have to pay to check a bag and how many items you may have to have dry cleaned when your trip is finished, the return on investment calculation looks pretty good. That doesn’t even include the time needed to pack your clothes so they don’t end up a wrinkled mess. They also offer a sports service to ship your equipment with care. I’d be interested to hear from any readers who may have experience with DUFL, because I hate going to the cleaners, as the pile of clothes on my dining room chair can attest.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/31/17

July 31, 2017 Dr. Jayne 1 Comment

I wrote a little in the last EPtalk about the interview Atul Gawande recently did with Tyler Cowen. I find Gawande fascinating and appreciate his measured, real-world thoughts around some of the challenges we face in healthcare. There’s a lot of push to try to have technology solve everything and his respect for simple solutions, such as checklists, is refreshing.

One of the topics covered in the interview was medical education, specifically what is missing from the way we train doctors. Many of us recognize that there has been quite a bit added to medical education in the last few decades – genomics, precision medicine, and the concepts of clinical quality and patient engagement. I started my medical education at a time when schools were first realizing that non-science majors could be physicians and that we had other knowledge to bring to the table.

Gawande notes that there isn’t any education “around the fact that we are no longer a craft. It’s no longer an individual craft of being the smartest, most experienced, and capable individual.” He goes on to say that medicine has “exceeded the capabilities of any individual to manage the volume of knowledge and skill required” leading to care delivery via teams. Students need to know how to function as a team, how to manage when the team isn’t being effective, and more.

I’ve found that it’s not just in medicine that people are missing out on functioning as teams. Our culture has become so competitive, even down to the ranks of toddler soccer, and activities that promote teamwork and team development seem to sometimes fall by the wayside. Although sports can be an avenue for teamwork, I see more push towards individual performance and trying to advance to more exclusive teams than I see towards working to make sure the team is the best it can be.

I’m working with a client right now that is a case study for this. They have a small stable of individual contributors working on process improvement projects. They can each recite a long list of their achievements and how they have climbed the ladder, but they are struggling to grasp the concept of themselves as a team. Some of it resolves around trust in the team, and teaching people to trust each other is a lot harder than people think. With this group, I’ve never seen as many eye-rolls as I did when I asked the group to read “The Speed of Trust” by Stephen Covey.

He shares his thoughts on physicians of the future needing to operate more as trusted counselors who have increased dialogue with patients about their goals and needs. During my career, I’ve watched the physician-patient relationship evolve from a more paternalistic model to one of shared decision-making and patient empowerment. Being in a more consultative role makes sense, but unfortunately our current framework for compensating physicians doesn’t support that. Even with the transition to value-based care, physicians are being paid for outcomes, which means following population-based protocols that may or may not be right for a specific patient.

He mentions the mismatch between treatment and patient priorities as being a cause of suffering. Additionally, he notes that the change in how healthcare is financed has altered care: “Just the payment incentives alone dramatically affect whether my tendency is to give you overtreatment in certain situations and undertreatment in others.”

I did find it funny and a little bit ironic that Gawande said, “The most powerful tool that a clinician has is their pen, and has the power to order medications to test, to doing an operation.” I haven’t used a pen in the exam room for years and usually I only use one to sign return-to-work notes or controlled substance prescriptions. It just doesn’t sound as exciting to say the most powerful tool you have is your computer, although I think it’s true. For many of us, it’s not just about ordering tests – it’s about having immediate access to information from around the world and to be able to bring that information to the discussion at the point of care.

Gawande was asked about the FDA and whether the new drug development process should be liberalized. Some of us weren’t around when there was no such thing as the FDA and he has some good reminders in that regard. Although it was a time of innovation, it was also a time with horrendous medical endeavors such as the frontal lobotomy and the Tuskegee experiment.

He notes that the process of regulating medical treatments has been sped up by patient engagement efforts around HIV and has led to more discussion of the balance between risk and speed of innovation. Increased speed has led to more drugs being withdrawn as a result of post-marketing surveillance and he supports balance in the approval process. He also mentions his thoughts on the FDA not only regulating drugs and surgical devices, but in tracking outcomes for surgical procedures. Although procedures can have some variability based on the patient and the circumstances, he feels there is a fair amount of institutional variability that could benefit from tracking and analysis.

The interview was a far-ranging discussion, including Gawande’s thoughts on Stevie Wonder (was overrated, now underrated); Michael Crichton (both over and underrated); and Karl Knausgard (overrated). He tags wearables as underrated, largely because they don’t do terribly much right now.

He also talked about his work as the director of Ariadne, an academic center that is part of Brigham and Women’s Hospital and the Harvard Chan School of Public Health. The center looks to study how science and innovation impact healthcare delivery. They recently did work with the state of South Carolina studying how to encourage surgeons to use a surgery checklist without regulations or mandates. Their program achieved 40 percent adoption, but he noted that it would likely take mandates or another process to bring the other 60 percent of surgeons to use it. I have to admit, the center has been running for five years and I hadn’t heard of it, although it sounds like something I’d be very interested in. I have a good friend starting her MPH at Harvard this fall, so I’ll have to see if she can get me an insider view.

There were some other interesting statistics in the interview. The average American has eight operations in his or her lifetime. He’s particularly interested in that because surgery is “the highest-risk, highest-cost, highest-failure moment in your lifetime.” Personally, I think the idea of having eight surgeries is something to be explored in its own right and would love to dig into those numbers.

I also appreciated Gawande’s thoughts on building his team and hiring the right people. He encourages the hiring manager to come up with a list of accomplishments for the next two years and hire someone who can meet the goal rather than hiring someone that is likable or fun. He notes that people should Intend: “Do what you intend to do, and do it with intention. Over and over, that’s what people fail to do.” I see a lot of that in my own world, people treading water or going with the flow, and moving with intention is significantly less common.

The interview closes with Gawande’s thoughts on indie music. He recommends Scottish band Frightened Rabbit, who he describes as “bards of sorrow and nonetheless sticking it through.” He warns that “they’re Scottish, so there’s a whole lot of cussing going on.” Based on that recommendation alone, I’ll have to check it out.

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EPtalk by Dr. Jayne 7/27/17

July 27, 2017 Dr. Jayne No Comments

I stumbled across a story on Amazon’s “secret” team that is supposedly looking at healthcare, including electronic health records and virtual visits. It’s supposedly called 1492 (if they chose that as an homage to Christopher Columbus, they had better rethink some of the cultural baggage around his “discovery” of North America). It sounds like they’re exploring interoperability as well, along with figuring out whether they can use the Amazon home-based devices like Echo in a healthcare capacity.

I’ve been a big fan of Atul Gawande ever since “The Checklist Manifesto” and enjoyed reading a transcript of a recent interview with Tyler Cowen. His opening comments on artificial intelligence were realistic and balanced, which was refreshing given the hype we’re used to seeing with headlines like “Dr. Watson Will See You Now.” He concisely explains how challenging it can be to fully understand what the patient is telling you.

Those of us in the trenches know this, but folks on the technology side underestimate the power of the story vs. data points. Patients often point to problem areas or sources of pain and have trouble explaining whether the problem is more external or internal. Some can’t offer descriptive words at all. Then there is the issue of individual perception of pain or problems. Of course, algorithms could probe into that, but there could be hundreds of questions needed to include or exclude various decision points.

He disagrees with the IBM Watson decision to address this problem and notes that the issue is complicated by the fact that the patient data changes over time. Not only discrete data, but the patient’s perceptions change, as does the patient’s willingness to bring new symptoms to the clinician’s attention and also the understanding of the interviewer. He sees technology as more of an adjunct.

I think most of us caring for patients agree. I’m tremendously fond of clinical decision support and systems that help me ensure I’m not missing anything I should be thinking about with complex patients. I think automated checklists are fantastic, and rather than making me practice “cookbook” medicine, they are helping me deliver the same quality care to every patient every time, regardless of how rushed or distracted I might feel at any given moment. They help level the care we deliver when we are trying to see patients in six-minute increments rather than the 30 minutes many of us wish we had.

He specifically mentions Isabel, which I’ve had available in a couple of EHRs that I’ve used in the hospital setting. Isabel prompts you to think about diagnoses you may be missing in rank order based on the data.

Cowen asks his thoughts on the potential of gene editing with CRISPR, which he finds concerning due to the “unpredictable things that people will discover that you can try to do with gene editing.” When those edited genes are propagated in living organisms, they can spread rapidly, and he doesn’t “think we’ve thought through that in the least.” There’s also the risk that people will want to genetically select against characteristics that they feel are undesirable without fully understanding the implications. On the other hand, he notes that many conditions are the result of the interaction of multiple genes and aren’t something that CRISPR will be able to significantly modify.

Gawande also goes on to talk about safety in the operating room and how the rise of procedures where the patient is awake is changing culture. That patient can now be part of the team and not just a passive participant. These procedures have been common in neurosurgery, where brain mapping is needed to try to protect the speech and movement centers while working on other areas. He notes that he’s seeing them in non-brain surgeries, where the team can interact with the patient about their medical issues and goals for the surgery.

Other patients don’t handle awake surgeries very well, so he does note that sometimes you have to adjust on the fly. I know this firsthand since I once had a procedure under “light sedation” and the surgeon asked the anesthesiologist to put me out a bit more because apparently I would not shut up and was getting sassy with the scrub nurse, who I recognized as having hazed me during medical school.

He notes that while checklists have been effective in reducing errors, there are still barriers to success because people either check the boxes by rote or end up not using the checklists at all. The first problem is something that I’ve seen in many organizations I’ve worked in. It can be as simple as running out of a supply and discovering that someone initialed an inventory form just hours before that the exam room was fully stocked.

As a busy urgent care, that’s a major concern in our practice, but fortunately we don’t have a lot of problems with people falsifying their inventory checks. One of our execs is a former Naval officer and “gundecking,” where someone says they did something that they really didn’t do, is a cause for termination. Leadership makes it clear that when you falsify logs, you undermine our mission of care delivery and it is not tolerated.

The idea of people blindly marking a surgical checklist is frightening. He mentions that organizations can take checklists to extreme, taking one 19-item checklist to an 81-item level that was unusable. Administrators rather than clinicians had bloated the content, which essentially led to people ignoring it.

They go on to explore the disconnect between healthcare and health outcomes. He notes that data from coverage expansions like the Massachusetts healthcare reforms has shown that some interventions are more powerful than others – namely primary care, chronic illness care, and mental health care. He also notes the difference between death reduction and changes in quality of life. Still, we’re not getting the biggest killers under control, like high blood pressure. Organizations like Kaiser have been able to improve outcomes through more assertive management of barriers to care.

I see issues with coordination of care and comprehensiveness of care daily, as patients come to the urgent care for situations that would be better handled by a primary care physician. Some days I struggle with the fact that I’m part of the problem – perhaps if we weren’t as accessible, or convenient, or fast, patients would put more pressure on their primary care physicians to re-engineer how they’re delivering care. I still see plenty of physicians who don’t leverage the technology they have in front of them or who refuse to change their office policies and procedures to better support their patients. I have experienced botched prescription refills, botched appointments, and general chaos when trying to get care myself.

The interview also covered the state of medical education, the FDA, and his thoughts on indie music, but I’ll have to leave you hanging for my summary of those topics. Tune in to next week’s Curbside Consult for the rest of my recap.

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Curbside Consult with Dr. Jayne 7/24/17

July 24, 2017 Dr. Jayne No Comments

One of the great things about consulting is developing long-term relationships with clients. I have a couple of clients that I’ve assisted for almost a decade, starting with some side engagements when I was a CMIO. When I transitioned to full-time consulting, they began engaging me for larger projects. Although we initially started with EHR optimization and organizational development work, they’ve seen the value of having outside help and we’ve been able to move into change leadership and strategic planning.

One of them is particularly great to work with, and not just because they’re located in a great city for live music and outdoor activities. Some organizations are nervous when working with consultants, afraid to expose parts of their operation that they think are problematic. Over the years we’ve developed a great deal of trust.

It’s one thing to let a consultant work on a process that has obvious problems, but it’s another to proactively bring functional-appearing processes to the table and ask for them to be examined in detail. Being given carte blanche to assess the organization at all levels, including the C-suite, has allowed us to identify many areas for improvement. As we’ve moved from department to department with standardization, increased technology adoption, and active management, we’ve stabilized their core practice areas while helping them through a time of unprecedented growth.

Part of their success can be attributed to the vision of their leaders, who are committed to playing the long game. Although they understand the need to keep up with regulatory requirements and to maximize incentives, they consistently put patient needs at the front of decision making. Effectively, they’ve tripled their size over the last five years, not only from a provider headcount perspective, but also when looking at patient volume.

As a Medicaid provider, they’ve seen an expansion of their patient panels due to increased coverage. Although they initially had to use locum tenens physicians to cover the surge, they’ve worked diligently to hire a good mix of both new and seasoned physicians who are committed to the organization’s mission. They’re not afraid to let a provider go when it turns out he or she is not a good fit and they’re not willing to be held hostage by staff with unreasonable demands.

We recently finished revising their plan for provider compensation. First, we did an analysis to look at how their provider compensation fits into their overall financial situation and their budget for growth. We also looked at provider salaries compared to industry benchmarks and to other healthcare employers in the region. It’s tempting to just use national or state data, but when you’re in the middle of a high-tech corridor that has a significantly different economic profile than the rest of the state, then you need to take a much more focused look at how employees are being paid.

We also had to dig deeply into the true cost of care delivery vs. the payments received, which was a project of its own. My client has historically received a lot of grant money and the employee culture was that they shouldn’t charge for certain services because they were “free.” This led to some financial underperformance, as front-line staff didn’t realize that grant money is sometimes tied to documentation of services provided, which can’t be demonstrated via reporting if it wasn’t documented. Although there were some significant findings from the analysis, we decided to pend a project to address them until we were done with the task at hand.

It’s tempting for organizations to dive headfirst into situations like this when they are discovered. Although I’m sympathetic to the fact that they were losing money, they appreciated my support of their plan to address this after the provider compensation project was finished so that the new project could have appropriate organizational focus and so that they could cultivate buy-in from site managers and clinical team leaders. The reality is that waiting another four to six weeks to get our plan together is likely to achieve a faster correction of the problem than if we tried to do it in a half-baked fashion.

I’m especially glad we waited, because our analysis of the missed charges led to discovery of some other workflow processes. Had we tried to have multiple training sessions and process changes, we would have lost a fair amount of productive time. By waiting and doing deeper discovery, we were able to retrain multiple processes at the same time and only pull people away from their clinical duties one time.

Now they’re getting ready to embark on a couple of facility expansions, which has led to the need to look creatively at how (and where) people in the organization do their work on a daily basis. It’s hard to completely remodel office space when people are working in it, and midsize medical practices don’t have a lot of experience with remote work. I’m spending time shadowing a variety of workers to determine exactly what happens during their work day.

It’s often surprising how much people’s day-to-day work doesn’t actually match up with their job descriptions. Employees are often assigned special projects that become part of their regular duties without them being documented. It turns out that staffers we thought could work remotely with little impact are in reality performing tasks that require more face-to-face interaction than would be possible with a telecommute. My goal is to see if we can identify ways to bundle those tasks and consolidate them among a smaller set of workers who would remain in the office, or arrange them so that people could take turns rotating into the office so they maintain the skill set.

The other challenge is to prepare people who haven’t worked from home for the challenges that are ahead. It always sounds great to be able to work in your pajamas, but the realities of working at home sometimes take people by surprise. I’m putting together some training programs to discuss how to set up a home work space, how to manage being away from your co-workers, and how to address the scheduling temptations that come with being a home-based worker. It’s great being able to throw in a load of laundry while you’re on your break, but I know a lot of people who need good advice on how to manage barking dogs when you’re on calls or how to manage when others are in the house with you when you’re trying to work.

It’s been rejuvenating to deal with problems that are a little outside the realm of healthcare IT and to help the organization realize that these issues are no less important to their overall success than interoperability or reporting their clinical quality measures. Figuring out how to best leverage your workforce and motivate your providers might even be more important at times. Too many organizations forget the people part of the equation. I’m excited that this group has been willing to be a laboratory for setting up the practice of the future.

How are you positioning your practice for the next decade? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/20/17

July 21, 2017 Dr. Jayne No Comments

I thought the travel gods were going to be favorable this week, starting when the rental car clerk gave me a free upgrade on a super-sporty car since I had a one-way rental and they needed to reposition it to my destination airport. Once I made it out of the rental car facility and got a few miles down the road, I discovered that the radio didn’t work. Or at least didn’t work in the conventional way, as it randomly turned itself on and off every 10 to 30 minutes and remained stuck on a static-filled station with some fire and brimstone preacher yelling at me. Did I mention the volume controls didn’t work either? There was clearly something wrong with the electrical system and the display would randomly show the back-up camera view even when I was streaking down the highway slightly in excess of the speed limit. By the end of my trip I was just glad to be back at the airport in once piece.

I had been traveling with a customer laptop, and when I got home, I discovered that my trusty Microsoft Surface had undergone an automatic upgrade while I was away. It was stuck on the “updating, please do not unplug your computer” screen and when I restarted it the endless boot cycle started. This led to a multi-hour trip to the Microsoft Store, where everything seems to be the user’s fault regardless of what prompted it. They were able to undo the upgrade and redo it segmentally, and everything seems to be back on the up-and-up. Still, I’d rather have those hours back because now I’m woefully behind. It’s days like this that make me miss the corporate world, where a magical Desktop Support representative would have dropped off a loaner within an hour or so.


HIMSS has opened nominations for its “Most Influential Women in Health IT” awards. This is only the second year for the program, designed to recognize “influential women at all stages of their career progressions.” Nominees should demonstrate an ongoing commitment to using IT to positively transform health and healthcare as well as providing active leadership in organizational use of IT in support of strategic initiatives. HIMSS never does anything without a hook — nominees must agree that if they are selected, they will contribute two pieces of content to HIMSS via blogs, podcast interviews, roundtables, etc. Nominations must include a biographical sketch and two letters of recommendation and will remain open through August 28.

ONC is continuing its “Interoperability in Action Day” series with a half-day webinar on “Advancing Interoperable Social Determinants of Health” on July 26. The session will focus on the current state of screening tools in care delivery and how they will play into new payment models, along with resources to increase tools around interoperability of social determinant data.

Social determinants have been used in primary care for a long time, especially in community and public health clinics. For some vendors, they’re relatively new additions to the EHR platform, feeding clinical decision support and quality measurement content as well as population health functionality. There are still challenges with communities agreeing on common vocabularies for data sharing. Other challenges include the fact that social determinants change over time and have variable impact on patient health quality. They’re often less quantifiable than physical or laboratory characteristics and combine in a multifactorial way to influence health. Discrimination, social support, and environmental factors can be hard to document in a discrete way, although other factors, such as insurance status, are easier to identify.

My EHR has some optional tools to document social determinants of health. We do gather some of them, but since surrounding health systems aren’t too interested in partnering with their competition, our data doesn’t get a lot of use.

CMS recently announced plans to delay implementation of the Appropriate Use Criteria (AUC) program by one year to 2019. The program mandates that physicians use clinical decision support when ordering certain types of diagnostic imaging, such as MRI scans. The clinical decision support information has to be included on billing claims. Physicians ordering too many tests without appropriate justification could be penalized through reimbursement cuts and radiologists performing studies identified as unnecessary would have claims rejected. Several advocacy organizations recommended delays. Based on some of the clunky EHR workflows I’ve seen created to handle this mandate, I hope vendors use the extra time wisely and for the benefit of their end users.


The American Medical Informatics Association has expanded the publication of its Journal, to be available monthly and as an all-digital publication starting in January 2018. The publishing world has changed dramatically over the last several decades, so I’m not surprised by the change, especially from a technology-focused organization. Research is also occurring more rapidly, making the extended preparation cycle needed for a paper journal more burdensome than beneficial. I’ll miss the paper copies, which I often loaned out to students and residents interested in clinical informatics. It’s a little harder to share an electronic copy. I’ll also miss the stack of journals that motivates me to dig in and read by sitting there and mocking me. An electronic “stack” of journals doesn’t quite get the shaming done as well as paper. AMIA is also looking for a new editor for the journal, as Lucila Ohno-Machado plans to leave the position after her eight years at the helm.


My thoughts go out this week to Senator John McCain and his family, after his recent diagnosis with glioblastoma. It’s a nasty kind of tumor that often persists despite surgery, chemotherapy, and radiation. Regardless of your politics, McCain’s reputation as a maverick has kept government activities interesting over the last several decades. He’s fortunate to be able to get care from a top-notch team and I wish him a speedy recovery. It just doesn’t seem fair that a guy who has made it through all life has thrown at him should have to deal with this. I hope the folks looking to cut funding for medical research and prevention think twice when they think of their colleague.

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EPtalk by Dr. Jayne 7/13/17

July 13, 2017 Dr. Jayne 3 Comments

I’m going on Hour 8 being stuck in an airport and I’m getting a little punchy. My flight has been delayed a couple of times and I’m now looking at getting to my destination airport at 2:45 a.m. I’ll then have another hour drive to my client, assuming I find an alert taxi driver at that hour since a rental car will be out of the question.

My road warrior readers know what this is like, but for those of you who haven’t spent a good chunk of your lives at the whim of the airlines and the weather, please have pity on the rest of us when we arrive tired and perhaps a little bedraggled. Hopefully the old residency adage that “a shower is worth two hours of sleep” will hold enough to get me through the day.

The airport I’m in has a number of seating areas with electrical outlets, but unfortunately none of them work. Airport decision makers that are OK with that sort of thing should be forced to spend a couple of days stranded at their workplace, left in limbo without charging their phones or using electronic devices yet still being responsible for their daily work.

As long as my battery lasts, it’s a good opportunity to catch up on some vendor updates and try to make a dent in my email backlog. I’ve unfortunately already finished the novel I brought for emergencies, so I may have to break down and go back through security to hit the bookstore, which is bafflingly not in the actual gate area where all the captive people are.

CMS released an article about the “modernized National Plan and Provider Enumeration System (NPPES)” which is used for providers to obtain and maintain their National Provider Identifier (NPI) number. The document is heavy on detail, but from what I gather, they’re making the process around non-individual providers more secure and efficient. Not surprisingly, people responsible for maintaining the IDs of hospitals, nursing homes, and physician groups were sharing credentials, which helped lead to the changes. New fields have been added to PPES to document provider-specific information such as languages spoken, race, ethnicity, accessibility, hours, and the provider’s direct email address.

I’m fine with most of that information being collected since I have to provide it every year on various credentialing applications. Hopefully it will be shared somehow so I don’t have to fill it out over and over. I’m not about to provide my direct email address, however, without understanding how it’s going to be used and who will have access.

CMS also published the 2017 CMS Quality Reporting Document Architecture Category III (QRDA III) Implementation Guide Version 1.0 for Eligible Clinicians and Eligible Professionals Programs. For anyone suffering from insomnia, I highly recommend it as an alternative to the Federal Register or Ambien. For those of you who aren’t familiar with the document or who have never heard QRDA, it’s the recipe for electronic exchange of clinical quality measure data. Vendors must keep expert resources on staff who not only know the material, but who can expertly digest updates to the specifications and deploy them to developers, engineers, and more. It’s incredibly dense information and I admire the people who master it and make the world safe for those of us who need to report quality measures.

I’ve received some feedback on my recent piece on training and adult learning. Most of it has been of the “right on” variety, but one shameless vendor used it as an opportunity to try to guess what hospital system I use and market their simulation software. There wasn’t even a decent introductory greeting, just a link to HIStalk and straight into the sell. Any vendor who thinks that kind of approach works is sad. 

One reader noted, “I have deployed and trained everything from a full EHR to portals to secure messaging to population health. The percentage of clients who let me apply even basic adult learning principles was sadly very, very low. Yet, as we know, the downstream impact of poor and/or incorrect or irrelevant training lasts for years.” I have good data on the costs of retraining as well as the loss of productivity after poor training and I drag it out frequently to convince reluctant practice leaders to do the right thing.

Early bird registration is now open for the AMIA 2017 Annual Symposium in Washington DC in early November. This year’s theme is “Precision Informatics for Health: The Right Informatics for the Right Person at the Right Time.” I like the fact that they used “person” rather than “patient” because we need to continue to understand the impact of technology on the users, not just on patient outcomes. There are days where I feel like I’m a human participant in an unregulated study that some deranged Institutional Review Board approved without regard to the safety of its subjects.

AMIA has also opened submissions for the Workshop on Interactive Systems in Healthcare (WISH) program, which aims to bring research communities together around the challenges of designing, implementing, and evaluating interactive health technologies. The theme for WISH is “Citizen Science: Leveraging interactive systems to connect to our data, our families, and our communities.” Submissions are open through August 7.

There are entirely too many conferences going on during October and November, so it’s going to be a challenge to decide where to spend my travel dollars. In addition to industry meetings, several friends are headed to a patient safety conference in New Orleans and it’s awfully tempting to select that over the technology offerings, especially when gumbo and beignets are on the line. I also have to start thinking seriously about my primary care board certification, which is coming due faster than I hoped, so that will factor into the conference shopping process as well.

One trip I did decide on is my semi-annual pilgrimage to put my toes in the sand and think about little more than whether I am reapplying sunscreen often enough. I’ve got my coverage arranged and am looking forward to being disconnected from my clients, at least for a couple of days.

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Curbside Consult with Dr. Jayne 7/10/17

July 10, 2017 Dr. Jayne 3 Comments


I saw this CPR training kiosk in an airport on one of my recent travels. It got me thinking about how we train people for various tasks, whether in the healthcare IT world or just in general.

There has been a tremendous amount of research over the last several decades about learning styles and individual strategies for education. Part of this has stemmed from the recognition and diagnosis of more conditions that require adaptive strategies. Other forces shaping it include various pieces of legislation, such as IDEA, the Individuals with Disabilities Education Act. Most of the discussion in these areas has been around children and young people, however. The body of knowledge looking at adult workers and adult education is still there, although smaller.

Some people can absorb knowledge readily from printed material and others need to see a demonstration. Some need to learn by doing, and others by doing a task over and over until they feel they have mastery, especially if they work in a high-pressure environment or one with many distractions. Some people shut down in a group environment, where others thrive in that type of collaborative setting. Others need to learn in a very focused environment with few distractions to do their best.

I’ve worked with dozens of healthcare and vendor organizations over the past two decades and have only encountered a couple that seriously considered the idea of different learning styles or learning abilities when creating training for their adult employees. It seems like most training is designed with efficiency in mind – namely, efficiency for those presenting or delivering the content.

Another pressure is the ability to track consistently in training, which leads to more packaged offerings. I can attest to the fact that it’s harder to ensure consistency in training when you’re sitting with a physician in his office eating spicy chicken wings while covering the finer points of the EHR rather than in a classroom environment. Sometimes, however, creative strategies are required to ensure that physician makes it to training at all.

When I was a CMIO, I had to push for approval to offer training through multiple modalities. Let’s face it — some people don’t do well in a classroom setting and others don’t do well with self-directed learning. Regardless of individual learning styles and abilities, others are going to just goof off regardless of how or where you try to deliver training.

I had a boss who loved the idea of conference calls, especially for a geographically distributed organization where managers didn’t want to pull people out of the office. Although some people can learn on a conference call with a couple of dozen people, others find it a recipe for distraction and lack of engagement. My experience is that most adults know what type of training is better for them, and if given the option, they will gravitate towards an environment where they will be successful.

In addition to providing training through multiple modalities, organizations have to work hard to make sure that the people delivering training are strong educators, not just subject matter experts. There’s an assumption that is sometimes made that because someone is knowledgeable, that they have the skill to share information with others in a way that is engaging and effective. I could provide testimony from a good majority of my medical school class that found they learned more efficiently from reading course transcripts than from sitting in a darkened lecture hall. These people are now out in our healthcare IT classrooms, and given other work pressures, are looking for the most efficient and effective way of learning material.

Due to these pressure, many organizations turn to e-learning options. Some of these are little better than recorded webinars with some questions thrown on at the end. Others are fully-baked interactive sessions where attendees are required to replicate workflows and prove some level of mastery before they can advance. I do enjoy the latter kinds of sessions, although they have to be constructed carefully with the emphasis placed on the right portions of the workflow.

I recently QA’d a client training module where the physicians were forced to replicate a complex set of steps around laboratory processing, which wasn’t even part of their workflow. But due to the cost and labor intensity of creating those types of sessions, the organization had settled on a single track for clinical resources, which ultimately wasted the time (and cognitive energy) of many of their end users one way or the other. In all, when you looked at the number of wasted training minutes, it would have been better to put together separate sessions. But since those wasted training minutes fell on the cost centers of the end users rather than the IT budget, the decision was made strictly based on IT resources.

I do a lot of work with organizations that are threatening to switch EHR vendors or who feel that their software isn’t up to par. When we actually roll up our sleeves and assess the clients, we find there are operational or training issues at play the majority of the time. Particularly with stalled EHR adoption, a lack of training and/or proof of mastery leads to reduced schedules that never quite get ramped back up or to features that never quite get implemented.

Often when we look at causality, we find that providers were not required to attend training or show mastery, even when other users may have been held to those standards. I understand dealing with physician attitudes, but letting them take a pass on training isn’t the answer.

The other issue I see frequently is that there has been staff turnover and the new staff hasn’t received the same level of training as others did at go-live, or that they are just expected to try to learn the system during an on-the-job orientation. Often these organizations seem surprised when I recommend what seems like a straightforward solution to ensure everyone in the organization has received an appropriate amount of training.

Another area where we help clients is in formulating training strategies,  not only on what types of modalities they should use, but also how to deliver the training content in a way that is engaging and includes the right kinds of clinical pearls and examples that will keep the attendees engaged. Sometimes when you’re presenting the driest material, having a good story can make the difference. I’m happy to share my tales from the trenches and let the clients take them as their own.

Most smaller organizations (and many large ones) don’t have anyone on staff who is an expert in adult learning and may not have even heard of the idea of differing learning styles, so we’re happy to fill that niche. Like the CPR training kiosk in the airport, we have to strive to meet our students where they are.

What strategies does your organization use to maximize training impact? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/6/17

July 6, 2017 Dr. Jayne 1 Comment

I’ve been watching a dialogue about medication reconciliation unfold on one of the AMIA email lists. The general consensus seems to be that medication reconciliation is a “wreck” and that there is tremendous variation in how/when organizations apply it.

In the various EHRs that I’ve used, there are many existing choices in reconciliation pick lists, and they may not always apply to a given care setting. For example, “substitute per formulary” might make sense for a hospitalized patient when they may go back on the original medication at discharge. But in the outpatient setting, if you’re doing a formulary interchange, you’re actually going to discontinue one medication and start another, which requires a different set of documentation.

There are also situations where you need to hold a medication because it’s not essential or could lead to complications (for example, oral contraceptives or daily aspirin) but still want it reflected as something that might have an ongoing influence on the patient’s current state (ongoing clotting or bleeding risk), but I have yet to see an EHR medication list that manages this well.

One respondent commented that there are options needed that don’t traditionally appear as choices during the medication reconciliation process, such as “the patient was never on this medication.” There are other choices such as, “patient’s family member says they are taking it, but patient claims they have never seen the pill,” and “patient taking every other day due to cost” that we’ll never see reflected on a reconciliation list but have to be added as a free-text or “other” type comment.

There are many patients for whom medication reconciliation is an impossibility due to dementia, psychiatric issues, or other medical conditions impairing memory and thought processes. Some of these patients have caregivers who can provide the information, but others don’t.

In the urgent care setting, we rely heavily on the medication history information available through our EHR, but unfortunately, it doesn’t always have the information for cash prescriptions since it often feeds from pharmacy benefit managers. The state prescription drug monitoring program helps fill that gap for some medications, but as a provider I often end up looking in multiple places or asking staff to call pharmacies or family members to try to get an accurate history.

For us, every patient is a transition of care for regulatory purposes as well as an opportunity for error when a medication gets lost in translation. The need for a formal reconciliation varies with the patient and their complaint. What if a visit is a transition of care but doesn’t require prescribing? Clinically a reconciliation really isn’t needed for an episodic complaint (laceration closed with glue), but there are challenges associated with saying staff can do it sometimes but not others.

The discussion brought other points about lack of functionality in EHRs in general, including the ability to trend increasing or decreasing doses over time. I know it took the better part of a decade for my previous EHR to get functionality that allowed prescriptions for different doses of the same medication to link, so that you could see the patient who started on 10mg of blood pressure medication and was gradually worked up to a higher dose. This was tricky because the system relied on NDC numbers initially, which are different not only based on dose, but also on how the medication is supplied. Personally, I don’t care whether the medication came in a blister pack or a stock bottle, but that’s how NDC worked. It was only after the system converted to RxNorm codes that things started making sense. Still, it’s hard to track things like when the patient is taking half of a 20mg tablet then starts taking a whole one, etc. That kind of documentation often winds up as unstructured data that can increase patient risk unless that unstructured data is kept attached to the medication list, which some systems don’t allow.

There were also comments about the fact that some providers don’t have any concept of ownership of the medication list. I saw this often in my past life as a primary care physician, when I would receive dictated letters from consultants that were missing most of the medications the patient was actually on. When transitioned to the EHR, these providers still didn’t feel the need to participate with the medication list, let alone try to perform a reconciliation. I saw at one hospital when they made reconciliation the job of the admitting physician of record that the procedural subspecialists (particularly orthopedic surgeons) developed a new habit of having the patients admitted under the PCP with themselves as consultants. In that case, no good policy goes unpunished.

At the same time this discussion was unfolding, I was contacted by a client who recently implemented functionality that allows them to electronically cancel prescriptions. Unfortunately, their local pharmacies don’t yet support this feature, which led to several days of confusion until they figured out what was going on and returned to their phone-based process. Until the pharmacies upgrade their systems, there’s little more I can recommend other than calling the pharmacies and discussing the impact and asking them to lobby their corporate bosses for an upgrade.

This has been the plight of physicians for some time now, as EHR vendors are forced to add functionality that isn’t supported in the real world. Despite electronic prescribing of controlled substances being required in several states, it’s not required in my particular locale. As a result, only a little more than half of pharmacies support the functionality. It’s kind of like being required to have LOINC codes for interfaced lab results but there not being a requirement for vendors to send the codes with the result transmissions.

I’ll be interested to see what comes of the medication reconciliation discussions and whether there is scholarly activity that might push vendors or regulators to change how they hope to steer medication reconciliation in the future. I was encouraged by the number of people willing to engage in the discussion or collaborate in future projects. A group of motivated clinical informaticists is a powerful thing indeed.

How do you feel about the current state of medication reconciliation? Email me.

Email Dr. Jayne.

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