EPtalk by Dr. Jayne 5/31/18

A reader sent me this piece about an Ohio hospital that added physicians to the emergency department triage process, helping them lower their wait times for patients to be seen by a provider. The headline was attention grabbing, but when you look at their process, basically they started running their triage area like a mini-urgent care, with providers performing H&Ps and ordering tests. They also created a separate waiting room for patients who were waiting for test results. I’m not sure how different this is from creating a “fast track” section of the emergency department or adding an on-campus urgent care or convenient care facility to divert non-emergency cases from the core emergency department. I’m sure it created some interesting flows for documentation, since providers would be using different workflows depending on whether they were working in triage or as traditional emergency department physicians.

When I work with clients who are “stuck” with their EHR projects, I occasionally encounter a physician who has built his own EHR and uses it as the gold standard against which he compares what we’re trying to implement or optimize. (I use the male pronoun intentionally, because I’ve never had a woman physician admit to it.) I’m all for home-based innovation, but I have to draw the line at DIY Gene Editing  which apparently is a thing. Apparently, there are meetups for these biohackers, including “Body Hacking Con” which was held in Austin. After reading how easy it might be to brew up a batch of bioweapons in your bathtub, I’m almost wishing I hadn’t read it. Plausible deniability might be better, after all.

EHR vendors take note: the next set of screening questions you add to your product might need to be around your patients’ tax preparation strategies, or lack thereof. The StreetCred program is a partnership between various hospitals and community organizations, including Boston Medical Center, where patients are supported so that they can receive tax benefits and other entitlements that might help reduce the impact of poverty on chronic medical conditions. BMCs program operates through the Department of Pediatrics and ensures that clients receive tax credits for which they qualify along with tax refunds. Families with improved financial stability have lower stress levels and higher participation in care programs than those whose situations might be more tenuous. Yale School of Medicine has a similar program based on the work at BMC.

Kudos to CMS for figuring out new ways to use acronyms to confuse us. The Direct Provider Contracting model is being referred to as DPC, causing confusion with the Direct Primary Care movement. In Direct Primary Care, patients contract directly with a primary care provider (usually a solo physician although some DPC practices are small groups with low overhead) for services and pay a monthly fee. Direct Provider contracting is different, and includes provider networks which receive Medicare funds in an advance-payment scheme, to manage their patients’ care. It’s considered a potential alternative to the Alternative Payment Model (APM) options already out there. MGMA has already voiced concern about this new direct contracting model and its potential negative impact on small groups.

CMS further sullies the acronym soup by referring to these provider networks as CIOs (clinically integrated organizations) which by necessity must include professional, technical, and hospital service components. Medicare would incent patients to participate by offering lower co-pays for patients seeking care within the CIO-created network, which sounds dreadful for anyone who has ever had to deal with an unexpected “out of network” bill. Most billing systems do a mediocre job of handling non-fee-for-service payments, so providers who might want to do this need to be discussing it with their EHR and practice management system vendors as this unfolds. It’s another nail in the coffin of ambulatory-only products since trying to do the cost accounting needed to make this viable becomes tricky when you’re working on multiple systems. I missed the boat on this one since CMS only accepted public comments on it through May 25.

Given our society’s obsession with smartphones, I am always on the lookout for articles discussing how people use them effectively or to their detriment. In my travels, I see more and more people who are so engaged with their phones they create problems for the people around them. On my flight this week, a woman deplaned a few people in front of me and pulled out her phone in the jet bridge. Her forward momentum dropped as she started fiddling with her phone, resulting in the person behind her (who was also fiddling with a phone) smacking into her. Heads up and hands out, people, and be ready to interact with the world around you. Unfortunately, judging by the number of children in the under-13 set who are also face down on phones or tablets, I don’t see any improvement in this over time. The Wall Street Journal covered the topic, discussing CEOs who have tried to address the issue. The statistics are staggering — the average person engages with his or her phone over two hours per day, including during work hours.

I’ve been in meetings were electronics are banned and find it unfortunate mainly because I take verbose meeting notes on my laptop all the time. Taking notes on paper results in lost productivity later as I have to transcribe my notes. I also like to fire off action item emails in real time rather than carry a list of to-dos back to my desk. On the other hand, I’ve watched people openly surf Facebook or play games during meetings and that’s just not acceptable.

Going “no phones” needs to also address the prevalence of smart watches and other notification devices. My clinical office has a “no cell phones” policy in the workplace and surfing the internet is against our code of conduct. Employees aren’t even allowed to have phones in their pockets for emergencies – they are expected to provide their children and loved ones with the office phone number so they can be reached in case of emergency. Although this may sound draconian, it has resulted in more engaged employees who look for tasks to complete in the office or who actually talk to their co-workers rather than head down the social media rabbit hole. Apparently, an upcoming version of the Android system will include a time tracker to help people track their phone use and I have some family members I can’t wait to try it on.

What do you think about smartphone overuse? Are we addicted or just bored? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/24/18

I’m having an ongoing debate with one of my clients regarding communication. Over the last several years of their major IT rollout, they’ve been sending out a biweekly newsletter informing stakeholders and users of what is going on with the project along with general information about regulatory and incentive programs such as Meaningful Use, MIPS, and more. The newsletter is relatively brief, but has links out to all sorts of other materials for interested readers. Users are initially opted in to the newsletter when they are hired, but have the option to unsubscribe if they desire. Looking at data over the last couple of years, the open rate is actually pretty good for an email newsletter.

Recently, however, with a move to a new infrastructure platform, they’ve had issues with outages and have been sending all kinds of downtime bulletins and outage notices. As one might expect, users have complained about the volume of communications as users feel peppered by announcements. They particularly dislike announcements that may or may not relate to them – for example, a member of the physical therapy department receiving communications about a laboratory outage.

As a result, the communications team began a project to reduce the volume of communications. Their first target was the biweekly newsletter. They’re still creating the newsletter, but they’re just not going to email it to people any more. Instead, they expect users to go to a static link periodically to see what is going on.

When I initially heard about the plan, I had concerns about this approach. For one, people are busy and may not remember to look at the information. Since the content changes every two weeks, users who want to keep up with the news would need to make an appointment for themselves or set up another reminder system. I asked about ways to publish the link or make it more accessible, such as including the information on the images that display when monitors go into screensaver mode, or making it a start page when browsers are launched. They were not open to considering either of those, so I also asked about adding a desktop shortcut, so employees wouldn’t have to create their own. That also got shot down.

The second reason I was concerned is that there were people that received the newsletter who aren’t end users but would benefit from the information, such as administrative leaders or other members of the management team. Those individuals probably weren’t getting the outage notifications or other emails, so there may be other factors in play.

I admit I was getting a little frustrated, so I asked if they had done any work to analyze exactly what the volume of communications is or to categorize them before taking a seemingly random approach to eliminating communications strictly in the name of volume reduction. Had they looked at how many emails were part of outages vs. how many informational, vs. how many were not even related to the project? Maybe the email volume was related to other entities, such as the various hospitals, the employed physician group, or other shared service providers. such as security or the facilities and maintenance group. It turns out my suspicion was correct — they had made the assumption that the issue was the project’s problem.

I got them to agree to take a look at data before they made their decisions, so we are working with the IT team to begin monitoring some of the email traffic. We should know in a couple of weeks what the real problem looks like rather than trying to operate on assumptions.

Far too often I see these kinds of decisions that are made on hunches or using assumptions rather than data, even when data might be available for the asking. Although scenarios like this one can be anxiety-provoking, they can also be one of the most fulfilling parts of consulting. When you convince clients to act on something that they haven’t thought about or that might really change how things turn out, it can be gratifying. Having a communication plan can be challenging for many organizations – I only find an actual written communication plan with about half of the clients I engage. Knowing the best ways to get the word out to your stakeholders, users, and other constituents is key to the success of any project. I’d be interested to hear what readers’ favorite communication strategies are, especially in thinking about how to keep things fresh on massive, multi-year projects.

A former classmate sent me a link to this story about strategies that Yale School of Medicine is using to improve physician satisfaction. It was being circulated at her organization as being relatively “revolutionary” advice. After reading the article, I hope my classmate’s IT and leadership organizations are ready to explain why they haven’t rolled out technologies that many of us take for granted and which are almost mandatory for high-performing organizations. After a system-wide analysis of the problem, Yale decided to implement login efficiencies with proximity badges, saying that traditional logins “had a disproportionate effect above and beyond the time with just the annoyance factors. Addressing this psychologically, as well as time savings, has been a huge win.” I’ve worked at hospitals with proximity badges for more than a decade, so it’s a bit surprising that an organization of this caliber wouldn’t have it.

They’ve also added speech recognition technology connected to the EHR, allowing a 50 percent reduction in the time needed to complete encounters. Speech recognition has a 30-40 percent adoption rate at Yale. There is a push for physicians to use the technology while patient-facing to aid patient engagement. This approach is a little more revolutionary for some organizations, but I’ve worked with clients who use it and it’s been very effective.

Their third strategy is to pilot virtual scribes, with 50 physicians in the program. Yale is doing other work to improve physician satisfaction, including communication training and programs to build clinician resiliency. They’re also providing meditation programs and mindfulness workshops. I’d be interested to see effectiveness data on the latter two offerings.

Does your organization promote meditation and mindfulness? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/21/18

It’s the time of year when many people are attending graduations for family and friends. The medical school where I’ve been an adjunct faculty member held their commencement exercises, putting one more checkmark on a long list of accomplishments for its students.

Although some of them will be pursuing additional degrees such as an MBA, MHA, or JD, others will be getting ready to receive their first physician paycheck in a few short weeks. Even though they’re officially receiving a paycheck and are finally called “doctor,” there is still much to learn. Residency is completely immersive learning. Regardless of whether you have work hour restrictions or not, whether you get days off or not, or whether the IRS classifies you as a student or an employee, this is where the real work of “becoming a physician” begins.

Similarly, residents who are already in training programs have been taking in-training exams, licensure exams, and completing the requirements that will allow them to be promoted to the next year of training. Traditionally, everyone moves forward on July 1 unless residents have taken time off or there have been other sidetracks to their educational program.

I’ve had the privilege of working with some great students and residents over the last several years, and enjoy continuing as a mentor as they move on in their careers. Over the last two years, I’ve been working with a young woman who I can only describe as a firecracker. She has an uncanny knack for seeing how processes can be improved and galvanizing people around her to make positive change. When her program sent interns onto the wards without the guidance and direction they needed to be successful, she and her intern peers created a “New Intern Survival Guide” to help the intern class that would follow them. They worked to incorporate opportunities for non-traditional rotations (such as clinical informatics and behavioral analytics) for the hospital’s graduate medical education program. They worked with other residents to lobby their program director and the head of resident education for better family leave arrangements and more flexible ways to maintain their own humanity during grueling years of training.

She’s finishing her second year of residency and getting ready to begin her job hunt in earnest so that she’s ready to roll when her training is done in 13 months. If I was still in traditional practice, I would hire her in a second. She’s a quick learner and loves the data-driven approach to clinical care. She also makes a mean martini.

I was surprised when she called me in tears after receiving a recent evaluation from a member of her residency program’s faculty. Like many other types of high-performing students, to a resident seeking competitive opportunities, grades and evaluations are everything. She’s been a straight-A student her entire career, graduated from medical school at the top of her class, and is being considered for selection as chief resident. After receiving her recent evaluation, however, she was in a state of questioning everything about herself and her performance.

Residents in the program are graded across a variety of disciplines on a scale of 1 to 5, ranging from “remediation required” at the low end to “satisfactory” in the middle and “exemplary” at the top. She’s had nearly all fives during her time in the program, so was completely dumbfounded to receive an evaluation that ranked her “satisfactory” across the board. Even more upsetting to her was the sheer lack of narrative feedback from her evaluator. There were no recommendations for what she could do better, what she should work on to improve her fund of knowledge, any gaps in patient care that could be addressed, or anything else actionable. The entirety of the feedback given to her for a four-week rotation on her own program’s family medicine service was “frequently seems dissatisfied.”

I know the faculty member who evaluated her. He has a reputation for not liking change and for wanting to preserve medical education as it was when he went through residency 30 years ago. I asked the resident if she had perhaps ruffled any of this faculty member’s feathers in her or her classmates’ work to move the program forward. She did recall a discussion about the sports medicine rotations, where the faculty member in question was the department advisor. She and her peers had asked about being able to do rotations with sports medicine physicians other than him and were denied. They escalated it to the graduate medical education committee, as there was an opportunity for several of them to work with a sports medicine group that serves a local professional sports team. They were again denied because they couldn’t get the faculty member to sign off on it.

Having seen this young physician in action, I can’t imagine that her performance had somehow slacked off on this rotation or that she had completely changed her way of doing things. I can’t imagine that she delivered anything less than topnotch patient care to the best of her ability, and with compassion and understanding for patients and their families. But somehow, she had gone from “exemplary” to merely “satisfactory” with no tangible feedback she could use to improve herself.

I advised her to make an appointment with her program director to discuss it, and if nothing else, to request a meeting with the evaluator and the program director together so that she could receive formal feedback other than the three words she was given. I didn’t say it, but it sounded to me like retaliation for too much perceived boat-rocking. I encouraged her to seek feedback from other faculty she worked with on the rotation but who were not her named evaluator, as well as other members of the care team such as nurses, therapists, and consultants. I’m confident that having feedback from those other constituencies will help counter some of the psychological damage that this single evaluation was bringing her.

In reflecting on her call, I couldn’t help but think about similar situations I continue to encounter in healthcare. Healthcare providers are immersed in a culture of safety, yet can be questioned when they ask for a time-out if it negatively impacts the surgery schedule or how quickly patients can be moved through the process. We’re asked to be in cycles of continuous quality improvement for our patients, yet those who question bureaucracy may be labeled as “disruptive” or the nebulous “not a team player.” Those who believe we should have less-toxic educational programs are said to have “gotten soft” or they may be “giving in to the snowflakes.”

There are countless sacred cows out there that are protected at all costs and institutions that seem to be preserved only for the sake of tradition. As healthcare leaders, we should be able to do better. The care of our patients and the future of healthcare depends on it.

What’s the biggest sacred cow in your organization? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/17/18

An opinion piece in the Annals of Internal Medicine provides data on what many refer to as “note bloat” in clinical documentation. Documentation in the US often contains information needed for billing or to meet regulatory requirements that doesn’t materially contribute to the care of the patient. The authors note different attitudes towards EHRs in the US compared to other countries, where physicians may be excited about using them to enhance patient care rather than viewing them as burdensome, and recommend strategies that many of us have been recommending since the dawn of EHRs, such as shifting administrative tasks away from physicians. My favorite quote from the authors: “Although EHRs have great potential to improve care, they may also have perverse effects.”

Alex Azar, Secretary of the US Department of Health & Human Services, spoke this week on drug pricing. He starts out by noting that pharmaceutical manufacturers are “one of the most aggressive industries when it comes to lobbying.” The proposals he highlighted include:

• Improved competition – positioning the FDA to “stop drug manufacturers from gaming our patent system to block generic competitors.” This includes allowing generic manufacturers to have access to samples of the branded drug so they can perform the testing needed to receive approval for generics. Manufacturers who abuse the system are to be publicly identified.
• Lower out-of-pocket costs – preventing pharmacy benefit manufacturers from enacting gag clauses with pharmacies, which would allow pharmacists to tell patients when they could get a drug cheaper by paying cash than using insurance.
• Enhanced negotiation – giving Medicare the ability to negotiate drug prices, starting with certain classes of drugs that are relatively protected under Medicare Part D and also for drugs covered under Medicare Part B which are administered in physician offices. There is also a plan to merge Part B into Part D.
• Incentives for lower list prices – changing how indicators like the Average Manufacturer Price are used in creating drug pricing. The AMP is inflated compared to what private payers are actually paying, since there are often rebates involved.

He also mentions addressing how drug companies reach out to the public, working to require pricing information when there is direct-to-consumer advertising. He calls on pharmaceutical manufacturers to do this now, including the list price in advertising, before it’s mandatory. I’d go a little farther: let’s stop direct-to-consumer (DTC) advertising altogether. Since DTC advertising started, I can count the beneficial patient-driven conversations I’ve had as a result of advertising on one hand. Conversely, I can’t begin the estimate the number of conversations I’ve had about DTC-marketed drugs not being right for a patient or having significant risks or cost issues.

While we’re at it, let’s create systems to prevent the US Food and Drug Administration from being gamed during the drug approval process. When we have drugs that have been effective for years and cost pennies, such as colchicine, don’t let drug companies play games where they send those drugs through the system again and are allowed to sell them at a tremendous markup (Colcrys), making patients wait years for a generic to return only to see it more expensive than the original generic. Most of the physicians I talked to about the proposals are in the “I’ll believe it when I see it” camp, noting that Azar’s past roles included being a pharma executive and serving on the board of directors of a pharmaceutical / biotechnology industry lobbying organization.

I don’t know who Ron Carucci is, but I think he’s planted listening devices at some of my clients. His excellent piece on how leaders create toxic cultures highlights some phenomena I see more often than I’d like. He calls out “scattered priorities” as a major issue. I see this in nearly every client I engage. Rather than doing a few key initiatives well, leaders overcommit. This tends to result in either under-delivering as they try to move dozens of initiatives an inch at a time or a frantic scramble to try to meet deadlines that were unrealistic to begin with.

Whenever I hear about leaders being double-booked or having to constantly shuffle meetings due to conflicts, there is usually a prioritization problem. This is often manifested through lack of regular leadership meetings and lack of agreement on team priorities. Those teams that do meet may have ineffective meeting dynamics and don’t accomplish much during their time together.

Another issue Carucci identifies is “unhealthy rivalries” and I see this as well, usually when teams have similar goals but may be competing for scarce resources or precious time with end-user champions. I also see it in organizations where one team ends up being rewarded for work that is performed by others. For example, a sales team member who receives a hefty commission for closing a deal with the support of analysts, programmers, and other staff who don’t get to share in the monetary rewards.

Oversharing and the blurring of work/personal lives on social media platforms such as Facebook may exacerbate this. A couple of years ago, I was working with a vendor sales rep who constantly talked on social media about his extensive car collection. It was a hot topic in the office as staffers Googled the value of the cars he owned (well over $1M) and talked about how unappreciative he was towards the workers who helped enable the sales that paid for his hobby. The culture around this rep was positively toxic, yet one of his peers who generated more sales but acted with humility never had his motives questioned.

He also talks about unproductive conflict, which to me extends to mismanagement of conflict. Companies that sweep HR issues or workplace complaints under the rug aren’t doing themselves or their employees any favors. He mentions workers who talk behind one another’s backs, along with holding back on opinions or vetoing decisions after they are made. I’d add the “meeting after the meeting” crowd to this bunch, when people who don’t show up are given the ability to change the course of decisions made by those who made the time to be part of the process. I urge people to think about whether they exhibit some of these traits or whether they’re present in company culture. Many of our organizations have an opportunity to make a change for the better.

I enjoy reading stories about people who selflessly give to help others, and this one definitely merits a mention. An Australian man has been donating blood for over sixty years, with a total of 1,173 donations. His blood contains a rare antibody used to treat hemolytic disease of the newborn and it’s estimated that over 2.4 million babies have received treatments derived from his donations. At 81, he exceeds the maximum donor age and has been officially retired off the Red Cross rolls, but his legacy will live on in the babies treated, including two of his own grandchildren.

Curbside Consult with Dr. Jayne 5/14/18

I had a chance to catch up last week with Jonathan Bush of Athenahealth while he was at the HLTH conference in Las Vegas. He had reached out a while back, after reading my Curbside Consult on burnout and the concept of “moral distress.” After some email tag with his team, we were able to get something on the books. The timing couldn’t have been better since he had been scheduled to present on the topic of physician burnout at the conference.

As a healthcare technology leader, Bush has a unique opportunity to try to address the fact that more than 70 percent of physicians feel disengaged. They’re pressured to deliver better outcomes while using new systems, sharing information, and trying to keep patients satisfied. I asked him what he thinks is the secret for solving this problem, and in true Jonathan Bush deadpan style, his response was, “Create a top-down mandate with a bunch of complicated metrics.”

Conversations with him are always fun, and in addition to being knowledgeable about many aspects of healthcare, he’s quick-witted and always has great analogies. In this case, he likened the inertia we face in healthcare to being “like a fused tectonic plate. All we seem to do is type new data all day and we have no new insights.” He’s encouraging healthcare leaders to consider what will happen if they don’t figure out how to re-engage physicians and bring back the joy in practicing medicine. He refers to the need to create “capability,” which constitutes the tools and resources physicians need to get the job done, as well as the organizational latitude to make decisions that can positively impact their situations.

He wants leaders to engage burnout just like they would engage any other agile project. We need to create a framework and gradually iterate, while over time watching the data to see whether we’re making a difference. We need to look at the resources and tools we are deploying, and how much latitude we are giving the front-line players, and keep tracking it.

Much of what he promotes aligns with the philosophy of having everyone work to the top of his or her license, where they are doing the work they are uniquely qualified to do rather than doing work that can be done by other members of the care team. He urges organizations to get rid of things that don’t matter, to replace portions of the doctor’s day that are inconsequential, and to help them focus on items that are consequential and where a physician’s judgment is necessary.

Although this seems straightforward, I continue to find organizations that simply don’t understand this and continue to mire physicians in day-to-day activities such as prescription refills, where a protocol and trained staff could get the job done with reproducible outcomes.

We chatted a bit about his days as an ambulance driver, where he would look at his run sheet at the end of the day and see how many of his trips truly mattered and how many were an “overpriced taxi service with a lot of paperwork attached.” He mentioned that, “Once in a while, there was a truly consequential run,” but that it was “anxiety-producing to have things that matter mixed in with things that don’t matter.”

I talked a bit about my time in the emergency department and now in urgent care, seeing similar situations and having some of it being amplified by the consumerism we are seeing in healthcare today. We talked about the good stress that can be “beautiful” when it’s productive and the bad stress that ensues “when it’s an ER shitshow.” For those of you who may think that term is crass, it’s the language of the trenches, and it accurately portrays what it feels like on a bad day.

That part of the conversation illustrates one of the reasons I am glad he is in healthcare and likes to poke the bear at times. Despite his family background, he’s had some real-world life experiences that resonate with us in the trenches. He knows how to bring the conversation to where you are, which is a big difference from other leaders I’ve talked to who tell stories that somewhat alienate the audience. Talking to Jonathan Bush, you want to believe in what he is selling, and I’m sure it resonates with his customers.

We talked a bit about telemedicine vs. emergency medicine and the potential of technology to help alleviate the “unfortunate misery cycle” that many providers find themselves in. We then moved on to the newest 1,800+ pages of proposed CMS rulemaking. His take on the regulatory environment is that, “Working on things that don’t matter leads to attrition, not just with physicians, but in healthcare IT as employee engagement goes down.” I agree, as I have seen some of the most brilliant IT people I’ve ever worked with move into non-healthcare jobs because they don’t feel like they’re making a difference despite working hard for good organizations. My two favorite architects have gone to work in the automotive industry and the packaging industry, with a significant decrease in stress and greater job satisfaction because they feel they can actually complete projects and deliver outcomes without a constantly shifting set of requirements and priorities.

Bush cites the various mandates as creating structures where it’s too hard to change the mold. He likens some of the challenges that organizations face to a nesting doll, where you keep peeling back the layers but find more of the same underneath. He noted that people don’t care about many of the PQRS quality measures and he’s not sure that the people who wrote them even care about them. I had to laugh at that, as I also did when he said that people “need to liposuction things like the Joint Commission out of their lives.” I told him about my practice’s experience opting out of Meaningful Use and MIPS and how we made the decision. He liked the fact that we were able to “break a rock off of that tectonic plate” and that our leadership felt the latitude to do what was effective and engaging for our practice.

We talked about interoperability and the need to not only connect to everyone who has data, but also to get rid of the “nonsensical” data. Having recently received a 22-page C-CDA that was almost undecipherable, I agree. Even with my EHR’s algorithm to try to de-duplicate the data, I still had a pile of data points to review with very little time on my hands. Bush has a vision of a data lake where EHR data flows and is normalized and rationalized, made relevant by the addition of AI, and fed back to you in ways that are relevant. Until then, though, “EHR is like a bad marriage. You do everything for it and it does nothing for you except ask for more money every year. How about telling me something about my patient that I didn’t type in myself?”

Hearing a vendor executive say things like that is refreshing. He wasn’t talking about how great his product was, or why it’s the best. He realizes that our current systems have flaws and wants the EHR to be a beautiful virtual assistant that finds out everything about your patient before they arrive and a cool tool that helps you be better. But to get to that point, we need more data science in medicine and need to address the governance around what needs to be reconciled and what can be left as is.

Although addressing physician burnout is essential to keeping physicians from becoming endangered, we closed by touching on the other benefits of dealing with burnout, namely the economic benefits. Happy physicians are productive physicians and happy physicians don’t have to be replaced, which in my community can result in a cost in excess of $250K for a primary care physician.

By that point, Bush was getting “the hook” from his team and had to run to his next engagement, but I appreciated his willingness to spend a little time with an anonymous physician. The conversation was engaging and inspired me to keep working to push things forward with the organizations I have the ability to touch. Those of us in healthcare IT need to build a better mousetrap, or at least work to break up those tectonic plates.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/10/18

Primary care physicians continue to look for ways to get off the hamster wheel that our profession has become. The Direct Primary Care (DPC) movement is the answer for growing numbers of physicians who engage with patients on a cash or retainer basis, cutting the insurers and health systems out of the equation. The 2018 DPC Summit will be held in Indianapolis in July, welcoming both existing DPC practices and those looking to explore their options.

I have several good friends with DPC practices. The movement is something that health IT companies should start thinking about if they’re not already. These practices often embrace electronic health records and technology that better enables connections with their patients along with comprehensive and high-quality care, but they don’t want the distractions of convoluted workflows to support billing requirements or other regulatory content.

My practice’s EHR has a setting that allowed us to completely turn off all of the Meaningful Use content, which was a great physician satisfier when we made the change. There are niche vendors such as Atlas.MD whose product is designed for DPC practices, but physicians often look for ways to transition their practices without a system switch. If your products can’t handle monthly recurring credit card billing, telemedicine, and plug-and-play interoperability, you’re going to miss out on these practices.

I’m often asked if I would ever go back to the primary care trenches. Informatics is definitely my first love, but I do miss the ongoing patient relationships I had previously. Given the stresses to the system and the level of burnout that many physicians are experiencing, I think the only way I would do it would be to either be part of a direct-type practice or part of a relatively closed system such as a civilian contractor to the military. Of course, there is a magical salary number that would take me back into the trenches tomorrow, but I have better odds of winning the PowerBall than I have of seeing a typical primary care physician hit that number.

I was somewhat puzzled by the headline on this CMS press release: “CMS Announces Agency’s First Rural Health Strategy.” Correct me if I’m wrong, but hasn’t CMS had a rural health strategy for a long time through the Rural Health Clinic (RHC) program? I’m a big fan of the idea that words mean something, so it’s kind of disheartening to think that people who have been working in the Rural Health arena for years might be hearing that their hard work wasn’t part of any strategy. CHS formed its Rural Health Council in 2016 and the Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy (FORHP) was created in 1987. I guess they didn’t have any strategy either. But maybe we’re just now calling it a strategy?

I’m unimpressed by the level of rhetoric coming out of CMS lately, which seems more political than patient focused. I’ve searched through some press releases I kept from previous years and I don’t see “this Administration” or “the X Administration” mentioned nearly as often as I see “the Trump Administration” mentioned. Of course, this is strictly anecdotal and has no statistical power – maybe one of my AMIA colleagues will consider doing an analysis of the content of HHS, CMS, and ONC press releases to see if the language really is that different.

Speaking of AMIA, the organization is introducing a new program to recognize applied informatics professionals. Fellows of AMIA will demonstrate education, commitment to the practice of informatics, contributions to the field of applied informatics, and a sustained commitment to AMIA. The organization plans to begin recognizing Fellows at the AMIA 2018 Annual Symposium and will begin accepting applications by July. I’m not sure I’ll qualify since my practice of informatics is far from typical, but I’ll check it out nevertheless.

CMS recently updated its Hospital Compare website with new Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data on patient experience. The new data was collected between July 2016 and June 2017. The patient experience ratings are separate from the overall CMS quality star ratings and cover 11 publicly reported measures. One available map I found listed hospitals in the wrong place, so I hope patients using the map look carefully at the legend to ensure they’re getting the right information. My 4-star hospital was replaced on the map by a 2-star hospital, so I had to do a double take.

The 11 patient experience measures are: cleanliness; nurse communication; doctor communication; staff responsiveness; pain management; communication about medicines; discharge information; care transition; overall hospital rating; quietness, and willingness to recommend the hospital.

I’ve spent quite a bit of time on aircraft over the last decade and continue to be amazed by the level of self-centeredness of some of the passengers. Despite recent in-flight incidents, people continue to ignore safety briefings and defy flight attendant instructions. Usually I sit in the exit row, but was near the front due to a tight connection, and watched four people try to use the lavatory while the seatbelt sign was on and the plane was on its initial climb. The flight attendant sent each of them back to their seats, but no one seemed to pay attention to the person in front of them being turned away or the multiple overhead announcements.

On another flight where the row in front of me didn’t recline, I had an irate woman (who had already been told by the flight attendant that the seat didn’t recline due to being in front of an exit row) lift herself up in the seat and try to force the seat to recline with her whole body weight, almost breaking my laptop screen. We had people jumping up and out of their seats while we were still taxiing, requiring the flight attendants to unstrap themselves and force people to sit down.

It’s not just the lack of following published rules, but the general lack of civility. I watched a woman berate a flight attendant for not putting enough cream in her coffee, even after the flight attendant carefully verified how many units of cream and sugar the passenger wanted. The coffee was almost white and I had to resist the urge to remind the passenger that this was a Southwest Airlines flight, not a Starbucks.

Right now, I’m watching a woman give a full-on back rub to a man with no shoes, using a massage tool that she pulled out of her carry-on. I also saw someone rubbing liquor on the lips of his sleeping companion, trying to wake her up. I had to look around and make sure I wasn’t on some episode of a prank TV show. If you’re a ground-based employee and interact with road warriors, give them a little slack if they seem grumpy. They may have just gone through three hours of wondering what crazy thing would happen next.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/7/18

Atul Gawande, MD is one of my favorite authors, and I’m currently working my way through his book “Being Mortal,” which discusses how we handle aging and infirmity in the United States. It is particularly relevant for me, since my family is dealing with some issues involving elderly relatives, and I know I discuss some of the book’s topics every time a child brings an elderly parent into the urgent care after a fall or some other type of accident. I was glad to see him featured on Freakonomics Radio addressing the “freaking mess” that is our so-called healthcare system.

When many of us think of the mess of the system, we think about the cost disparities, access disparities, and the regulatory burdens. Gawande cites challenges with the time it takes for good ideas to take hold in medicine, largely because of delays between the obvious or immediate impact of change and the delayed effects that may be difficult to see. He uses the examples of anesthesia and antisepsis in the 1800s as examples. Anesthesia was rapidly adopted, where antisepsis through hand washing and disinfection of medical equipment took significantly more time. Gawande attributes this difference to the obvious benefit of anesthesia as opposed to the somewhat invisible impact of disinfection. There were also cultural changes associated with antisepsis in the surgical realm that took time to resolve. He goes further to discuss the release of the drug Viagra, which had immediate impact on patients and was widely prescribed in short order. However, surgery checklists have been “harder to sell” because they represent an investment of time to prevent “problems which are often not immediately visible to people.”

Gawande talks about a conversation with a Cheesecake Factory manager about how to approach the healthcare industry as far as quality control, cost control, and innovation. The approach involves breaking down processes and standardizing them, along with figuring out what the best-performing organizations are doing and translating that into a “recipe” that can be used by many organizations. He talks about the problems he has to solve as a surgeon, including arranging care for uninsured patients, having to skirt around information that patients don’t want shared with their families, and working with patients who have high-deductible or narrow network health insurance plans that add layers of difficulty for patients. He does note that in his Boston practice, he rarely sees uninsured patients due to the universal coverage provisions in Massachusetts that preceded the Affordable Care Act. Despite being covered, however, patients with high deductibles might be skipping medications that control chronic conditions. He writes, “It’s been dramatic to me to see people who now have deductibles in the thousands of dollars routinely making decisions – you can see people are not filling their high blood pressure medication, and they’re not taking their statins for cholesterol control, and things like that that have long-term consequences, but on a day-to-day basis don’t feel any different.”

I enjoyed reading his comments on the intersection of politics and healthcare. He notes the disconnects between academic knowledge on issues and the questions that politicians are trying to answer: “Often people are trying to come to experts for technical answers to questions that don’t have a technical answer.”

Regarding the Affordable Care Act, “people fundamentally disagree on what the goal of the healthcare coverage is. Is it to free up a trillion dollars for tax reform? Is it to secure universal coverage for all? Is it to cut costs? You can’t take a trillion dollars out of the healthcare system and make healthcare better at the same time and increase coverage in a short time frame.”

He discusses the challenge of taking academic knowledge and applying it to actual care delivery, noting “We’re drowning in the complexity of the knowledge that’s been discovered over the last century.” I remember talking to a senior physician during medical school, who had been in practice probably close to 50 years. He told us that when he graduated from medical school, there were two antibiotics – penicillin and streptomycin. I think of him every year when I purchase my updated “Pocket Pharmacopoeia” reference and it continues to grow in size even despite shrinking print. Physicians are trying to not only make sense of new treatments, but to figure out how to deliver them in a cost-effective way that is also clinically effective. Yet, Gawande goes on to mention that one of the basic problems we’re dealing with is high blood pressure. Many of the medications are inexpensive, but the follow through and execution of treatment have significant opportunities for improvement.

The interview asks Gawande’s thoughts on the need to address healthcare fragmentation and the misalignment of incentives. He responds that a technical improvement like a better computer system isn’t going to fix fragmentation, and sees the tying of healthcare coverage to employment as one of the major problems in healthcare today. He cites data that when one looks at job growth over the last decade, more than 90 percent of new jobs don’t have healthcare benefits tied to them – contract work, freelancers, temporary workers, etc. He states that having “a regular source of care over time, over years” leads to better outcomes at five years. Those of us in the primary care trenches knew this to be anecdotally true, because as we got to know our patients, we were able to better strategize with them around their health and their willingness to change to healthier behaviors and better compliance with recommendations. When I was in the family medicine trenches, however, the average patient stayed with me only two or three years due to insurance changes, which hampered the development of those relationships. Fast-forward a decade and patients want even more convenience, preferring to visit a retail clinic, urgent care center, or telemedicine provider rather than wait weeks for an appointment with a primary care physician. Gawande also notes that high deductible plans often lead patients to “sacrifice” primary care, changing the playing field for preventive medicine and long-term cost savings.

Regarding healthcare informatics, Gawande calls our current state “the MS-DOS phase of computerization and healthcare.” He mentions that systems are great for billing but challenging for recording clinical data such as allergies: “We’re at the stage where it’s ripe for the Apple of healthcare to come knock the C-prompt out.” He goes further to say we need to move from being “cowboys delivering the care” to “pit crews” with teams of physicians, nurses, social workers, and health coaches caring for patients by “dividing and conquering and communicating,” but states we only take that approach a small part of the time.

Gawande also talks about being a writer, which resonated with me. He notes that physician writers have “this daily exposure to the human experience” that other writers don’t have, including exposure to money, technical challenges, family dynamics, and more. He states, “I feel like I would have totally burned out on my medical-practice work if I were only in the trenches and not able to lift my head up and see what’s really going on.” I understand where he’s coming from – some days as I watch organizations swirl around and people struggle with new mandates and requirements, it’s only when I sit down to organize my thoughts to write HIStalk that things start to become clear about how I need to advise physicians or care teams.

He also comments on juggling his clinical work with his public health work and his writing, saying “every day is a problem to solve” on how he sorts out his various priorities including to “make sure I get enough sleep most of the time.” I totally get that – often I’m writing at midnight or into the wee hours of the morning, or stealing scraps of time in between conference calls and meetings.

Gawande doesn’t claim to have all the answers, but he does provide ample food for thought that should be consumed by healthcare policymakers and financiers. How can we better tackle the “freaking mess” that is healthcare today? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/3/18

I had a medical student working with me this week and delivered a mini-lecture on healthcare funding in the United States and why some practices don’t take Medicaid or opt out of Medicare. It was an eye opener to a student in his third year, which tells me that healthcare finance isn’t part of his medical school’s curriculum. He was surprised to learn that compared to the cost of delivering care in our metropolitan area, that Medicare typically pays 80 cents on the dollar but Medicaid only pays 24 cents on the dollar. Something tells me that after our conversation, his primary care fire is not burning bright.

We spent some time talking about concierge medicine and direct primary care, and he found this piece about concierge emergency services. Apparently, patients on New York’s Upper East Side can afford to pay upwards of $5,000 annually for access to a private emergency practice plus per-visit fees. According to the article, the facility keeps two physicians and a physician assistant ready to see patients at all times, but only see a handful of patients each day. I couldn’t help but try to calculate their expense model in my head while he was telling me about the piece, and as I saw my 16^th patient in three hours, I began to wonder if they are hiring.

We also discussed this American Academy of Family Physicians “In the Trenches” blog post addressing the need for competition and innovation in the EHR market. It brings up some good tidbits that I had forgotten. First, let’s take a look back to 2004. President George W. Bush included computerized health records in his State of the Union Address, and in April of that year launched a campaign to promote healthcare transformation. The initiative projected that “within the next 10 years, electronic health records will ensure that complete healthcare information is available for most Americans at the time and place of care, no matter where it originates.” That decade has come and gone, and for most of us, health records are held in a patchwork of systems that don’t talk to each other.

My favorite quote from blog author Shawn Martin is regarding EHRs: “They suck. They suck as products, and they suck the life out of everyone that uses them.” He goes on to describe other technology platforms such as Facebook, Twitter, iPhone, Uber, and others, which significantly transformed how people communicate and interact, and the lack of transformation in healthcare technology. That’s not to say that innovative tools aren’t out there, but there are quite a few dinosaurs that feel like they should already be extinct. One of my colleagues jumped into the conversation, and we reminisced about a couple of key features that we used to have in our ancient Medical Manager OmniDoc system circa 2003 that we still don’t have in our current system in 2018, despite numerous “enhancement requests.”

Martin hits the nail on the head with his summary of the AAFP efforts to improve innovation: “Eliminate or reduce administrative requirements placed on health IT products – the poor usability of EHRs is often due to external requirements established by regulators and payers, such as clinical documentation, which do not add clinical value.” I remember the copy of the physician note that my father brought back from a trip to Australia, when he had a wicked case of sinusitis. Basically, it documented a brief history, described the physical exam as it related to sinus findings, then proceeded to a diagnosis and an antibiotic recommendation. There was no capturing bullet points to substantiate billing requirements or other such nonsense. The detail told me exactly what was going on with the patient and didn’t drive me to distraction. Sure, it didn’t include an assessment of my father’s chronic conditions, his nutritional status, whether he is a fall risk, or a number of other data points, but I envy the physician who was able to focus on the problem at hand and still get paid, even in the outback. I look forward to the day when we have systems that are better at highlighting important data while allowing less-critical data points to fade to the background unless clinical decision support or other algorithms identify a need to bring that information to the front.

I heard about the idea of “signing your scrub cap” several months ago, but hadn’t seen it in person until this week. I was attending a Grand Rounds lecture at my hospital, and several people walked in with their name and role written on their scrub caps. Of course, one always has to wonder why people wear their caps outside the surgery suite, but I appreciate the move towards clear identification of the care delivery team. Having been the nameless student responding to “you, more tension on the retractor” for several years, it might have added some humanity to medical school rotations. As a patient, there are so many people in and out when you’re having a procedure, it would be great to not have to guess who is who especially when you have mind-altering drugs dripping through your IV.

I wrote about the All of Us Research Program some time ago, and its national launch is finally here. Beginning on May 6, adults 18 and older can join this project, which is part of the Precision Medicine Initiative. Billed as potentially the longest and most diverse longitudinal health research program ever developed, it needs more than a million individuals to provide data. Participants will share both patient-generated and EHR data, and may also be asked to provide biometric data along with blood and urine samples. The consent process takes up to 30 minutes to complete and can’t be interrupted, so if you decide to take part be sure you have a comfy chair to work from.

Not from Weird News Andy, but might as well be: A hotel guest recently allowed to stay at the Fairmont Empress in Victoria after being banned more than a decade ago due to some bad decisions involving pepperoni. As the story goes, the traveler had a “suitcase full of pepperoni” and left it near an open window so it would stay cool. While he was out of the room, seagulls discovered the suitcase, ate the pepperoni, and left a mess in the room. I’ve seen a raccoon open a tab-top soda can, but after reading the story I wasn’t exactly sure how a seagull opens a suitcase. Fortunately, NPR had some more thorough reporting and explained that the pepperoni was actually laid out on a table near the window.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/30/18

A former colleague of mine is working on some health system initiatives to deliver community-based care. They’re working to identify the disease states that have the most potential to benefit patients who frequently wind up in the emergency department due to lack of care for chronic conditions. While they sort through the data, they’re already partnering with a set of local charities to address basic issues such as food insecurity through school-based food pantries. For many of the children in their target communities, the federal school lunch program may be providing the only balanced meal of the day, and this changes dramatically when schools let out for the summer. They are also working to provide clothing including school uniforms, and have found additional challenges with families who may receive uniforms but don’t have access to facilities to launder them. The health system is working under the hypothesis that they’re not going to be able to drive the needle on patient outcomes unless they address some of the basic needs in the community, in partnership with organizations already working in that direction.

The health system is already targeting adult populations with a mobile unit that performs diabetes outreach, but they’ve found that many of the patients that come to the mobile unit are already diagnosed and have physicians, but visit the van for testing that they feel is more convenient than going to the doctor’s office. There’s a risk of care fragmentation in that scenario, and the mobile unit has had to change its protocols to shift from strictly performing screening to adding care coordination and communication with primary care physicians. In looking at the next phase of community-based care, they have completed an amazing amount of analysis with emergency department records, community health clinic records, and data from state registries.

She told me about a couple of organizations that they have researched as potential models for their programs, and I took a peek at one of them. There is truly some amazing work going on that goes right along with the transformation to value-based care, but aren’t readily visible to many of us in the trenches. One of them is Mobile Care Chicago, which deploys vans to address childhood asthma in underserved communities. Their community health workers partner with schools to screen children for asthma symptoms, then reach out to the parents of those children to consent for care. Those who opt in receive an examination and often a diagnosis of asthma. The van visits schools monthly and tries to ensure the patients have continuity of care with providers over time.

Patients are seen an average of four times during the first year, and those who are not showing progress are referred for home visits. The cost savings data is pretty impressive, especially considering that some children with asthma might visit the emergency department more than a dozen times in a year, often without a formal diagnosis of asthma or a commitment for follow-up. Missed school days are down; emergency department visits and admissions are down as well, from 36 percent to 3 percent. The cost savings is impressive – it costs $900 annually to deliver care via the van, versus $15,000 for children who have to be hospitalized. The potential savings to local health systems is over $6 million.

Mobile Care Chicago also offers a dental van and a general children’s health van in addition to the asthma van. I’m curious what systems they use for documentation, to ensure the patients have a comprehensive health record and to make sure data is available for continuity purposes if a patient would arrive at the emergency department. There are always challenges when public and private organizations are involved, and sometimes data ownership and coordination become barriers. Years ago, I worked on an HIE project where various community clinics couldn’t agree on data sharing and governance, resulting in a structure that resembled more of a data vault than something that was truly interoperable. Providers could view data from other facilities but couldn’t download it or incorporate it into the clinical chart, making it less attractive to use especially given the separate login and clunky web interface. There were always battles about how new interfaces were going to be funded and whether new member organizations would be allowed to submit their data for viewing. Based on recent projects I’ve seen, those kinds of challenges are still out there.

I’d be interested to hear from clinical informaticists that are working with organizations like Mobile Care Chicago on how they leverage technology to make this all happen. Are they using available public health data from sites like HealthData.gov or gathering their own from local providers and facilities? How do they decide what communities to target? Do they change their outreach strategies based on modeling versus current data trends? Is it better to expand over a wider geographical area or to add more depth to services in areas that are already being served? In looking at potential models for our community, there will have to be a fair amount of consideration of the mobile approach versus trying to develop school-based clinics. I’m sure there are a multitude of legal and regulatory hurdles that will need to be fully evaluated for either option.

The Mobile Healthcare Association helps connect groups interested in mobile clinic operations, and offers regional coalitions for shared learning along with special interest groups for mammography and vision care providers. The organization advocates for mobile health delivery organizations and hosts an annual forum for members. They also help connect organizations with other members who might be selling their pre-owned clinics, and provide tips on selecting a diesel- or gasoline-powered vehicle. Those are entirely new dimensions for healthcare delivery that I hadn’t even considered.

Bringing healthcare to the people isn’t a new concept, but it’s something to think about every time a hospital builds a shiny new addition. Are we really serving patients better by expanding tertiary referral centers versus considering alternate delivery options such as mobile, school-based, or workplace clinics? It should be fairly straightforward to analyze the data over the next few years and determine who really is getting the best bang for their buck.

Are you involved in the delivery of mobile healthcare? How does your organization leverage information technology? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/26/18

It’s good to see data backing up things you know are true from an anecdotal perspective. Recent data from Black Book Research reveals that younger healthcare consumers prefer healthcare organizations that have greater technology capabilities. These respondents don’t want to engage hospitals and other healthcare providers in a traditional face-to-face way and often prefer digital interaction. This parallels the rise in social media usage as well as what I observe in the real world. On a recent trip with a youth group, I watched a crew of teens stand around texting each other rather than having an actual conversation. I’m not in the under-40 crowd that was mentioned in the survey, but I know that I prefer online bill pay and online scheduling to sitting on the phone trying to take care of things, or having to write a check or send my credit card information through the mail.

The piece goes on to note that hospitals still aren’t putting budget or priority behind patient engagement or interoperability as well as they could. Revenue cycle issues such as billing or payment continue to represent a low-point in the patient experience. After dealing with the bills related to a surgery last year, I would agree. Interoperability is still a barrier, whether you’re talking about hospitals or ambulatory practices. I had a recent cringe-worthy experience trying to track down some lab results from a practice that claims to have a patient portal but that in reality has failed to configure it so that patients can View/Download/Transmit or even see their CCDA. They don’t have online scheduling but do have online bill pay, but I haven’t been able to test drive it since they haven’t sent my claim to insurance yet, even though the visit was more than 30 days ago. That shows that they have opportunity for improvement in ways other than communication, and if I have to go back I’m going to be tempted to offer them my business card – especially since I know they attested for various incentives and lacking VDT capability is a big red flag.

The Net Neutrality repeal went into effect this week, even as members of the House Energy & Commerce Subcommittee on Communications and Technology debated so-called “paid prioritization” where Internet providers can charge higher fees to allow certain content to move faster. Paid prioritization was compared to TSA PreCheck, allowing better access for those who can afford it. Informatics advocacy organization AMIA submitted comments suggesting that Congress should thoroughly evaluate the issues and consider situations where prioritization might benefit the common good, such as telehealth service traffic. AMIA encouraged the subcommittee to think about broadband access as a social determinant of health, providing examples of mental health services in rural areas and noting that healthcare is increasingly delivered outside the walls of hospitals and healthcare facilities. So far, I haven’t noticed any appreciable slowness for any sites except LinkedIn, which is always a little squirrely anyway.

There has been a fair amount of anxiety in the physician lounge as practices await their first encounters with the long-awaited new Medicare card. As seniors become eligible for Medicare, they will be issued the new cards, although existing beneficiaries may not receive their cards for months depending on what state they are in. The CMS website lists a wave deployment for the new cards, with 13 states and territories scheduled to receive their cards in May, and with everyone else listed as “After June 2018.” It boggles the mind to think that despite knowing how many beneficiaries are out there and how many cards can be produced in a given length of time, that they can’t be more specific than that. Practices that see a large volume of Medicare patients would be wise to try to update information while scheduling appointments and during telephone encounters so that they don’t bottleneck at the front desk once the new cards are widely distributed in their state.

Watch out for patients with the old Medicare card who might have read this article that recommends they don’t carry their card and instead carry a photocopy with the numbers blacked out. It suggests that patients should tell medical providers their SSN/Medicare Number verbally for a visit. That will go over like a lead balloon at most medical offices, and I can only imagine the denials from number transposition or other errors.

The Leapfrog Group released its Spring 2018 Hospital Safety Grades, scoring approximately 2,500 facilities across the country from A to F. Five formerly failing facilities made it to grade A this time, with a total of 46 hospitals earning an A for the first time. My favorite academic medical centers scored a B and C, while small community hospitals that handle few complex cases scored As. Although I appreciate the need to try to report data in a meaningful way, as a patient I would choose the academic medical center regardless of score in the event I needed a complex procedure.

CMS is again trying to make us crazy, with the recent release of nearly 1,900 pages of fun hidden in the guise of its Inpatient Proposed Rule for Fiscal Year 2019. I do like the idea that CMS wants hospitals to publish their charge masters on the Internet, but the charge master is less relevant than knowing what the range of accepted payments is on those charges. CMS has requested public comment on the latter, so it might be forthcoming as well. Whenever I have to transfer self-pay patients from our very cost-effective urgent care to the nebulous costs of the hospital, I always have the conversation with them about saying up front that they are self-pay and asking if there is a discount for paying promptly in cash. Especially with younger patients, they don’t know they could end up with collections agencies hounding them, bad credit, or even a medical bankruptcy.

Although there’s an increase in the overall inpatient payment rate, higher numbers of uninsured patients will lead to more delivery of uncompensated care. I’m a big fan of the proposal to eliminate duplicate measures across Pay for Performance and Inpatient Quality Reporting programs, as well as the elimination of reporting for measures identified as “topped out.” Even with high scores, generating, parsing, and distributing reports is a pain for technology and operations support teams. There’s always at least one provider who thinks he should have had 100 percent rather than a meager 98 percent, and demands a chart review to prove his point. The comment period is open through June 25 with an expected final rule due sometime around August 1, although we know those release dates can be fluid.

Have you read the 1,882 pages yet, or are you just waiting for the movie? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/23/18

I met up with a colleague this weekend who is knee-deep in an enterprise-wide EHR installation. They’re rolling it across several hospitals and are dealing with the challenges of trying to unite community-based physicians, hospital-employed physicians, and a couple of residency programs on the same platform.

My friend is one of the hospital-employed physicians. He splits his time between clinical and administrative duties. Originally hired to streamline implementation of the hospitals’ soon-to-be-legacy EHR nearly a decade ago, he has a great deal of experience in change leadership and trying to unite people around a common goal. He was looking forward to the new project, thinking it they could use some of the same strategies and techniques that had been used with success in the past.

The first thing that set him back was the way that the project was legally structured. Since it is a joint venture between the hospital and the residencies (which have ties to both the hospital and a medical school in the region), the software purchase was handled by a new entity with representation and funding from the constituent entities. Although technically they’re supposed to be partners, it sounds like there is constant tension between the parties as each struggles to be in control of various decisions. The hospital is definitely larger with its employed medical group and large number of community physicians who are on staff, but the residencies try to bring the weight of the medical school to bear and play the prestige card when they feel they’re not being allowed to be in charge.

From my time at Big Medical Center, I know that often the employed physicians are easiest to deal with. Although they will hem and haw and posture about various decisions, they ultimately understand where their paychecks come from and will eventually get on board with the project. There will be tensions among the specialties and between the hospital-based physicians and the ambulatory-based medical staff, but usually there is enough common identity to get everyone to pull together.

Then there are the community physicians, those who have admitting privileges at the hospital but who might also see patients at various other facilities. They tend to be a little more challenging to work with since they frequently will threaten to pick up their patients and go elsewhere if decisions aren’t to their liking. Depending on the specialties involved (think orthopedic surgery and interventional cardiology), the financial impact to the hospital can be significant, so project teams are often instructed to “play nice” with them.

The reality of the threat to “go elsewhere” is that it tends to be a hollow one. If you’re in a city with multiple hospitals or health systems, everyone has an EHR and everyone has similar challenges and mandates, so it’s unlikely that they can move their cases across the street and have 100 percent of their demands met. They’re going to run into employed physicians and hospital administrators over there, too.

Although some community physicians still attend at multiple hospitals, the stresses of that type of practice are great. We’re seeing more and more community-based physicians who have put their proverbial eggs in one basket with a single hospital and the pain of change is worse than the pain of same when it comes to moving to another facility. They already know how their current hospital schedules, what schedule they can be guaranteed in the operating room, if the hospital carries their preferred joint implants and medical devices, etc. Still, the EHR project teams have to deal with these threats and pressure from administrators to ensure physician happiness, so it’s something that has to be considered.

Residency programs are another situation entirely. In some of the smaller programs that aren’t based at an academic medical center, there may be a mix of attending physician types. Some might be from a local medical school, but rotate through the residency program a couple of weeks or one month a year to provide that academic pedigree. That can mean accommodating a dozen or more physicians and their opinions, although they don’t have a lot of dedication to the program since it’s not their primary focus. There may be full-time hospital-employed or community-based physicians that form the core of the faculty, and then part-time physicians who provide additional coverage or who keep working in the program as they move towards retirement or who just want to keep their toe in the residency world.

Then there are the resident physicians. Some may be dedicated to the program and will be part of the care team for three or more years. Others may just rotate through a month or two across a three-year span, such as family medicine residents who rotate through OB/GYN programs. These various structures lead to the need for a lot of users who are in the system but not on the system with great regularity, as well as a breadth of opinions about how the system should work that you won’t see anywhere else.

As we caught up over coffee, my friend lamented the fact that the organization seems to have underestimated how diverse the opinions would be when they began working with these different constituencies. He thought they would be able to apply some of the governance principles that they had used successfully on the hospital side in the past as they united with the other two hospitals, but the reality was very different. He’s been pulled into nearly a year of infighting, posturing, threatening to leave the legal entity, and backstabbing behavior. The lack of governance is a real challenge and he doesn’t have a lot of hope that it will be resolved anytime soon.

They’re also faced with cost overruns as they discover that certain parts of the project were under-scoped or not scoped at all. For example, the pathology lab interfaces were forgotten – the scoping team assumed they were part of the main hospital laboratory system. There were plenty of similar misses across the facilities, each of which adds a little bit more to the price tag. In the realm of under-scoping, they forgot to account for the needs of community physicians and part-time physicians in the training budget, failing to appreciate that these providers would want to train after hours or through different modalities than the hospital classroom. They’ve been working with consultants, but recently decided to add several other consulting groups to handle various subprojects, which will likely add more challenges to the situation.

It was good to commiserate and I think my friend felt validated in the fact that I see similar situations across the country. It doesn’t seem like there are a lot of good answers unless you have strong leadership that is willing to find the right mix of persuasion, financial incentives, and maybe even a “take no prisoners” approach to get the job done.

As our catch-up time wound down, my friend asked whether I knew of any good opportunities in the area or whether I had any recommendations on working with physician search firms. It seems he may be reaching the end of his tolerance for the process and I certainly sympathize with him. We scheduled another coffee date for the end of summer. I’ll just have to see how he is hanging in there.

How has your EHR project team handled governance? Did you survive a situation like this one? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/19/18

So many things are going on in the healthcare IT world that it’s impossible to keep up. I came across an article about the telehealth program at New York Presbyterian, which has been implemented in the emergency department to reduce wait times. The Express Care program is credited with a significant impact, moving the needle on low-acuity patients from a more than two-hour wait to one that sits closer to 30 minutes. The patient care flow is integrated into the existing emergency department care path. At the time of the initial nursing examination, patients who meet criteria are asked if they want to participate in a virtual visit in a private room rather than waiting for an in-person visit. Patients are seen by the system’s existing emergency physicians, which is said to reduce potential patient concerns about quality of care.

New York Presbyterian is known for some of its other virtual programs, including a second opinion program that is delivered through an online patient portal. They also have an inter-hospital consult program for system physicians to collaborate along with a digital urgent care service. Virtual visits can be done in lieu of some office visits, and they also staff a mobile stroke unit.

I did some additional research into telehealth, looking particularly at the demographics of patients who gravitate towards the services. One might be tempted to assume that it would be millennials and Generation Y. I found some data from an Advisory Board survey of close to 5,000 patients that indicated that although more than 75 percent of patients said they’re open to a virtual visit, only 20 percent have actually experienced one. Of those who have used the services, nearly 60 percent are under age 50.

This might be due to payment policies more than affinity for technology, due to the Medicare restrictions on telemedicine services. It could also be due to employers providing telehealth services as a way to offset declines in employer-paid coverage and rising deductibles. A good number of parents would consider using a virtual visit for a sick child, and I suspect this is not only a function of accessibility and wait times but also one of convenience as workers struggle with leaving work for medical visits.

There are some variations in how medical providers want to approach telehealth. I was approached at HIMSS by vendors in two different models – one which was third party and another which hoped to leverage a client’s existing physicians to deliver services. As a provider, there’s a certain allure to having your patients cared for by members of your group, but that arrangement still requires providers to take call and provide services after hours. That arrangement is less appealing to physicians who see medicine more as a business than as a calling. Telemedicine visits tend to skew around a couple of key areas – acute care needs, and routine requests such as medication refills.

Lots of conversation in the physician lounge this week about Amazon exiting the pharmaceutical business before it even really got started. The company has spent the last year soliciting approval from state pharmacy boards so that they could become a wholesale pharmacy distributor. They completed the process in just 12 states and apparently discovered that it’s harder to recruit large hospitals away from their existing suppliers and contracts then they thought. In my experience, hospitals tend to be locked in with either McKesson or Cardinal Health or tend to be part of larger group purchasing programs that don’t make it easy to change suppliers. According to some reports, Amazon also failed to fully appreciate the complexity of fulfilling medical supply orders when some of the items must be refrigerated or frozen. That’s a wrinkle that certainly doesn’t fit smoothly into their well-oiled logistics and warehousing process.

Some of my procedural colleagues in smaller organizations had been hoping Amazon would be able to make a go of it, to enable speedy deliveries of smaller-scale orders so that they don’t have to deal with the larger vendors. The ability to ask Alexa to ship you a couple of cases of normal saline or some assorted suture materials certainly might be a draw when you’re already using her to order your coffee and restock your household supplies. Amazon may still head in this direction, delivering medical office supplies such as gloves and other consumables to smaller organizations such as independent ambulatory surgery centers and physician practices. For that book of business, they’re already approved for licensure in 47 states plus the District of Columbia. There is still a fair amount of speculation that Amazon might be entering the retail pharmacy or direct to consumer spaces. It would be interesting to see how they tackle some of the rebate issues that exist in the retail space and add confusion to the price of medications.

A reader reached out regarding my recent comments about groups that compensate providers based on RVUs as opposed to making the transition to value-based compensation. She recently did some compensation analysis research and noted that the majority of physicians are compensated largely based on productivity, with potentially 10 percent or 20 percent being paid relative to quality metrics, patient satisfaction, or access. She found an interesting trend with groups that are moving towards paying physicians a guaranteed salary in order to account for time spent on non face-to-face activities such as chronic care management. Guaranteed salaries are also cited as a way to help smooth out access issues in group practices, where one provider might create bottlenecks because he or she won’t allow patients to see a colleague due to fear of lost income. Guaranteed salaries may also hold potential for reducing burnout and increasing collaboration. These goals are typically aided by structures which might pay bonuses based on group growth rather than individual productivity. New models of compensation which include guarantees typically include a performance threshold to ensure physicians maintain a minimum level of activity.

These new compensation models may lead to increased reporting needs for organizational leaders, which translates to requests for IT teams to generate data for compensation analysis. Several of the practice management systems I work with struggle with functions like capitation and prospective payment management, so they may also be ill-equipped to handle this level of productivity reporting. If you’re on the technical or support side it might be tempting to ignore trends in provider compensation, but it might be worth following if those trends are going to start sending more work your way.

Is your organization structuring compensation to encourage collaboration? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/16/18

I’ve written a bit lately about burnout and how it’s impacting people in healthcare IT. A couple of years ago, I took up a hobby that was 180 degrees from my day job. I don’t fancy myself an artist, but it was a way to use my mind in a different way than I typically do while creating projects that others can enjoy, or at least find useful.

The Internet has been a great teacher. I’ve been able to benefit from various teachers who have published videos to help beginners, as well as some who conduct web-based educational sessions. With travel and work responsibilities, I don’t have much time to attend classes or workshops in town, but I keep my eye out for various opportunities. I had heard about a craft retreat more than a year ago and languished on the waitlist for nearly a year, but ended up being able to go this weekend.

I was looking forward to getting away from the informatics rat race and focusing on learning new techniques, meeting new people, and being able to spend some time in a beautiful place recharging my mental batteries. Of course, there was the standard pre-vacation hustle as I tried to tie up all the loose ends before leaving, and I’m not looking forward to the post-vacation shuffle as I work to handle everything that accumulated in my inbox and on my voice mail while I was gone.

Since most of the meetings and conference I go to revolve around healthcare or IT and are held at large convention centers or well-known hotels, I was looking forward to the more casual atmosphere of the state park where it was held (although I did opt for a room in the lodge rather than in a yurt, which was also available.)

When I’m meeting new people in a non-work environment, I don’t advertise that I’m a physician, especially when part of the purpose of doing something like this is to get away from the industry and the stress. People do tend to talk about what they do in their day jobs and I usually say I work with medical office software. I was surprised when the first person I said that to asked if I worked for Epic, since knowing what company is your physician or hospital’s vendor might not be the most common scenario. The woman I was talking to was a nurse who recently retired from a hospital as they transitioned from McKesson to Epic. We talked about burnout in nursing and she mentioned that several other people at the conference that she knew from previous years were also in healthcare.

It turns out that of the 80 or so people at the retreat, more than a dozen were escapees from the healthcare arena. Mostly nurses, with a respiratory therapist, a hospital social worker, and a medical transcriptionist in the mix. It was really a cross-section of people, with 26 states and two countries represented besides the US. The organizers encouraged people to mix it up at meals and breaks. I met a former welder who became disabled after a car accident, a recent MBA grad who found his accounting work “soulless,” and quite a few retirees and semi-retirees who are supplementing their incomes through craft fairs and online shops.

I didn’t hear a peep about healthcare until breakfast on the last day, when someone was talking about flu season and the conversation morphed into a discussion of unanticipated medical expenses. As a physician and as someone who works closely with healthcare organizations in crafting their strategies, it was like watching a focus group without having to recruit people or do the meeting planning. A few minutes into the discussion, I wished that I had a hidden camera to capture the conversation, because it hit on many of the issues that patients face that sometimes we on the administrative, care delivery, and informatics sides don’t understand as well as we might think we do.

As expected, high premiums and high deductibles were topics. One attendee is a teacher in Colorado and is thinking about switching her insurance to a catastrophic plan, but is worried that she can’t get coverage because of her age. She is a fairly savvy consumer, having researched what it would look like to pay cash – and having received a quote from her primary care physician of over $600 for a well visit with some basic lab work. The physician didn’t offer any kind of discount for being self-pay up front, which seemed surprising. She mentioned the practice is hospital-owned, which may be part of the issue. Her plan is to use the urgent care, which charges $99 for an office visit, as her primary until she goes on Medicare.

Other topics included the wackiness of pharmacy benefit management plans, how long it takes to get bills from medical providers, and liking the fact that they could see their lab results on their phones. One attendee at our table was from Canada and spent a bit of time explaining her personal experience with that health system (which was overwhelmingly positive).

Each person had some kind of healthcare story. The general theme is that we in the healthcare business can do better and should be doing better for our patients. I’d love to have hospital executives hear about people’s experience with the cost of healthcare when they are thinking about building that new bed tower or spending tens of thousands of dollars rebranding the hospital. I’d enjoy seeing legislators hear the stories of people who live in rural areas and have to drive hours to see physicians because their states haven’t figured out how to address telemedicine. I’d like to see IT directors and software engineers sit down with people who have retired from caregiver positions because the tools they are expected to use to do their jobs add stress with little benefit. And I’d like to see policymakers interact with people who just want to get the most out of life so they can spend time fishing, crafting, raising their kids, or playing with their grandchildren and keep everyone as healthy as possible.

I’d like to challenge people in healthcare, technology, and administration to get out and interact with the people they serve, whether they serve caregivers, end users, patients, or other parts of the system. Hear their voices directly, not just through marketing and survey data. Understand the challenges they’re facing and what we can do to help. Learn what is working and what is broken in our crazy system.

And while you’re at it, sit by a lake and watch the ripples in the water. Contemplate the value of things other than your stock price or what your shareholders will think. As yourself whether you’re doing the right thing for the people you serve or whether you’re just marking time or playing it safe. Listen to pine needles crunching under your feet. Find something outside of work that challenges you in a different way or makes you feel happy and fulfilled. It might just give you a new perspective when you go back to your day job.

How do you recharge your emotional batteries? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/12/18

I read a lot of press releases and this one from CMS particularly caught my eye this week. Normally a fairly bland and non-partisan source of news for all things CMS, the media relations group has really dialed up the rhetoric on this one. I don’t disagree that the Affordable Care Act is imperfect and we have a long way to go in achieving a workable and affordable system of healthcare in the US, but it feels like we’re losing the ability to participate in constructive discourse and everything is becoming polarized.

From Gone to the Dogs: “Re: burnout. My institution has dealt with this issue as it deals with many issues. The phrases ‘pennywise and pound foolish’” and ‘putting lipstick on a pig’ are perhaps the best descriptors.They’ve put together various wellness committees, invited speakers on mindfulness, and hired (costly) consultants on ‘improving communication.’ The most legitimately helpful thing they’ve done is have a puppy-petting party with a group of prospective guide dogs (which helps the dogs get socialized and relaxes the staff). At the same time, they continue to ratchet up required numbers of RVUs (on threat of contract non-renewal if targets aren’t met), throw people under the bus for any untoward events, display a general lack of supportiveness, etc. The broader burnout issues are also unchanged: insane regs, endless documentation requirements, frustrating pre-approval demands from insurers, and still trying to help really sick patients.” Our local high school invites a therapy dog agency to work with the students during finals week. I have to say, it’s hard to be aggravated when you’re staring at a cute puppy (unless that cute puppy just chewed the heel off your favorite pumps). The comment about RVUs is also particularly striking since we’re not supposed to be focused on visit volumes in the new world of value-based care. Keeping patients healthy and having fewer visits should be the goal, right? I still see RVUs as a metric in 90 percent of the organizations I serve.

Several readers sent their own “weirdest interview ever” stories.

My weirdest interview was with a major consulting firm. I had passed two telephone interviews and was flown out to have the final round of interviews with major players. I first met with president of the branch and he was bland and did not have many questions or comments (or energy). Then I met with one of their directors who had previously worked at another consulting firm that I had also worked at. He was a great interview and covered a lot of items. But the kicker was the last interview. This director sat down and nearly choked on her coffee when she realized that the date on my resume was when I graduated with my masters and not what she had assumed was my birth date! She didn’t believe I had any of the experience on my vitae, nor did she want to hire someone of my age. She excused herself and had security walk me out of the building. I’m not sure if she had many bad experiences with interviewing candidates, but security? At least I had a nice trip on their dollar.

I once interviewed for a position with an organization where the decision-maker shared a large office with another high-level person in the organization. Let’s call them Mr. Abbott and Mr. Costello. Mr. Costello would ask me questions, while Mr. Abbott, within earshot the whole time, was ostensibly engaged in other matters. But at different points in the process, Costello would call across the room to ask for Abbott’s thought or opinions. Abbott generally replied, “It’s your interview, I don’t know why you’re asking me,” or, “I don’t know – you should know that.” This went on for about 20 minutes or so, at which point I got up and said, “Thank you very much. I am not interested in the position” Costello had difficulty understanding why I abruptly made up my mind that this was not a place I wanted to work, but was apologetic. I don’t know where those two and the firm wound up, but I hope they started group therapy sessions as soon as I walked out the door.

That last story really resonates with me. As a candidate, when we attend interviews, we tend to be on our best behavior and I think we assume the people we are meeting with are likewise on their best behavior. I am sometimes left wondering that if what I have just seen is an organization putting their best foot forward, how wild it must be when they’re not trying.

From Crazy Ivan: “Re: tradeshow booths. This is my favorite ever. The only thing missing is the unmarked white van.” Every year one of my booth crawl BFFs and I fantasize about taking over one of the no-show booths at HIMSS and using the company’s name to create a fake business just to see if we can get prospects to stop by and chat. This year our delusion expanded to a couple of other people in our circle and the idea is gaining steam for next year. Another good reason to always check out the “little guys” on the trade show periphery – you never know who you’re going to find there.

From The Big Divide: “Re: this article. Would love to hear your thoughts. Is this a trend? It makes me nervous. Can’t help but believe it does deepen the divide in healthcare.” Concierge medicine is certainly a trend, although its market penetration varies across different regions of the country. I do see a fair number of direct primary care practices, many of which are priced in a way to be much more accessible to a broader swath of patients especially when those patients have a high-deductible health plan. The more accessible versions differ from typical concierge practices in that they’re more about cutting out the middleman (insurance) and providing value then they are about the white-glove service or 24×7 access than some retainer/concierge practices would be. I think the Michigan program especially raises concerns because of its association with a teaching hospital, and many teaching hospitals have a historical mandate to serve the underserved.

The hospital affiliated with my medical school had a “concierge floor” back in the day, where VIPs were cared for in swanky rooms with better meal service and no house officers. We only had a chance to breathe that rare air in the event of a code blue, when it was all hands on deck for the on-call team. They also sometimes had poorer outcomes because there were no house officers, which sometimes means less attention. Depending on the reason you’re in the hospital in the first place, not having interns and residents and students bothering you can be a bad thing.

On the other hand, when looking at concierge practices, they seem inevitable with the commoditization of medicine. One knows that when one purchases a Lamborghini, they will receive a different level of service than if they purchase a Chevrolet. People of means pay cosmetologists to come to their house to perform a pedicure rather than go to a salon. They have housekeepers rather than clean the bathrooms themselves. If the practice of medicine is no longer a calling but rather a business, why should it be any different than any other service? Even in a hypothetical single-payer system, there will always be people who are willing to pay more to get more. The question is whether we as a society are willing to commit to a minimal level of care for everyone else.

What do you think of concierge practices or direct primary care? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/9/18

It was a strange week in my little health IT world. I had my first prospective client call to ask about an “extension” in MIPS data submission. Although CMS extended the deadline from March 31 to April 3, my client had confused the deadline with the federal income tax deadline and thought that you could file an extension to get an even longer time to report.

Sorry, folks, but if you haven’t submitted by now, you’re out of luck. We’re in the 2018 reporting year, so if you haven’t started to get your plan ready, you need to dust yourself off from 2017 and head into the new year.

I also went on the strangest job interview of my life. I had been introduced to this potential position by a mutual friend who works for the medical group in question. The backstory I was given was this — a mid-sized medical group is looking for a blended CMIO / clinical role to complement existing CMO and medical director positions. The group is growing and realizes that they need more administrative leadership to move them through programs such as MIPS and to assist with managed care contracting and their transition into the ACO space.

It sounded right up my alley. The recruiter from the group validated the role by sharing a job description, doing a phone screen interview, making sure we were in the same compensation ballpark, and then scheduling me to come meet with the group.

My first conversation was to be with the group’s physician president, who apparently was “called away.” He didn’t give advance warning to the interview team, which is never a good sign. I was left sitting in a hallway for 20 minutes while they scrambled to find someone else to fill the time block, who of course was unprepared for the meeting and didn’t really know what the role was about. They were, however, a provider, so they could tell me what practice with the group was like, which was important since this role would involve a certain amount of time in clinic.

From a few things he said, though, it sounds like the president gets “called away” quite a bit, which sounds like either poor time management skills or a certain level of chaos that requires the group president to sort it out.

From there, I met with some nursing team representatives who told me more about the clinical aspect of the job as well as some of the pain points they hoped that the new CMIO role would help address. The discussion was candid, the interviewers were friendly, and I felt it was a good opportunity to share my philosophy of clinical practice as well as how I think teams best work together.

They handed me off to members of the informatics team, who met with me over lunch. It was a mix of interviewing and grilling, with many questions about whether I would try to restructure the informatics team or change how their jobs work. There were a lot of very pointed questions about how I work with technical resources. One analyst flat-out asked if I would automatically take a physician’s side in the event of a disagreement between the physician and IT.

The analysts seem to be a good group of people. Although they’re pulled in many directions, I think they are excited about the possibility of someone helping with governance and making sure they are doing well-considered projects rather than reacting to squeaky wheels or shiny objects.

From there, I met with the COO, who talked me through some of the nuts and bolts of the organization and how much she thought the new role would interface with the financial and operational aspects of the organization. It sounded like there has been some friction in the past among operations, IT, and the clinical stakeholders as they decide how to prioritize scarce resources and how they decide which initiatives to pursue as they create their annual planning and strategic roadmaps.

At this point, none of this was surprising or out of the ordinary compared to other interviews I’ve been on, except for the missing interview with the group president. At the end of the talk with the COO, she let me know that I’d have a brief break and then would be able to meet with the president, who had rearranged another meeting to accommodate our interview. It sounded good, so I grabbed a cup of tea and made some notes about what I was thinking so far about the position.

An assistant came by to escort me back to a conference room, which seemed a little strange that we’d meet there rather than in the president’s office. Regardless, I headed in and sat down. That’s where the wheels fell off.  Apparently, the group president wasn’t on the same page as anyone else about this new position. I’m sure my face betrayed what I was thinking about what I was hearing.

The conversation was fairly one-sided. It essentially sounded like he isn’t in support of the position, implying that the people I’d talked to weren’t supposed to be advocating the position I was interviewing for. He said that someone shouldn’t just get to “walk right in and be a leader of this organization,” but rather needs to be a staff physician first and considered for a leadership position only if he or she “falls in the top 25 percent of our productivity curve.” However, any potential CMIO would need to first be a medical director, then given a chance for a promotion if they prove they can “walk the walk.”

He then proceeded to explain that the medical director positions were “stipend positions” on top of a full clinical schedule, which basically means the job would be a 1.25 full-time equivalent. Being anything less than a full-time clinician would be non-negotiable.

I wasn’t sure I heard it right the first time since my brain was still trying to wrap itself around being at the top of the productivity curve, which is terminology I haven’t heard since value-based care started picking up speed. Most of the interviews I’ve been on describe evaluating physicians based on metrics that are scored for clinical quality, patient satisfaction, access, chart completion, cost of care, etc., but not outright productivity. I asked a few questions around that and it sure sounded like their docs are being incented on a cross between RVUs and clinical quality scores, but it wasn’t clear.

By this point, given the total disconnect between the group president and the rest of the people I had talked to, I knew this wasn’t going to be a process I wanted to take forward. Clearly this gentleman didn’t understand how CMIOs and other leadership-level physicians are usually brought into an organization. Can you imagine a hospital CMIO being told that he or she needed to work his way up through the ranks and maybe then he or she would get a shot at the C-suite?

I can’t help but believe that at some point during the conversation my mouth was agape. The rest of the interview ping-ponged around for awhile until the recruiter came back to pick me up and close out the day. She asked what I thought and I threw out some vague comments about it being an interesting opportunity and there being a lot to think about.

I’m not sure if they know how off-script their leader was or what was going on, but at this point, I don’t care if I hear from them or not. I hope they get their act together before they “interview” the next guy or gal (I use that term loosely considering how the day ultimately went). I can laugh about it after a glass of wine, but in retrospect it was rather bizarre.

What’s the weirdest job interview you’ve ever been on? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/5/18

I appreciated this article shared on Twitter earlier this week by Farzad Mostashari. He noted, “This particularly resonates – much of the physician anger and burnout is due to cognitive dissonance between how to make a living & doing what they know would be better for patients.” Although the article deals with the larger issue of fee-for-service vs. fee-for value, many of us deal with the micro versions of this on a daily basis. It’s more than just being caught between two payment models. We deal with countless requests for medications and tests that are of questionable value, but are caught between ordering the requested therapy and risking poor patient satisfaction scores that might impact our livelihood, or potentially risking outright patient anger.

In my current clinical situation, I don’t receive any financial boost from ordering more tests, but there is a perceived reduction in medical liability when more tests are ordered. This is common in emergency medicine and urgent care, as we are less able to rely on our knowledge of the patient and their history as we evaluate a problem. There is a pressure to practice defensive medicine that is independent of the compensation issues (although one could argue to that a lawsuit would be financially devastating, so there is indeed a financial reason to practice defensive medicine.)

I would love to be able to sit and explain to patients what they need to do to be well, or avoid injuries, or why they don’t need a medication or a CT or any other testing. However, since coding needs to be accurate and undercoding is as inappropriate as overcoding (at least according to the compliance audits I’ve had at my last three employers), that would mean that I should bill the time spent under the appropriate “counseling and coordination of care” code — which would likely be perceived as padding my bill — vs. billing a less-costly visit for a “treat ‘em and street ‘em” approach.

In this situation, how do you quantify the value of a physician sitting with you and counseling you? The reality is that this service isn’t valued in our current healthcare paradigm. Such interpersonal interactions are now to be delegated to ancillary providers in a team-based approach to care. However, the physicians are now financially liable for the results and outcomes of those patient interactions along with other treatment strategies.

This puts a tremendous amount of pressure on clinicians, regardless of where they fall on the care team. Being liable for the behavior of others is something that most of us are only willing to assume through the bonds of marriage or parenthood. In my community, this assumption of responsibility is one of the prime reasons that clinicians are resistant to value-based care. The article notes that, “many physician organizations have concentrated their energies on maintenance of the fee-for-service status quo, rather than providing a unified professional focus on improving health and creating value.” Although I don’t doubt that this is a real phenomenon, I’m not seeing it in the primary care organizations I’m working with.

I wholeheartedly agree that if you’re ordering more tests or drugs or whatever because it increases your reimbursement and not because it’s the right thing for the patient, you’re doing it wrong. But in real life, there is a fine line involved in figuring out what the right thing is for the patient. What do you do with the 88-year-old diabetic who might live another 10 years? How aggressively should you treat their diabetes? Do they need multiple medications or should they be allowed to relax their diet in their remaining years? Can their medications be reduced to save money in a fixed-income situation? There’s not a lot of data out there for patients in this age group, so how do you apply the evidence?

It’s not easy to point at a given clinician and discern their motives for a particular course of care with a particular patient. Perhaps in this situation, the patient’s spouse is significantly ill, the relatively healthy patient is the primary caregiver, and being aggressive makes sense because there are actually two patients in the picture. Or perhaps this patient has other issues, such as dementia, that might impact treatment and might make a relative “undertreatment” the better option. Unfortunately, our current understanding of data sometimes lumps these patients in the same category. Are you undertreating because it’s the right thing to do for the patient, or because spending less will give you a bigger bonus? Are you overtreating because the patient is demanding it, or because getting lower hemoglobin A1c scores gives you a bigger bonus? These are the forces that are shaping physician-patient interactions across the country and also shaping the data requests and dashboards that they’re requesting from the IT side of the house.

In addition to evolving physician sentiments about value-based care, we need a wholesale cultural program to educate patients and families about the cost of care and what they can do for themselves at low cost and with high return. It’s not as simple as enrolling patients in high-deductible health plans and expecting them to be able to sort it out. We expect patients to be educated consumers, but we don’t provide the level of education needed to really change behaviors. Patient advocacy organizations and patient engagement movements help, but there is just such a tremendous need.

Our state recently voted to require CPR training prior to high school graduation. Additionally, I’d love to see the state-required health classes include material similar to what is taught in the state-required personal finance class. Let’s talk about the future value of money vs. the future value of health in the context of preventive medicine. We teach students how to write a check – let’s teach them how to read an Explanation of Benefits document. Let’s teach them what a deductible is and how in-network and out-of-network works before they wind up with unanticipated medical bills that set them up for medically-related bankruptcy.

If we’re going to ask physicians to completely reject fee-for-service medicine as the article suggests, then let’s make sure we’re setting the system up for success. Not just with their patients, but with the value-based care scoring system. I recently worked with a practice that is coping with state and payer requirements that are just different enough from the MIPS-related clinical quality measures that they can’t use their certified EHR for reporting. They’re having to pay a not-insignificant amount of money to have custom reports created, as is every other practice that plans to participate in these programs.

What waste. Wasn’t the Meaningful Measures initiative supposed to help with this? After watching what this practice is going through, and knowing there are many other organizations in the same boat, I’d like to see rulemaking to halt the promulgation of any more programs like this until they’re brought into alignment with a single set of standards. That might actually get the naysayers on board as we work towards one set of common goals rather than multiple paradigms.

This is an exciting time to be in healthcare IT because we have the power to engineer solutions to help solve some of these problems. If you’re in industry, you have the potential to streamline workflows and put data at the point of care so all of the clicking becomes meaningful, but it might take some money that would make shareholders say “hmmm.” If you’re on the operations or health system side, you have the power to financially incentivize your providers to embrace value-based care, but it’s going to take boldness and bravery. If you’re a provider, you have the knowledge to research the evidence and determine whether you’re in the new game or not. And if you’re a patient, you have the opportunity to vote with your feet and your pocketbook if you want to embrace value.

It will be interesting to see what the next few years hold. There will be ups and downs. but if nothing else, it’s guaranteed not to be boring.

What do you think about payment and delivery model changes? Is your technology keeping up? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/2/18

Spring is here, or at least sort of. We’ve had 17 straight days of rain, finally followed by one sunny day that was decent enough to migrate from the treadmill to the streets. The daffodils were blooming and everything was greening up, and then we got the April Fools’ joke of snow. Still, the transition to spring is a good one and hopefully the snow won’t stay around for long. Watching the outdoors perk up tends to give people energy to take on new projects and embrace new things. In that spirit, I’m going to offer some challenges to the healthcare IT leaders out there.

Challenge #1

Look through your library of applications and find a feature that you’re not using but that might benefit your users. Maybe it’s a feature that you didn’t need at the time it was created, so you didn’t implement it. Since then, your business might have changed, or maybe healthcare in your community changed, and it might be a good thing to roll out now. We also see organizations not implement features because they’re forced to upgrade on a specific timeline and don’t have time to address everything that comes with a new release.

I often challenge organizations to do this and the results can be impressive. One group originally shied away from allowing user-level personalization even though the EHR supported it. They were afraid that allowing users to reorganize icons and set too many preferences would make it difficult for the help desk team to provide support. Over time, the lack of willingness to allow user personalization hampered workflow, leading to many meaningless clicks that didn’t contribute to an individual user’s workflow. Even where personalization was allowed, it wasn’t encouraged – the majority of physicians didn’t have user-specific medication favorites that they could use to quickly enter drug orders nor did they have links to their preferred patient education materials. (Some of them were even still pulling paper photocopies from a file cabinet.)

If you’re really nervous about rolling out a feature, consider piloting it, perhaps selecting one clinical division or practice location to use a new feature. This allows you to not only complete a proof-of-concept exercise, but to ensure your training and implementation approach is solid before you roll it to the rest of your organization. Although sometimes we will see a failure, in most cases new features that are carefully rolled out will be embraced and can save end users time and frustration.

In addition to user personalization features, other features we often see put on the back burner: e-prescribing; e-prescribing of controlled substances; real-time eligibility checking; patient portal appointment scheduling; online statements and bill pay; secure messaging; clinical decision support; and condition-specific documentation favorites.

Challenge #2

Review your policies, procedures, and processes and find one that isn’t required and doesn’t add value, then eliminate it. In observing clinical workflows, I often find data collection points that aren’t used and no one questions why they are gathered. Maybe it was a grant that your practice had three years ago that wasn’t renewed; maybe the data is now automatically fed from another system (such as registration or the bed board system) and no longer needs to be collected separately in the EHR.

I often suggest that organizations review their patient intake forms and look for redundancy. At a recent physician office visit, I was asked to write my pharmacy information on three separate sheets of paper. It was clear that the office had evolved their intake forms, but had done so in a siloed fashion. The “front desk registration sheet” asked for it, the “clinical history” sheet asked for it, and they “why are you here today” sheet asked for it. For a returning patient where only the “why are you here today” sheet might be filled out, that might make sense, but for a new patient filling all three sheets out, it was a bit much. Not only does asking for data multiple times irritate and inconvenience your patients, but it increases the risk of error as people are overwhelmed and are copying information multiple times.

In a typical clinical / financial workflow analysis, I usually find close to a dozen processes that could either be eliminated or benefit from significant streamlining. Processes that can be eliminated often grow from distrust of electronic systems. For example, making patients verify paper copies of their history forms even though they just filled them out online within the past 48 hours and already electronically attested to their accuracy. Or making patients completely fill out new patient paperwork annually rather than printing them a copy of their current information and asking them to confirm and update.

Other processes might be unrelated to patient flow but important to business. I see a lot of waste in processes that organizations use for shift scheduling, time-off requests, expense reimbursement, and more. I also see a lot of policies that are “required by HIPAA” or “required by OSHA” that are truly nothing of the sort. Make sure if something is “required” that it really is, unless you want to be called out on it.

Challenge #3

Spend time as a leadership group reviewing organizational values. There are a lot of mission statements and vision statements out there, but in many cases, they are so remote from day-to-day business operations that they’re not having any influence on how people work or how they interact with patients or other clients. I still remember the mission statement of my first EHR project at Big Medical Center – probably because we actually believed it and lived it on a daily basis, rather than just seeing it posted in the hallway or once a year in some slide deck. If your vision has gotten hazy or cloudy, maybe it needs an update. If people don’t know what the mission is, then your corporate culture might need some attention.

Organizational values should be more than just a plaque on a wall somewhere. They’re more than a logo or brand statement. Values should be easily understandable and should guide the actions of people doing business whether with internal customers, patients, family members, or anyone else. If you find people in your organization conducting themselves outside of the values, be open to addressing it rather than taking the easier road of letting it go by or being glad it’s not happening on your team.

Spring is here and it’s a great time to make a change. Is your organization up to the challenge? Leave a comment or email me.

Email Dr. Jayne.