EPtalk by Dr. Jayne 8/30/18

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/27/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/23/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/20/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/16/18

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/13/18

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/9/18

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/6/18

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/2/18

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/30/18

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/26/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/23/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/19/18

Every fall, providers across the country are required to update their ICD-10 codes in order to be compliant for services performed on or after October 1. A quick review of this year’s changes offers some insight about healthcare and culture in the US.

New codes were added for elevated lipoprotein(a), postpartum depression, and newborns affected by maternal use of opioids and other substances. Other codes help document forced labor and sexual exploitation. The one I found most disheartening was Z28.83, Immunization not carried out due to unavailability of vaccine. It’s unfortunate that practices that want to administer vaccinations can’t do so for a variety of reasons – manufacturing shortages, cost of supplies, cost of appropriate storage, and more. Vaccines are one of the most clinically-proven and cost-effective services we can provide, and access should be universal.

I appreciate the book recommendations that readers have been posting in response to my recent Curbside Consult. Bill Gates has also been recommending books over the last eight years, and they’ve been compiled into a list by Quartz.  Many of them address public health issues, including:

• “Dirt and Disease: Polio before FDR” (Naomi Rogers)
• “House on Fire: The Fight to Eradicate Smallpox” (William H. Foege)
• “Infections and Inequalities: The Modern Plagues” (Paul Farmer)
• “The Fever: How Malaria Has Ruled Humankind for 500,000 Years” (Sonia Shah)
• “Vaccine: The Controversial Story of Medicine’s Greatest Lifesaver” (Arthur Allen)
• “The Checklist Manifesto: How to Get Things Right” (Atul Gawande)

As a confirmed Atul Gawande fan-girl, I’ve read the last one, but will add the others to my list for when I need something substantial to counter my summer reading diet of chick-lit.

I have to admit that I was pulled in by the headline “Pay Bump for PCPs Fails to Drive Medicaid Participation.” Looking at data for 2013 and 2014, when payments increased under the Affordable Care Act, researchers didn’t see an increase in the number of physicians willing to accept Medicaid patients or the number of Medicaid patients seen by the cohort of 20,000 physicians. It should be noted that the boost only took the payments to the Medicare amount, not all the way to the amount paid by commercial insurance carriers. If Medicaid payments were increased to that amount, I think you’d see a boost, but not a tremendous one.

Medicaid patients are some of the most challenging to treat due to concomitant social and resource issues. Providers and their practices spend a large amount of time trying to coordinate care, identify subspecialists who are willing to consult on Medicaid patients, and trying to figure out how to improve outcomes and quality of life while dealing with issues such as unemployment, lack of transportation, low health literacy, poverty, overutilization of emergency services, and more. Providing those additional services costs money, which is one reason (besides low payments) that providers limit their care of Medicaid patients.

The article goes on to mention a possible solution with advanced payment models, including risk-adjusted capitated payments with bonuses for outcomes and cost-control. This would only work if you also provided the other necessary economic and social supports that complex patients need in order to successfully navigate our healthcare system.

In other news, LA Care Health Plan is throwing $31 million at efforts to recruit primary care physicians in a move to reduce physician shortages at safety net clinics that see its 2 million members. LA Care Health Plan is publicly operated and understands that physicians are more likely to choose employment with larger organizations such as health systems rather than opt for the smaller salaries often paid by clinics and health centers. They’re targeting younger physicians through grant programs, medical school scholarships, and loan repayment programs and are intentionally not recruiting physicians already serving in the county or working with underserved populations. Additional moves include salary subsidies, signing bonuses, and payment of relocation costs. The latter two are fairly standard for physicians in a highly sought-after specialty, so it’s a bit surprising that they’re just adding them now.

Focusing on loan repayment doesn’t incentivize some older physicians, who have had theirs paid off for some time. I know quite a few seasoned family physicians who would be willing to move to a more meaningful care environment if the compensation was right. However, when loan repayment comes from grant and other funds, potential employers are not able to compensate with a higher salary for physicians without loans, and the recruiting falls apart. Employers are eager to trumpet “total compensation” except for when employees do the analysis. I have several colleagues who don’t take health benefits from their employer, which is a substantial savings for the organization, but were unsuccessful in negotiating higher salaries to offset the change in the total package. Finding the right physicians will reduce turnover and save them money in the long run, so I wish LA Care Health Plan the best of luck.

As we swing into another hurricane season, the Food and Drug Administration has formed a Drug Shortages Task Force to address shortages of medically necessary drugs. Our practice is still contending with supply chain issues impacting IV fluids, which manufacturers continue to attribute to Hurricane Maria’s assault on Puerto Rico. We’re also short on local anesthetics, injectable anti-nausea medication, and several injectable antibiotics. It’s nerve-wracking to have to use a drug that you’re not familiar with that is the only available substitute for something you need. I hope they can find some long-term solutions quickly.

This one almost snuck under my radar, but the FDA has given its first approval to a drug for smallpox treatment. Smallpox has been considered eradicated since 1980, and I hope it stays that way. There aren’t any human clinical trials due to the lack of disease, but it has proven effective in animals. It has also been shown to have no severe side effects during human safety tests. The drug has been in development since 2001 and approval went to Siga Technologies, which developed it under a federal contract. Smallpox is a nasty disease, killing a third of those infected. Although research stockpiles remain in Russia as well as at the Centers for Disease Control and Prevention in Atlanta, there is concern that gene hackers could create strains for release. For those of us without the telltale vaccination scars on our arms, it’s a terrifying thought.

What disease do you fear the most? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/16/18

I’m a voracious reader and enjoy many kinds of literature. I’m part of a book club, largely composed of women in healthcare IT, that meets monthly via Webex to talk about a good read. I see hundreds of manuals, summaries, and business documents come across my desk every year.

Given all these things, I’m a firm believer in the concept that words mean something. Unfortunately, I don’t think this belief is shared by some of our fellow travelers in healthcare IT. We may understand how a claim needs to be properly formulated for it to be paid, or a lab result so it can be delivered through an interface, but sometimes we fall short in the realm of communicating with people.

Almost every end user has complained about user guides or technical manuals at one point in their career. There are hazards in trying to convert a technical process into something that clinical people can follow, or that distracted physicians are willing to sit and read. My first EHR vendor put out a 1,000-page user manual that was nearly unreadable and would rival any piece of federal legislation for its sleep-inducing properties. They blamed its size on the included screenshots, but part of it was the overly-wordy description of a complicated documentation system that was a hybrid between legacy green screens and something more graphical.

My undergraduate institution’s English department has a program in technical writing. I’m surprised they don’t turn out more than the one or two graduates who earn degrees each year because it should be a skill that is in demand.

The language of healthcare itself often gives physicians something to chat about in the physician lounge. “Reimbursement” implies that someone is getting paid back for something  in an amount equal to a previous expenditure. It’s fancier than saying “payment” and tries to mask the transactional nature of the business of healthcare. Many physicians agree that those reimbursements don’t adequately cover the time, effort, supplies, and overhead required in delivering the service, especially when looking at payers such as Medicaid. Can you imagine your HVAC contractor or auto mechanic talking about reimbursement for their time as opposed to just delivering a bill for services rendered?

I also hear physicians complaining about marketing campaigns directed towards them, and there are certainly plenty of those to make fun of. We’ve grown out of having photos of physicians playing golf and fishing as a proxy for the free time that technology solutions are going to give them. Instead we’re depicting them in the office seeing patients, which is where they belong, but that does agree with how physicians see themselves working increasingly long hours. There’s greater emphasis on showing physicians and providers of various demographics, old and young, male and female, and of diverse racial and ethnic backgrounds. Although vendors have done better with some of their pictorial efforts, there are still issues with the words they use.

One of my bigger pet peeves is the overuse of the word “holistic.” Newsflash for marketeers: holistic means something that has parts that are interconnected and that the whole is greater than the sum of the parts. A holistic approach to a problem does not mean providing a laundry list of solutions that a client might want to purchase in order to solve a business problem. Holistic also has a certain connotation in medicine that I think vendors fail to understand. A reference to holistic medicine often implies complementary and alternative therapies, non-western medicine, naturopathy, and other modalities. Depending on the beliefs of the physician you are marketing to, use of the word holistic can either be a blessing or a curse. Beyond that, if your “holistic solution” doesn’t provide any benefit beyond that of its parts, then it’s not holistic and you just look confused about how you are describing your offering.

Other words that have lost their sparkle include innovative, novel, revolutionary, and cutting-edge. Everyone claims that their solutions and offerings fall into these categories, to the point where the words no longer have meaning. I had a rep recently pitching a tabletop lab analyzer machine which was similar to the one we already have in the office. He acted like it was something groundbreaking when there are multiple competitors in the field that offer similar devices. The real difference between his offering and others was the price point, which in his case was a disadvantage. Costing almost twice as much as the nearest competitor might be novel, but the data trying to show it as a better device wasn’t going to swing us into buying 36 of them.

Then there are the folks who are killing us with mostly meaningless buzzwords: artificial intelligence, blockchain, synergy, cloud-based, mobile, virtual reality, and more. I think people assume that if they include one of those words in an email that it means people’s ears will perk up and they will instantly be attentive. I think we’re all hyped out on many of those terms, at least until there is proof that their respective technologies can really make a difference.

Words also have meaning with interpersonal communication. I see far too many emails where people respond rapidly and appear that they may have done so without thinking. It feels like people are so concerned with moving messages out of their email boxes that they’re just flinging information back and forth without proofreading or making sure their responses make sense.

I see emails where someone has asked multiple questions and the response addresses only one of the points, or where it’s clear that someone wasn’t reading for comprehension. There are emails that are full of nonsense words – talking about circling back to review deliverables and determine which items are deal-breakers and the like. I once saw an email about “prioritizing show-stoppers” prior to a go-live. By definition, if they are show-stopping defects, aren’t they all of equal priority since they will bring the go-live to a screeching halt? It was worth a number of laughs, so I can’t make too much fun of it because it made several of us smile.

I’m a firm believer that people who are strong readers are better writers. If you’re responsible for creating content, writing blogs for your company, or preparing user guides and manuals, when is the last time you read something non-work-related? I want to challenge people in those roles to read a good book and see if it changes your frame of mind or if it positively influences your work.

What’s the last good book you’ve read? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/12/18

California’s new data privacy law comes under fire from tech companies that want to modify its impact before it goes into effect in 2020. The California Consumer Privacy Act of 2018 (CCPA) is one of the most stringent data privacy laws in the US. Under the law, Californians can access and delete the data that various companies collect on them, and can opt out of the sale of their data. The law is aimed at businesses with more than $25 million in annual revenue, or that amass data on more than 50,000 persons, or that generate more than 50 percent of their revenue from selling consumers’ personal information. Although this protects small businesses, it draws in a large number of entities.

One of my favorite privacy advocates was just at a seminar covering the General Data Protection Regulation (GDPR) enacted by the EU and notes many similarities between it and the CCPA. The so-called “right to be forgotten” is similar, along with the rights of data access and portability. However, the CCPA includes a provision for explicit damages in the event of a breach. The CCPA covers “consumers” who are California residents and also addresses metadata through the use of categories of personal data, categories of data sources, and categories of third parties with whom data may be shared. The CCPA also includes more prescriptive language about explanations that cover what data will be used for and requires businesses to add an opt-out link to their web page.

The CCPA also has a provision that allows the attorney general to prosecute on behalf of a consumer, along with some language that may limit class action lawsuits. There will be a public consultation period in 2019 where modifications may be made before the law goes into effect. Given the large number of tech companies in California, there’s a lot of lobbying going on for the likes of Google, Uber, Amazon, and Facebook, that are worried that the law will impact their operations. The Internet Association trade group has indicated it will be part of negotiations over coming months. The passage of the law prior to a June 28 deadline ended a movement for a ballot action in November, so it will be interesting to see what consumer groups think of industry lobbyists and whether the law will stay in its current state as it goes into effect. Critics note the speed at which the law was passed (one week) compared to its impact.

While tech companies hope to limit its impact, the American Civil Liberties Union of Northern California feels it hasn’t done enough and that it “fails to provide the privacy protections the public has demanded and deserved,” noting that it was “hastily drafted and needs to be fixed.” California is progressive in a variety of ways, so we’ll have to get out our “fifty nifty” scorecards and see who is ready to follow suit.

It’s a sign of our times: GoFundMe’s CEO tells Minnesota Public Radio that medical bills and related expenses now account for one-third of GoFundMe campaigns. There are over 250,000 medical requests launched each year, with more than $650 million raised. The campaigns include both uninsured and underinsured individuals, and request assistance for high medical bills, travel to specialty care facilities, and procedures denied or uncovered by insurance.

JAMIA publishes a study titled “Research use of electronic health records: patients’ perspectives on contact by researchers.” The authors note that “researchers will almost certainly discover discrepancies in EHRs that call for resolution, and in some cases, raise the ethical dilemma of whether to contact patients about a potentially undiagnosed or untreated health concern” and set out to “explore patients’ attitudes and opinions about potential contact by researchers who have had access to their EHRs.” Researchers used focus groups where situations were described and discussed. Many patients did feel researchers should act if a current health issue was identified, but felt that communicating through the patient’s physician was the best way to handle notification. Rural participants had a strong preference for researchers to take action compared to urban participants. The authors conclude that study construction should allow for addressing discrepancies found in the EHR and communicating with patients. The article is worth a read to see some of the actual patient comments noted in the focus groups.

The various federal rules that have come out over the last year are so large that I never make it through any of them in their entirety. I missed the fact that CMS intends to force adoption of the NCPDP SCRIPT Standard, Version 2017071 beginning on January 1, 2020. Although some may think it’s just another item to mark off on a checkbox, it adds significant benefits for many providers. My favorite improvement closes out an “enhancement” request I made back in 2003, when I implemented Medical Manager’s OmniChart product which used ProxyMed for e-prescribing. If you’re a provider who has ever had to prescribe a complicated prednisone taper or give detailed instructions for migraine medications, you’re going to be happy. Once the transition to the new standard is complete, providers will be able to send instructions that are larger than the current 140-character limit. They’re giving us a full 1,000 characters to play with, but there will be issues during the transition if provider systems are upgraded but pharmacies are not. In those cases, if instructions of more than 1,000 characters are sent, they will be rejected on the pharmacy side.

I’m looking forward to being able to spell out my favorite treatment for severe poison ivy without resorting to error-prone abbreviations. Until then, you’ll have to take your prednisone 3 PO TID for three days, then 2 PO TID for three days, then 1 PO TID for three days. And remember to wear long sleeves and long pants and also wash with Fels-Naptha soap when you come in from the woods.

What’s your favorite custom SIG for medication instructions? Are your providers going to do a happy dance? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/9/18

I took some time off this week to celebrate my birthday along with our nation’s 242nd. In coming back to the office, I heard some awful stories of fireworks injuries that made me glad I wasn’t working over the holiday.

According to our friends at University of Washington School of Medicine, legal “shell and mortar” fireworks cause the most adult injuries based on data from Harborview Medical Center. Each year, more than 10,000 people seek care for fireworks-related injuries, which doesn’t account for those tending injuries at home. Teens are more prone to injuries from homemade fireworks, and children are at higher risk from injuries from bottle rockets and similar products. More than 90 percent of injuries occur in male patients. Not surprisingly, limb and eye injuries lead the pack, with 37 percent of hand injury patients requiring at least one partial or whole finger or hand amputation. More than 60 percent of patients with eye injuries had permanent vision loss. I hope you had a safe and injury-free Independence Day.

Summer typically brings a boom in trauma for hospitals, which can present challenges when critical drug products are in short supply. My practice is still dealing with intermittent shortages of IV fluids that our distributor indicates are due to manufacturing disruptions following last year’s Hurricane Maria. Basic medications, such as injectable morphine and lidocaine, are also only available in limited quantities and sometimes in sizes that staff members aren’t used to dealing with. When you’re used to drawing up 4mg of morphine from a single vial and now the vial contains 5mg instead, it’s a recipe for medication errors.

We’ve had to redo some of our EHR templates and defaults to address these changes in our drug supplies, which has led to issues with executing orders and quite a lot of read-back and clarification. Generic products such as IV fluids and morphine tend to have low profit margins, narrowing the available sources and increasing the risk of disruption. There have also been some quality-related recalls that can be at least correlated with manufacturers failing to invest in facilities that make these low-margin products.

Drug shortages aren’t something we like to think about in the US, but they can be challenging when a physician has to use an unfamiliar drug because of availability issues. I recently removed an embedded fish hook from a patient’s finger, and rather than having access to quick-acting lidocaine to deliver a nerve block, I had to use a drug with which I was less familiar and which took five times longer for the patient to experience anesthesia after I injected it. It meant more time for the patient to be in pain as well additional time for staff monitoring and disruption in my ability to see patients while I had to keep checking to see if he was numb. A recent survey  from the American College of Emergency Physicians notes that four in 10 physicians surveyed felt patients were negatively impacted by drug shortages. The FDA is trying to ease some of the shortages by allowing damaged products to be sold when they previously would have been recalled – morphine with cracked syringes was allowed onto the market with instructions for physicians to filter the drug before using it.

Speaking of the FDA, mobile app maker Headspace is hoping the agency will approve a prescription app for meditation. It subsidiary, Headspace Health, hopes to submit an application by 2020 and is preparing to launch clinical trials in support of the project. The app aims to help treat a variety of health problems, although the company is keeping mum on which ones due to concerns about competition. While meditation is increasingly popular, the health benefits have not been proven to the degree required by many evidence-based institutions although some studies show impacts on lowering blood pressure, reducing back pain, and improving irritable bowel syndrome. There is even less data on app-guided meditation. I know my Ringly bracelet and its associated app have some meditation features, but I haven’t tried them yet. I do like my singing bowl, however, for bringing calm into my often crazy days.

The Government Accountability Office released a document this summer that looks at the challenges faced by small and rural practices participating in the Merit-based Incentive Payment System (MIPS). The GAO interviewed 23 stakeholders including CMS and Medicaid employees, physician groups, and small/rural practices. Smaller organizations often experience challenges maintaining EHR systems of the quality needed to succeed under MIPS. In my experience, vendors can underestimate the complexity of running a rural health organization, whether it is specifically designated as a Rural Health Clinic by Medicare or is just in a rural area. Small and rural practices typically have fewer employees and are challenged by a smaller hiring pool that may not include potential employees with significant EHR experience.

I’ve worked with my share of rural practices, who often find the travel costs for onsite assistance to be daunting. This makes it difficult to see how their providers are using the system on a daily basis. Having them explain their pain points over a web conference just isn’t the same as following them into the exam room and watching their interactions with the patient and with the computer. It also makes it challenging to figure out causes of performance issues, such as office staffers streaming Netflix in the break room, because you’re not there to see it.

As a small-time consultant, I can get creative with those engagements and am willing to sleep in the hospital call room rather than at a hotel 90 miles away if it helps convince them to bring me onsite so I can roll up my sleeves and really see what is going on. I once stayed with a pediatrician at his home, which had a “mother-in-law” suite that hosted visiting medical students and prospective partners before I arrived on the scene. It was almost like being at a bed and breakfast, although he did ask me to bring a jar of sun-dried tomato spread with me when I arrived “from the city.”

If you’re a consultant or a road warrior, what’s the weirdest place you’ve ever stayed? Leave a comment or email me.

Curbside Consult with Dr. Jayne 7/2/18

I received quite a bit of correspondence after my recent piece regarding the CareSync shutdown. I had some pushback about my comments about the risk of working for a startup, where I said, “For people higher in the company who fully understood what it means to be part of a startup, they are likely prepared for such a scenario. For lower-wage workers on the front lines, especially for those living paycheck to paycheck in a relatively tough economy, it’s devastating.”

One correspondent essentially blamed the employees, stating they should have known that working for a startup is risky. I would argue that there were probably a fair number of people who worked there who either didn’t understand that they were working for a startup or didn’t fully understand what kind of risks are inherent in that situation. If you’re a nurse or care coordinator who isn’t as familiar with the healthcare IT space, it might look pretty good. Especially when a company leases a shiny office building and hires a couple hundred workers, people might not register that it’s a startup.

Even in established companies, there can be startup-type projects that put workers in as much jeopardy as they might be with a startup, but it’s not obvious. I watched some of my dearest friends get downsized when their company blew through scores of millions on a project, only to shut it down while the rest of the company went forward in a profitable state.

Another reader commented on the issue of survivor’s guilt:

I read your blog about CareSync today and found myself nodding my head in agreement at most of your points. I’ve been working for a startup company the past couple of years. Prior to that, I held a variety of roles in a different industry, where survivor’s guilt was a daily thing. I can’t tell you how many hundreds of jobs I saw disappear, often for selfish reasons such as protecting the C-suite’s annual bonus. At some point, I had enough and retired and that’s how I ended up in healthcare IT.

There is a huge difference between that industry and healthcare IT. The major players all have negative sales growth, and any growth you see on their quarterly statements comes from expensive acquisitions instead of organic growth. Healthcare IT is experiencing a nice growth curve still since most practices are underserved in my segment. I talk to many different practices weekly and each of them appreciates the help we give them.

The CareSync debacle just highlights the fact that there are people running businesses that they shouldn’t be. Given the amount of funding CareSync received, it is clear to me that they did not have a sustainable business model. The C-suite should have either pivoted or reorganized to a sustainable model. After what happened at Theranos, if I were a CareSync investor, I would be looking into whether or not a crime was committed.

I’m not the legal eagle in the family so I can’t comment about the criminal piece, but these types of examples should give investors pause and encourage them to ask more questions about the businesses they are supporting. I’ve been asked several times to support ventures in a much smaller capacity, from money to labor, mostly because of the personalities involved and their track record for success. Even though I’m a small investor, you have to do due diligence. Just because someone made money in the past in one industry or another doesn’t mean they understand healthcare IT.

I did a deep dive into a company that was courting one of my relatives as an investor, and not only was there really not a market for their product, but how they were approaching it was flawed. It was a bolt-on user interface designed to “improve the EHR experience,” but they were going after it by trying to court major EHR vendors. I gave them a bit of free advice — it’s probably not the best idea to go to a vendor and call their baby ugly. Maybe they’d have a better shot at going after either a regional or specialty-specific user base and getting some grassroots traction then moving up from there and trying to be acquired by a vendor. They ended up cold-calling a bunch of vendors and have gotten exactly nowhere in the last three years.

I also heard from one of my favorite healthcare startup CEOs, whose response made me respect him even more than I already did:

Today’s post is near and dear to me, as it is something I battle every day as an employer in this space, especially in a startup-like environment. I take very seriously the lives I am in control of. I worry greatly about what could happen if bad things happen and I need to make significant cuts. I would have to be a sociopath to not lie awake with that concern as it relates to each client / prospect / lead we are trying to get business and revenue from. If we lose all of our clients, what will I tell the people who rely on our bi-monthly paychecks to feed their families and cover their expenses?

First, I make clear to the entire organization, from board to rank-and-file folks, that everything is subject to change. Even though runway is a great indicator of longevity for overall company success, growth, and existence, that doesn’t mean that there are no risks whatsoever. If projects / prospects don’t come through, certain folks will inevitably face a departure. Fundraising concerns are also a part of it, and with each pitch, it is my job to make sure the health of the company (and therefore the team itself) is well taken care of. Even with revenue, capital, a great plan, and strong leadership, no company is truly protected and no employee is truly safe. It is my job to provide opportunity for folks, protect that opportunity as a condition of their employment, but also be smart and savvy about investment and spend every day. If you come into a company and start counting share price on equity and think it is all rosy, you’ll probably be the first to be shocked if and when things don’t go as planned.

Second, I suggest to employees that not get too whimsical in their spending. I toe a delicate balance, but try to instill in every employee, from executive to intern, the realities that could present themselves and what it would mean to be 180 days without income. This has happened to me earlier in my career, so I can speak from experience — if you aren’t prepared, you will struggle. Saving, being cautious with spending, and being aware of the frailties of life are messages I try to impart during regular check-in with all employees. They don’t teach people these skills. Many assume that the career ladder is a short hike up stairs. Few are aware of what may lie ahead, and it should scare everyone.

Third, I have a separate near-term savings that is a rainy-day fund. Not for purchases, travel, college savings, or retirement, but an account that I fund every month that could carry the family through any immediate challenges that could be faced. Whether it comes with having elderly parents who have poorly prepared for retirement, small children who are likely to need care that may not be covered, or pets that will do absolutely idiotic and expensive damage to themselves and the world around them, I think I have enough liquid capital to get through a rough patch, which took over a decade to stash away. It pains me to think of the things I missed out when I was younger by putting so much money aside, but it makes more and more sense each passing day when I hear stories of friends, neighbors, and colleagues going through career issues that are really scary.

Whether you run a health tech startup, work for one, or are working for a huge health system in any capacity (I have been all three), I think it is important to reflect on your immediate needs in a responsible way. Nothing is guaranteed in life, nothing lasts forever, and getting a heads-up doesn’t normally happen.

I’ve worked with several CEOs who spend money like water and it’s not always clear whether it’s personal money or the company’s money. Knowing my own temperament, I would prefer working for someone who is willing to talk to employees about the possibility of a downturn and his own rainy-day planning rather than talk about his new boat or her condo in Aspen. You may be buying the finest liquor and the best cigars, but how are you doing running the company?

I once worked with a hospital CIO who kept the security camera footage of his house in the Florida Keys running continuously in a window on his desktop, mostly to show off his dock and his boat. The only thing I could think of was how much time he was wasting every day.

My CEO friend went on to hypothesize that perhaps his conservative attitude towards finances comes from being “in healthcare” since we see people who have life-changing medical issues or end up changing their own career plans to care for others. I agree, but also think some of it is also generational, since many people in my age bracket are working under the assumption that Social Security will be a historical footnote by the time we are of retirement age. He went on to close with this:

One last thought on this topic. I don’t think it is specific to healthcare or startups. I just had a friend that works in insurance / re-insurance for the past 25 years get RIF’ed on a random Friday. The entire team of a Fortune 250 company was cut as the company migrates to blockchain. I can laugh about the blockchain part, but the reality is that here is a mid-50s executive who was part of a mass cut of staff unexpectedly. Three kids, mortgage, college for at least one child. How prepared are even the most well-heeled Americans from the unlikely (though statistically incredibly likely) scenario where job goes away and the next one doesn’t seem like it will come too easily?

The blockchain reference definitely made me chuckle, but it’s a serious topic. If you’ve been “released to the workforce,” what advice do you have to give that you wish you knew before the layoff? Leave a comment or email me.

Email Dr. Jayne.