Curbside Consult with Dr. Jayne 7/9/18

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

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

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

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

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

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

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

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

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

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

Curbside Consult with Dr. Jayne 7/2/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/28/18

Amazon is leaping into the world of healthcare with its acquisition of PillPack online pharmacy. This should have retailers and drug suppliers looking closely at their business models. Investors are already questioning the impact, with Walgreens and CVS shares each dropping 8 percent.

Amazon is paying $1B for the Boston-based company, expected to close in the second half of the calendar year. Retail prescriptions are a $300B business in the US, with CVS and Walgreens having large pieces of the pie. PillPack is licensed to deliver mail-order pharmacy services in all 50 states and also has connections to pharmacy benefit managers such as Express Scripts and CVS. It provides pre-packaged drugs to patients and automates tasks involved in the prescription refill process.

I put my physician hat on to think about its potential impact to the industry, and one concern is patient safety. With the different packaging, patients on complex medical regimens may need to change how they handle their meds and will want to watch carefully if they are transferring pills to home tracking boxes. Physicians will need to be aware of this new supplier and whether specific orders are needed for medications, for example the often-added instruction to put meds in an easy-open container or to label in a foreign language. Still, competition is generally good in most industries, so we’ll see where this goes.

I work with a number of clients that need help in translating their vendors’ communications about clinical quality measures into instructions that their internal teams can follow. The content and readability from different vendors varies, and there are definitely some superstars out there who hand-hold their clients through the entire process. There are also companies that provide vague instructions and don’t even include workflows, leaving clients to guess at where the need to document certain data elements.

There’s always some uncertainty with CQMs early in the calendar year, as vendors are responding to federal and other requirements that may be issued or modified in October, November, or December with the expectation that they be fully built and available in EHRs and quality management tools on January 1. That’s a tall order to fill for many vendors, and clients are typically twitchy, so I’m going to offer some free consulting advice. If your vendor hasn’t shipped the measures yet and you can’t run reports, you can still launch quality improvement projects to your organization. Create awareness, deliver training, and make sure your users understand and incorporate any workflow changes. Then, you’re already down the change management pathway, and when reports become available, you’re ready to go for continuous improvement. I see a lot of clients that try to use the lag between January 1 and the vendor’s delivery of reports as an excuse for not doing their part.

I write a lot about the physician space and what providers are thinking, but I had a chance to meet up with one of my friends who is on a major vendor’s implementation team. He always has good stories and our catch-up over cocktails did not disappoint. Early in my informatics career, I had to serve as a part-time implementation person because our hospital didn’t see the need to pay for a full-time clinician to do clinical informatics. I deployed small practices, doing everything from project management to re-routing cables under desks so we could streamline the check-in area. I was yelled at by physicians for no reason (other than they were angry about even having to think about touching a computer) and made friends with office managers who hoped that I could be a “physician whisperer” and get difficult providers in line. It gave me a new respect for the team that does implementations full time and the challenges they face.

My friend just worked with a practice that was recently acquired by a hospital system. Apparently his managing partners were much more keen on the alliance than he was, so he spent the first hour of their training time railing on the decision to join the hospital and his need for autonomy and to be able to do things the way he thinks is best for his practice and his patients. The hospital is enabling physician autonomy by providing then the option to simply dictate notes using voice recognition technology or to use scribes, as an alternative to template-driven documentation.

However, when the first patient of the day came in with a chief complaint of “my mother-in-law says I have dark circles under my eyes,” he demanded to know which template he should use in the system to complete the note, refusing to dictate the note on this uncommon reason for a physician visit, and stating that if he was going to have to use the system, it better be able to support him. I don’t know what to tell people about that situation other than to chalk it up to an end user who is reactive and illogical due to the stresses he is under. All we can do with people like that is to try to support them, try to show them different ways to document, and to hope they understand that the EHR is not going away.

He also shared the story of an “emergency go-live” that he was summoned to recently. Apparently a large provider network was adding an incremental physician in a new office and forgot to arrange for provider training and go-live support (the staff was being moved from other locations and already had knowledge of the system.) I sympathized with his road warrior tales as he tried to book a ticket with a few days notice and the client was refusing to approve it due to the high cost, leading to an impasse with the client and a delay in the go-live to when the ticket was more affordable. Clearly having a contracted physician idle in the office was a better ROI than buying the ticket.

He also does a fair amount of support for his company’s sales team and had a good story about a lead for a 200-doctor group that came in three days prior to the end of the quarter, but which his sales team actually thought they could close before the deadline. Of course it’s possible if the practice doesn’t want to ensure stakeholder buy-in or doesn’t want to fully understand what they’re getting into. At this point in the healthcare IT game, neither would surprise me.

What’s the wildest last-minute project you’ve seen? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/25/18

I’m gritting my teeth after the recent CareSync debacle, especially as it comes hot on the heels of so many other closings, layoffs, restructuring, and “right sizing” maneuvers across the industry. I realize that CareSync, like so many other companies that find themselves at the end of the line, was a start-up, but that doesn’t make its closure any more palatable for its customers or its employees. One of my clients had done business with them, and although the integration with the product moved at a snail’s pace, they seemed to be on the up-and-up and eventually did deliver what was promised.

When billing for Medicare Chronic Care Management services, there are specific rules that must be followed in order for the billings to be valid. For primary care practices caught in the “chicken or egg” phenomenon, where you have to collect more money to hire care coordinators to perform care management to make more money, a vendor like CareSync seemed like it was sent from above. They were willing to take on the care management functions for a share of the Medicare reimbursement, allowing the practice to provide the services without having to increase head count.

I know there were some bumps at the beginning, where patients in the practice were less-than-willing to talk to perceived “outsiders” who had access to their medical information. However, I had heard that after a while, CareSync had begun to virtually embed care coordinators within particular practices, so that patients became familiar with the personnel and it seemed less like an outsource function. I only had a couple of connections with them through my clients, and don’t know a lot of the details, but I can imagine the practices are wringing their hands about what to do next and how to get their data, even though CareSync is assuring everyone that the data will remain accessible. It’s not clear for how long it will remain that way, and the one practice I reached out to hasn’t heard anything from the company (not surprising, given the way it shuttered itself).

It’s surprising that the sale that was supposed to save it unraveled so quickly, with the potential buyer visiting with employees on Monday and the company closing down on Thursday. When things fall through in deals like this, you usually see the wheels come off during the due diligence phase or during the negotiations, not while the bride and groom are at the altar but just haven’t signed the wedding license yet. There have been comments about the company “running out of time,” but what exactly that means just isn’t clear.

In any of these layoff or closure situations, my first thought is with the people who were just let go. This case is particularly bad because the company has simply closed, with no severance packages offered, no provisions for insurance coverage under COBRA, and possibly not even a last paycheck or settling of other benefits such as flexible spending accounts. For people higher in the company who fully understood what it means to be part of a start-up, they are likely prepared for such a scenario. For lower-wage workers on the front lines, especially for those living paycheck to paycheck in a relatively tough economy, it’s devastating. According to surveys, as many as three quarters of full-time workers fall into that category. A full 40 percent of us can’t cover a $400 emergency expense, and it’s especially challenging for workers who are paying off student loans or have other challenging circumstances.

I have several good friends who have entered the ranks of the jobless this year, from three different companies and from different segments of healthcare IT. Most are in their mid-to-late 40s, but one is in his late 50s and has some family issues that make working a traditional nine-to-five job challenging. The odds of him finding a new full-time position with an employer willing to allow him to work flex time right out of the gate are very slim, especially in his part of the country. It’s hard to know what to say to a friend who has just lost his job, especially when you work together and you know it might be you the next time. There is a certain level of survivor’s guilt while you’re still trying to understand what you can do to be helpful. My friend said the hardest thing for him was having people tell him things like, “Now you can spend more time with your family member who needs you,” when they don’t understand that without income, a very delicate stack of spinning plates is going to crash down on them. Sometimes it’s better to just say, “I’m sorry, how can I help?”

I have another friend who now refers to herself as a “layoff magnet” since she has been “made available to the workforce” three times in the last five years. It’s not like she’s picking sketchy employers, but has been with several big players in the EHR space, only to have her project canceled, her division sold off, or her entire team downsized. She’s not even sure she wants to continue in the healthcare space, which really is a loss to the industry, but I don’t blame her. Other friends have gone to the automotive industry or financial sectors, with at least theoretically more stability. Another one got his real estate license, and although isn’t making as much money as he did in healthcare, feels like he has better quality of life. One is teaching middle school. I think he’s the gutsiest of them all.

For those of us who are fortunate enough to remain employed, it’s a good time to re-evaluate priorities and spend a few minutes thinking of how you would fare if they showed up at your desk with the proverbial cardboard box. Do you have an emergency fund? Do you have life insurance or disability coverage separate from what your employer offers? What would it take to get health insurance on your spouse’s plan or in the marketplace? Is your resume up to date? I hate to be doom and gloom, but given recent movement in the industry, it’s worth your while to get a plan in order, even if you never need it.

Have you been impacted by a layoff, reorganization, restructuring, or other synonyms? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/21/18

I was excited to learn that the Amazon-Berkshire-JPMorgan health care venture has selected Atul Gawande MD as its CEO. My first reaction was to wonder how he was going to fit this into his schedule, given his responsibilities as a surgeon, educator, author, and more. Although Gawande will assume the CEO position on July 9, he will be continuing in his roles at Harvard and Brigham and Women’s Hospital. He will, however, move from executive director at Ariadne Labs to the role of chair. Initially, Amazon-Berkshire-JPMorgan set a goal to identify technologies that would enable “simplified, high-quality, and transparent health care at a reasonable cost.” We don’t fully know what that will mean, other than we can probably count on checklists being involved. Given the scope of what it could mean, I hope he has some friends at Harvard working on a clone. I also hope someone comes up with a name for the company in short order.

Jeff Bezos, Amazon CEO, noted: “We said at the outset that the degree of difficulty is high and success is going to require an expert’s knowledge, a beginner’s mind, and a long-term orientation. Atul embodies all three, and we’re starting strong as we move forward in this challenging and worthwhile endeavor.” I’m a huge fan of Gawande’s work and recently finished his book “Being Mortal.” I found it to be thought-provoking, heart-breaking, and inspiring all at the same time. I’m looking forward to seeing how this progresses, and if he’s looking for a CMIO fan girl, I can be available at a moment’s notice.

Speaking of being a fan, the Honor Flight Network is right up there on my list. Its regional affiliates work tirelessly to enable our veterans to visit their memorials in Washington, DC. Unfortunately, space on flights is limited and many veterans are aged, ill, or otherwise unable to travel. Hospice provider Vitas Healthcare is helping bridge that gap, bringing the memorials to veterans in the organization’s care. These “Virtual Reality Honor Flight” experiences are pre-recorded visits led by retired military tour guides, and provide a 3-D tour of the WWII Memorial, Korean War, and Vietnam War Memorials, Women’s Memorial, and Arlington National Cemetery. The first virtual tour was conducted in Atlanta, and Vitas hopes to share this experience with its veteran hospice patients in Georgia and other states in the future. Kudos to Vitas for thinking outside the box and helping honor our veterans.

Given the tight margins in the healthcare industry, I’m surprised that patient-facing organizations don’t demand better solutions from their vendors, and that vendors don’t provide better options. One of my medical providers has separate portals for clinical information and bill pay, which makes very little sense from not only a patient engagement standpoint but from a practice management standpoint. Maybe there are contractual issues, maybe they think their vendor’s portal is poor on the collections side, or maybe they just don’t know better. I’d love to be able to ask in situations like that but don’t want to wind up enabling free consulting services while I’m freezing in a paper gown.

DrChrono has teamed up with Square to incorporate payment processing into the EHR. Practices can now save patient credit or debit card information, and can collect payments anywhere within the clinic workflow or remotely. Patient balances are automatically updated, which should improve cash flow with minimal labor cost. Existing Square customers can connect their accounts for a seamless transition. The ability to collect payment at various points in the workflow rather than just at the front desk or checkout is key, especially in smaller practices that may be maximizing staffing through cross-training or novel workflows. In my original solo practice, we didn’t have enough staff to have a check-out person, and the medical assistants often did the honors of booking follow-up appointments and taking care of labs and referrals before the patient left the exam room. Being able to have them collect and issue a receipt would be a plus, especially if you’re working with a system that can estimate patient portion due. I have used Square for various charity events and fundraisers and found it to be reliable. It’s also easy enough that a Cub Scout can set up the inventory and charge master functions.

Although I’m a clinician at heart, I love digging into financial and revenue cycle business problems. It’s amazing what goes on out there, particularly when a client doesn’t understand the power of their practice management system. I had one client that was processing refunds on individual patient encounters without checking to see if the patient had an overall patient balance. When the patient came in for a post-operative follow up and was erroneously charged a copay during the global billing period, they refunded the $25 (which incidentally cost them another $6.50 to have the check cut) once they received the communication from the payer. There wasn’t a process, automated or human, to identify the $900 balance the patient had outstanding on his surgery. It costs money to keep sending out paper statements, and the cost to the practice just grows. Those little things add up over time, and I’m always excited to be able to identify these opportunities for practices to fix their processes.

This week has been one of the more challenging travel weeks I’ve experienced in a while, with crammed airport parking lots, oversold flights, and weather delays that made me miss a much-anticipated dinner with a friend whose fair city I was visiting. It’s the height of family travel season, so as a road warrior I try to cut some slack to the families with fussy kids, people racing through the airport, and those who don’t know that your carry-on goes under the seat in front of you rather than trying to stuff it into the space below your own seat. However, there is no slack cut for healthcare vendor reps who act boorishly, fail to observe basic airport courtesies, or get sloppy drunk while wearing corporate-logo shirts and carrying logo backpacks. Be on alert folks – next time I’m going to name names. For now, we’ll just call it “bronchoscopy reps behaving badly.”

Does your company prohibit alcohol consumption while sporting the brand? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/18/18

One of the hot topics in the physician lounge lately has been telemedicine. Several of the larger physician organizations are pursuing strategies to incorporate telemedicine into their practices. It’s interesting to see the different strategies they’re taking, and given the similarities of their patient populations, I’ll be looking forward to seeing which one is more effective.

The first group wants to render the telemedicine services in-house because they think it’s going to be key for patient loyalty. They’re looking at different platforms that will enable their physicians to not only perform video visits in lieu of face-to-face visits in the office, but to perform after-hours services. One of the major drivers of the latter is trying to prevent some of the revenue leakage that’s currently going to urgent care and retail clinics. Of course, they pay some lip service to quality of care and continuity of care, but the conversations their decision-makers are having seem more about the revenue than anything else. The members of the group that are part of administration are completely on board with it, but the rank and file physicians aren’t entirely in favor.

The group is multi-specialty and leadership seems to think that the primary care physicians are more willing to consider telemedicine than the subspecialty physicians. Even among those willing to consider it, though, there are some doubts since many of the primary physicians have given up non-office practice. They no longer see patients in the hospital and haven’t taken call in years, preferring to use nurse triage services rather than being awakened in the middle of the night. For physicians who aren’t even willing to call out antibiotics for an uncomplicated illness without seeing a patient in the office regardless of the validity of the symptoms and history, it will be a huge cultural shift for them to sit at the computer or use their phones to speak with patients who are angling for medication or other treatments over the phone.

For them to be successful, they need a platform that will help them document what they’re doing. It will need to connect seamlessly with their EHR to ensure that the records of evaluation and treatments are not lost. The physicians aren’t going to tolerate having their documentation sit in a separate system or be unavailable to them in the future. They’re also going to have to figure out how to divide up the work and the revenue for the visits, because I can’t imagine every physician wanting to be on call 24×7. If the subspecialty physicians agree to it, they may adapt more easily since they’re already used to sharing call and taking care of each other’s patients without specifically being compensated for it since many of their procedures are billed on a global basis. Many of the procedural subspecialists have physician assistants that work with them and I can imagine the PAs will handle most of the telemedicine work.

Unfortunately, they’re on an EHR platform that doesn’t have telemedicine capabilities and hasn’t integrated with any of the telemedicine companies they’re looking at. Although the group’s leadership is eager to get started, I suspect it could take a year for them to really be ready to implement a solution. First they have to make a decision, then they’ll enter the contracting phase (which is never speedy for them), and then they’ll have to figure out the integration and implementation pieces. If they are smart, they’ll work on the cultural pieces and figure out the call schedule and compensation parts while the IT team is working their magic.

The other group has a similar patient population, but they believe their analysis shows that their patients are less concerned about loyalty than they are about being able to reach a physician quickly after hours. The physicians aren’t terribly interested in video visits as an alternative to office visits, but they do want to capture the revenue that they’re losing to after-hours competitors. They’ve elected to outsource telemedicine for primary care since that’s where most of the business is – it’s not like there are after-hours orthopedic surgery or neurology clinics that patients are going to, so the group is going to hold off on doing anything with their subspecialty physicians. They’ve found a vendor that will send documentation to them for all telemedicine visits, and although the data is going to be formatted as a document rather than as discrete data, they’ll be able to have the solution up and running in a matter of weeks.

If you’re an informatics purist, that might not be a palatable solution. But if you’re looking to solve the business problem of revenue leakage, they’re at least going to get a percentage of the revenue if they go about it this way, rather than getting zero revenue for patients going to urgent care or retail clinic facilities. They’re also contractually guaranteed to receive records from the visits rather than crossing their fingers and hoping they’ll get something back from the pharmacy clinic. Hopefully their understanding of their patients is accurate and there won’t be too many concerns about being cared for by physicians who don’t know them or their histories. I asked the physicians I was talking to whether the telemedicine company will have access to the EHR for medication lists or notes and they weren’t sure. That will need to be ironed out during the contracting process for sure.

Once they are established with the after-hours component, they have the option to expand how they use telemedicine technology. I think their strategy is prudent. Rather than waiting for the perfect solution, they’re at least going to dip their toes into the proverbial waters and see how it plays for their patient population. I’ll have to make a point of checking in with them in a couple of months and see how things are going – whether they were able to get through the contracting phase quickly and whether they were right in their assumptions about how their patients will receive their new offering.

Have you implemented telemedicine? How is it going? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/14/18

Mr. H has mentioned the rise of private equity in healthcare, most recently in this week’s news and morning headlines. I’ve seen it both from the consulting side and from the trenches as I’ve watched several of my friends sell their independent practices.

It’s amusing to watch their thought process. These are the same physicians who wouldn’t consider selling their practices to a local health system for fear of being beholden to “the man,” yet they’ll get in bed with private equity. Even before the ink is dry, some of them have seen their worlds completely reorganized with less of a focus on clinical quality and patient care and more of a focus on profits. I’m not sure why my colleagues are surprised when this happens. By definition, private equity firms are investment management companies,. Not healthcare companies, not charities, and certainly not physician-led organizations.

Allowing private equity investments puts you on a slippery slope, but selling to private equity moves you squarely into the realm of being a for-profit business, whether you want to put an altruistic healthcare face on it or not. I’ve been in consulting engagements (working for physician groups) where the PE firm brings in its own consultants and starts slashing and burning before even trying to understand the practice’s culture, patient population, and what they’ve tried to do already. I’ve watched dermatology practices converted to almost exclusively cosmetic enterprises over the protests of the former controlling physicians who actually want to practice dermatology.

There’s only so much money out there. It’s tempting to think that the PE firm is actually going to invest in you and grow your business the way you might have done on your own, but in reality, they’re likely to drastically change your way of life and profit will be the driving force behind most decisions moving forward. Caveat emptor!

I got a kick out of Jacob Reider’s comments about potential suitors for Athenahealth following the departure of Jonathan Bush. He discounts the possibilities of Apple, Cerner, and Microsoft, but gives 10 percent odds to Salesforce. He also throws the possibility of Roper/Strata Decision into the mix. I agree with Jacob that Strata CEO Dan Michelson gets the EHR market, and the last time I saw him in action, it made me want to go home and learn more about cost accounting – something you don’t hear too many people hankering to do in their free time.

From No Surprise Here: “Re: HDHPs. Check out this article about high-deductible plans keeping patients from accessing preventive care services. No surprise, right?” The link is from the American Academy of Family Physicians and cites a study from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. The study found that patients who have high-deductible health plans but who do not have health savings accounts to go with them are less likely to receive preventive care or care from primary physicians or subspecialty service providers. The authors looked at data from 2011-2014 for almost 26,000 privately insured adults in four categories: no deductible, low deductible, high-deductible plan with savings account, and high-deductible plan without savings account. Those in the latter category were 7 percent less likely to receive breast cancer screening and 8 percent less likely to receive a flu vaccine. Screenings for hypertension were slightly (4 percent) less.

Under the Affordable Care Act, preventive care is supposed to be exempted from out-of-pocket charges, including deductibles, but this only applies to certain identified preventive services. It definitely doesn’t apply to my breast MRI, which is indicated due to my very high lifetime cancer risk, and fortunately as a physician, I can afford to pay for it. But for those services that are explicitly exempted — such as well visits, screening tests, and vaccinations — many patients don’t realize they have access without a deductible, so they don’t seek care.

As I’ve said before, there’s not the greatest incentives for insurance companies to advertise all the services they cover at minimal cost to the patient since the return on investment is likely to be years down the road when the patient may be with another payer. One would hope the payers could adopt the attitude of “we’re all in this together” since the number of patients moving around is likely to impact all of them, but I haven’t seen much education to patients in this regard. Failure to have patients take advantage of preventive services that are shown to be cost-effective illustrates the lack of attention to public health efforts in our nation. We’re relying on the primary care workforce to identify all these gaps in care and take care of them, but if the patients don’t have a primary to see (the wait in my community is well over six months), aren’t eligible to be seen at a clinic, or just don’t go, then no one is handling it for the patient.

I’ve always found the AAFP to be a solid source of information, both as a physician and as a patient. I was sad to see their writeup on increased suicide rates across the US. Looking at data through 2016, the suicide rate has increased nearly 30 percent, with 45,000 Americans age 10 or older taking their own lives. We hear about the celebrities, but we don’t hear about the others, and we don’t hear enough about the people who tried and didn’t succeed.

One of the most heartbreaking situations I ever encountered was a pre-teen who tried to hang himself and was found by his parents, but not quickly enough, resulting in severe anoxic brain injury. I cared for him several years later due to some complications of his multiple medical issues. It’s never to early to talk about mental health.

In the times that suicide has touched me personally, for most, there was no warning. This is borne out by data that shows that in states reporting complete information for 2015, 54 percent of the time there were no known mental health conditions. The data also shows an increase in visits for non-fatal self-harm, rising 42 percent between 2001 and 2016. Firearms were used in 48 percent of cases.

Suicide is preventable. The article lists key strategies:

• strengthening economic supports (housing stabilization policies, household financial support)
• teaching coping and problem-solving skills to manage everyday stressors and prevent future relationship problems, especially in early life
• promoting social connectedness to increase a sense of belonging and access to informational, tangible, emotional and social support
• identifying and better supporting people at risk (military veterans, people with physical or mental health conditions)

As a side note, the next to last bullet does not refer to Facebook, Snapchat, Instagram, or other social media that can actually increase feelings of decreased self-worth and hopelessness. We’re talking real, interpersonal connections that might be made when people are actually together interacting like human beings. I see a lot of people who are well “connected” but have no one they can really turn to. Reach out to your friends, your neighbors, and the people you know and consider getting to know them better.

I’ll get off my soapbox now and get back to the business of working on a lab interface. Thanks for listening.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/11/18

I’ve been doing a bit of locum tenens work lately. It’s always interesting because it exposes you to not only new people, but different healthcare technologies. It also tends to invigorate my consultant brain, as I am exposed to all kinds of people and situations.

This particular assignment was a veritable cornucopia of adventure. I was looking forward to it, because the rural emergency department I signed up to staff has an EHR system I’ve not used before. It’s always good to see whether the grass is really greener on the other side of the fence or not, but in this case it was hard to tell whether there was going to be grass there at all.

Typically, my locum agency will send me some introductory training material or links to online training if the facility has a system that I haven’t worked with before. That lets me get up to speed before I have a crash course with a super user at the site once I arrive. Depending on the contract, the facility might allow a couple of hours for training or maybe even a half day. Facilities that have scribes may not include training time, but I think that’s a bad idea since the physician still needs to be able to use the EHR in at least a rudimentary fashion. Generally, I avoid those kinds of postings, because if the facility is too cheap to include a couple of hours for training, it’s probably going to be painful in other ways.

My agency said the hospital never sent any materials despite having been asked for it several times. They didn’t even provide a version number for the software so I could do a little research on my own. Without it being clear what product was in use, I didn’t want to waste time trying to scrounge up materials, since that’s a challenge in itself because vendors don’t exactly broadcast their workflows on their websites. Not to mention that even the most straightforward product can be customized to the point of being nonfunctional. I decided to just see how it went when I got there.

I arrived in town over the weekend because I wanted to be able to check out the area, stock up on groceries, and figure out my non-work plans for the engagement. In smaller towns, the lodging facilities vary greatly and it’s worth spending a couple of hours figuring out if you’re going to be able to stock in a week’s worth provisions, whether you can cook, or whether you’re going to be working with a dorm-sized refrigerator and a sketchy toaster oven. This was one of the better assignments, with a hospital-owned apartment that they use to house locums and visiting subspecialists from a children’s hospital that sends out subspecialists a couple of days a month. I knew I’d have the place to myself the first week for my 24-on, 24-off adventure.

People always ask how I handle those long shifts, and in a rural emergency department it’s not that big of a deal since there’s not a steadily high volume of traffic. It’s possible to nap during the day and often to get at least four hours of uninterrupted sleep overnight. However, when it’s busy, it can be scary-busy since you’re the only show in town and some of the cases are challenging – patients having strokes when the nearest stroke center is hours away, patients having heart attacks, and patients with major trauma.

Often in the smaller facilities, attending physicians come into the emergency department to work up their patients, which is great as far as feeling like you have backup along with generating a sense of belonging. People also tend to do double-duty at times, such as seeing pediatric patients when they’re not a pediatric subspecialist or covering subspecialty areas that are bit outside what their specialist colleagues would practice in a larger city. I learned this all too well a bit later in the engagement.

The first day of work was uneventful, with me getting my badge, signing paperwork, having a four-hour block of training with a super-user, and then working 10 hours in the emergency department as a “training shift” with one of the full-time emergency physicians. The patient mix was pretty routine, with asthma exacerbations, pneumonia, a motor vehicle collision, some stitches, and a broken arm following toddler vs. trampoline. They were handled the same way I’d handle them in the urgent care at home, and patients didn’t mind my slowness as I documented in the room with them. I went home, ready to hit the sack and return the next morning for my first solo shift.

The next morning was pretty slow as far as emergency patients, although I was called to the medical / surgical floor a couple of times to assess patients who were having issues and there was going to be a delay in their own physician being able to get there. Most of the physicians work out of an office suite that is attached to the hospital, so it’s not a frequent problem during the day unless the attending physician has a day off without close coverage. It was kind of fun feeling like a resident again, when we could be called to see a patient on any floor for any issue, although I was much more comfortable reliving those non-glorious years in a sparsely-populated 60-bed hospital as opposed to the 600+ bed hospital of my residency days.

When I got back to my cubby after one of those sojourns, I found a printed email and packet of documents from the ED nurse. Apparently there had been an EHR upgrade over the weekend and they were just sending out the vendor’s release notes – three full days after the upgrade. This was a new one for me since I’m used to being on the other side of the equation, translating the vendor release notes into an actionable document for my end users. Maybe the unmentioned upgrade was the reason they wouldn’t send over any documentation or training materials prior to my arrival.

This particular document was not only less than timely, but included documentation of features that clinical users normally don’t see, like the charge master setup screens, along with features that the hospital didn’t even have live, such as patient portal statements and payments. Did I mention the document was 24 pages long, in spreadsheet format, and printed landscape with items wrapping from page to page? It’s unlikely that physicians are going to sit and read that, not to mention the level of distraction with irrelevant features.

The only pieces that were important to me were the fact that a medication database update was installed as was a formulary update, and those were both summarized in the email. The rest of the features were specific to other disciplines, but it was fun to see what other vendors do as far as documentation. Pro tip: less is more.

Mid-week, I was invited to attend a medical staff meeting, which seemed like a great chance to meet other physicians as well as to score a dinner I didn’t have to cook myself or eat at a local restaurant where everyone else knows each other. In reality, it was a prime opportunity to see the kind of turf war I hadn’t seen in years.

In a large city, people are always competing for business and insurance is always changing, so when patients move around, it’s not a big deal. In a small community, though, where there may only be two physicians in a given subspecialty, “poaching” may be taken as a personal affront. There are complex unwritten rules about non-solicitation of patients, even after physicians cross-cover each other’s patients, and apparently someone had stepped out of line. I thought it was going to come to blows, but the president of the medical staff did a great job disarming them. Although he is young and the squabbling physicians were his senior in several ways, he used some great de-escalation skills and leveraged other leaders in the room to calm the situation. It was like being in a role play for management training.

Over the first weekend, I had my first “pack and ship” experience, which basically means the patient is critically ill and needs to go to a facility with more capabilities, either by ambulance or by air. The facility had a great checklist and the nurses were outstanding, making all the phone calls and getting the paperwork ready while all I had to worry about was the patient. In situations like this, the first thing the physician should do is check his or her own pulse. At moments I did have to remind myself to breathe, but in less than an hour, the patient was on his way to a higher level of care. I’ve spent more time on the receiving end of those cases and have seen people at the tertiary care center belittle the work that’s done at smaller hospitals, but I have to say my team was first rate.

The second week was largely uneventful, with a steady flow of respiratory problems, orthopedic injuries, and minor trauma. The one thing I noticed was that during the time I had been there, the patients were much sicker than I saw at home and often had been referred in by their physician, who called ahead for them rather than just having patients show up. The primary physicians and orthopedic doctor in this community tended to see many walk-in patients every day and patients were happy to wait in line to be seen where they were known, rather than roll to the emergency room first. You knew when they sent someone over that they needed help – patients weren’t just coming out of convenience or lack of being able to be seen elsewhere. I had expected to see more minor sick cases since there isn’t an urgent care or retail clinic anywhere around, but it just didn’t turn out that way since they were being seen at the office.

The uneventful nature of the week came to a screeching halt, though, during the overnight portion of my second-to-last shift. I was napping in the ED call room when one of the nurses threw open the door and flipped on the light switch. Since they would never normally do that (these were nurses that apologized profusely when they had to wake you), I knew something was up. She threw me a set of shoe covers and said, “We have to go to the OR.” I knew something was up. We headed to the operating suite, where an emergency C-section was about to take place.

Long story short and intentionally left vague, I was asked to pinch-hit for a provider who was called in but couldn’t make it to the hospital. In a case like this, I suppose a family medicine doc turned ED locum tenens is better than no one when you need multiple licensed physicians in the room and lives are possibly at stake. It’s amazing how your reptilian residency brain kicks in. I started to scrub while thinking through what might happen next. My ears caught up to my brain as the staff told me which providers were already in the room and who was on the way — they only wanted me there as a precaution. I must have missed that on the way over and was glad to hear it, but still on an adrenaline rush.

I was gowned and ready, but mom and baby were stable. I got to stand there with a surgical towel over my hands, watching a midwife and a physician assistant give directions and prepare the patient until the rest of the team was in place. You can bet that my pulse slowed considerably at that moment. I was ready to head back to the ED once everyone was scrubbed in, but they asked me to stay just in case they ended up needing an extra set of hands with the baby.

As much as health IT has evolved, C-sections haven’t changed much in the decade since I last saw one, and we’re still using the Apgar score after 66 years. I did wind up helping a bit and was still hopped up on adrenaline when I made it back to the ED, so I stayed up chatting with the night nurse. Apparently, similar situations happen more often than you’d think, with weather being a challenge during the winter as well as the chance of two patients needing to unexpectedly go to surgery at the same time. Many medical leaders have the luxury of not thinking about that kind of scenario, but it was a good reminder of the fragile system of care that many Americans live with every day.

My last shift in the ED brought a cake, a couple of jars of homemade pickles and jelly to take home, and a goofy picture of me with one of the nurses at the local sale barn after I had just stepped in something less than floral but decidedly fresh. Overall, it was a great experience, and I hope they request me the next time they need a locum. At least then I’ll know what EHR to expect and I’ll remember to bring an old pair of boots.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/7/18

Quite a few of my clinical informatics colleagues do public health work and the discipline is certainly part of the informatics board exam. I enjoyed this article mentioning the return on investment for public health interventions. As the article notes, funding for public health is low because “the private sector can’t make money on it.” Many of the interventions are long-term plays, such as the return on investment for vaccinations or disease prevention. In many situations, by the time the “savings” happens the patient will be on Medicare, so unless there’s a shorter-term benefit payers might not be willing to spend the money.

Given the current mobility of our work force, employers are challenged to see return on investment for the longer-term conditions as well. Even in this high-tech day and age we still struggle with things like safe drinking water. It’s not just in underdeveloped nations – it’s in places like Flint, Michigan. Even if spending on public health didn’t have demonstrable ROI, it’s something we should simply consider as the right thing to do for the future of humanity.

I just finished reading Atul Gawande’s book “Being Mortal,” which should be required reading for broad segments of the population, such as people who have elderly relatives or anyone who might at some point be elderly, which is (hopefully) most of us. I’m a huge fan of his work and now that I’m at a point in my life where handling affairs for elderly relatives is a reality, it was a timely read. It’s good for those of us who live on the bleeding edge of all kinds of healthcare technology to think about the value of interventions and, as Gawande says, “what matters in the end.”

Speaking of reading, one of my favorite professional journals is Family Practice Management, put out by the American Academy of Family Physicians. Historically, family medicine residency programs have put an emphasis on being able to actually run a successful practice, not just learning the medicine, and the journal cuts to the chase on many of the financial issues that primary care physicians face today. The journal’s online “In Practice” blog addressed quality reporting this week, simplifying some principles that I know many physicians are not thinking about when they consider MIPS quality measures reporting.

Here’s the Cliffs Notes version for those of you who advise physicians in this area. Because they care about their patients, physicians are often tempted to report on measures that have clinical significance to their practice, or on measures that they know they are doing well on. However, this doesn’t take into account the fact that MIPS quality reporting is based on performance to a benchmark and that decile scoring is involved. Even though a provider might do the “right” action 90 percent of the time, which sounds like good performance, if the rest of the world is performing that action 95 percent of the time, the provider may receive fewer points than they expect because they’re actually a low performer relative to benchmark. Some of these measures are also considered “topped out,” where the benchmarks are high enough that it’s extremely difficult to make it into the top decile.

Physicians may also not be aware of bonus points available for high-priority measures or certain reporting strategies. For providers trying to navigate MIPS and other programs on their own, it’s very challenging to understand all the nuances. I would encourage them to reach out to their professional societies to see what guidance is available, whether by specialty, region, or practice type.

The American Academy of Family Physicians does a fair amount of advocacy work for docs in the trenches. I applaud their recent efforts to encourage major national laboratory vendors such as LabCorp and Quest Diagnostics to improve reporting mechanisms so that data is more easily shared among care teams in value-based care paradigms. They’re also encouraging the labs to facilitate data sharing for small practices so they can more easily stay in the game and not be burdened by interface and other costs.

I’d love to see AAFP get into the fray with them (along with many other labs) about reporting LOINC data with results. LOINC codes are critical to strong performance in several reporting arenas, and when codes aren’t sent, it can result in low data quality or large amounts of manual work for practices to try to map results to codes. The latter can be problematic due to many LOINC codes for tests that are similar but not identical, resulting in errors.

I used to provide LOINC mapping for my clients, but there ended up being so much back-and-forth with the performing laboratories and too little information available in their online test directories to the point where I couldn’t make it a cost-effective offering. Ultimately, the performing laboratory is in the best position to know exactly what test they are performing and which methodology is being used, which drives the code. I’d like to see reference labs be mandated to provide the codes in results transmissions so that providers can have solid data.

Failing to require labs to send LOINC codes reminds me of requiring physicians to e-prescribe but not mandating that pharmacies deploy systems that can accept electronic prescriptions. Our patients deserve better and it’s time for non-provider parts of the healthcare system to start ponying up.

It’s never too early to begin shopping for great shoes for HIMSS parties, so I was delighted when a friend sent me a pic of these sparkly numbers. Alas, they’re halfway across the country, so I won’t be getting them, but they give new meaning to the term “reach for the stars.” Speaking of HIMSS, now that it’s summer it’s probably time for me to think about booking my hotel so I don’t get stuck riding the shuttle bus from somewhere in conference Siberia.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/4/18

From time to time, I get together with one of my colleagues from residency to catch up on what’s going on in the primary care community. We used to be able to make it happen quarterly, although as her practice has gotten busier and as her children have gotten older, it’s more and more difficult to do. We last got together almost a year ago, and then had a flurry of rescheduling and canceling until we finally arrived at the following summer.

Of the residents I trained with, she is one of the few still practicing traditional primary care. The rest of us have either hung it up entirely or moved into semi-related careers in urgent care, emergency medicine, sports medicine, aesthetic medicine, telemedicine, or clinical informatics. We were finally able to catch up this week and dish a bit about the healthcare landscape in our fair city.

We both initially worked for Big Health System, both in start-up practices in relatively underserved areas where the economics proved to be unsustainable. I felt a little guilty because she was a year behind me in training and I had recruited her to work in a practice situation that was similar to my own, and because neither of us could ever “make it” given the economic model used by the health system. Typically, a newly employed physician is on a salary guarantee and is expected to break even in the first few years of practice. At the time, hiring hospitals were offering modified “eat what you kill” salary arrangements, which if you did the math academically using average reimbursement for the area, seemed very doable.

Despite being more savvy than some of our peers, both of us wound up in the same trap as far as payer mix. As straight fee-for-service providers, we were negatively impacted when both local auto plants closed and many of our patients lost their jobs along with their well-paying insurance.

I had already been forced to limit the number of Medicaid patients I saw after coming to the conclusion that having 30 percent of my panel leading to reimbursements of $24 per visit wasn’t going to be economically sustainable. I did make exceptions for patients who were already established, but wasn’t taking new Medicaid patients, which created a crisis of conscience for me as I was caught between economic realities (getting off that guarantee so I could start paying back my student loans) and caring for people as I thought I had been called to do.

My employer was ill-equipped to deal with self-pay patients, barely offering a discount and making it difficult to care for people who didn’t have solid commercial insurance or Medicare. Although my visit numbers and my billings were great, my collections were terrible, and I was faced with a steep drop in salary at the end of my guarantee period.

Digging into the finances revealed the fact that my employer was charging the costs of building my office against my practice’s cost center, which although not specifically mentioned in the contract, was apparently allowable. Had I taken the easier route and joined an existing practice with no build-out required, I wouldn’t have had any construction costs attributed to me and the cliff I was about to fall from would not have been quite as high. Fortunately, my colleague had gone into an existing space while her office was under construction, so she wasn’t getting hit with the build-out costs and had time to maneuver before her guarantee ran out.

Meanwhile, we were watching our friends who had gone out into affluent communities beat the guarantee in barely over a year since they had a stronger payer mix and fewer patients with public aid and bad debt.

I was offered the opportunity to transition to clinical informatics, working a bit of urgent care on the side. She didn’t have that option, so she terminated her contract and decided to take her chances with the non-compete clause and work urgent care while she looked for a full-time position. She was quickly snapped up by a rival health system, who offered her a position outside her non-compete radius and with a better compensation plan.

Her new employer had realized that they weren’t going to be able to recruit physicians into relatively underserved areas (her new position was rural) without finding a way to make the finances work. This organization used more of a RVU-based compensation model, where physicians were paid more equitably based on the work they did rather than by their payer mix. They also had more of their salaries attributable to quality scores. Looking back, they were much more on the forefront of pay for performance than we had been at Big Health System.

Fast forward more than a decade. She is still in the same practice, but coping with the ups and downs that many physicians do. First, there was the EHR conversion to Epic, which created a lot of upheaval and several years of slow progress while the system tried to synchronize content and features across a multi-state environment. Then, there was the birth of Meaningful Use and its respective pains and the rise of Patient-Centered Medical Home and other incentive programs, all of which put stresses on providers. She and her partners are trying to have a semblance of work-life balance when they’re being asked to better engage patients by providing expanded evening and weekend hours, by delivering after-hours telemedicine services for their regional physician group, and ensuring their quality numbers are at the top of the scale.

At her age, she should be a good two decades from retirement, but she’s seriously contemplating a change now. In addition to the challenges already mentioned, she cites her biggest struggles as low health literacy and socioeconomic issues – but the challenges are at two different ends of the spectrum.

At one end, there is the stereotypical situation where patients lack education about health-related issues and lack the means to address some basic needs. She has patients in her semi-rural community who struggle with food insecurity, transportation issues, lacking support systems, and more. At the other end are relatively affluent patients who have been streaming into the community to take advantage of inexpensive housing and who have much more economic means. However, they have similar levels of low health literacy, but due to insurance coverage and the perceived need for services, rank as “high utilizers of healthcare” similar to their lower-status peers.

She finds the latter group more frustrating, as they seek care for many conditions that could be treated at home and with over-the-counter remedies. They tend to use urgent care and retail clinics for convenience, demand care within hours of having any kind of symptom, and often want tests performed when a history and physical would reveal the answers. She’s tried to get many of them to use the after-hours nurse line rather than urgent care or the emergency department, but hasn’t been successful, leading to increased work handling coordination and transition of care issues the next time these patients present to the office.

We talked a little bit about moral distress. With one group, she feels she is delivering poor care because they lack resources. With the other group, she perceives the care as poor quality because it’s fragmented and sometimes the patients frankly receive too much care. It seems that dealing with these polar opposite situations adds stress of its own, with too few solutions in sight.

For a while, she entertained the idea of direct primary care or a retainer practice, where she could define the terms of care as part of the agreement, but was not willing to give up serving her less-economically advantaged patients. She’s been having thoughts about trying to start some kind of educational foundation or organization that would specifically target health literacy and appropriate care issues, but it’s hard to find seed money for something like that, especially when one of your constituencies is well off.

We talked a bit about the idea that “too much care” is relative, that as we empower patients, it’s up to the patients to decide whether they’re receiving too much (or not enough) care and to decide when, where, and how they want to engage with caregivers. It’s a tough spot to be in, especially when you’re trying to manage a business, raise a family, and control your own stress level.

I didn’t have any good advice for her other than to validate her feelings and talk about different approaches I’ve seen in my travels. It’s a shame that a physician with so much to offer feels like she is at a crossroads like this, with few choices when she still has a potentially long practice career ahead of her. The health systems in our community tend to suffer from shiny object syndrome, ranging their attention from telemedicine to school-based clinics to medical home to employer-based clinics to retail clinics and beyond. Neither of them seem to be acting very strategically, which adds to the madness of the system.

What we’ve arrived at is a two-tier system without admitting it. There’s the “public” safety net system and the “private” alternative for those who can afford insurance. We pay lip service to quality and value-based care and the providers and other clinicians are caught in the middle somewhere.

I’d love to hear from people in progressive healthcare systems or delivery networks how they’re addressing this and whether they can make it work, keeping all of the parties engaged and reasonably satisfied (at least enough to keep them at the table). Have you figured out how to keep primary care physicians from leaving practice before they hit the tender age of 50? Do you have an answer in your Magic 8-Ball? Leave a comment or email me.

Email Dr. Jayne.

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.

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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.

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