EPtalk by Dr. Jayne 3/29/18

The obnoxious post-HIMSS vendor behavior I mentioned last week is getting worse. One vendor was already harassing me, having left messages every day or two by both phone and email. After a week of this, one might assume that your potential sales lead is cold and give it up. This guy hasn’t gotten the message, though, and is now leaving messages that don’t even mention the company name. Maybe it’s intentional, like I will assume he’s someone I know and return the call, or maybe it’s just sloppy. But, “Dr. Jayne, it’s Dave. I’ve been trying to reach you. I’ll try again tomorrow if I don’t hear from you” isn’t terribly professional. I recognize the number from last week’s harassment and you’re not going to hear from me.

My suggestion for salespeople: if your lead seems cold, leave one last message and include who you are and what you have to offer, then give it a rest. “Hi, Dr. Jayne, it’s Dave Smith from HotVendor. You might remember speaking to us at HIMSS about our new retina-scanning drug inventory system. We’ve tried to reach you and I know you’re busy, so if you’d like to connect, you can reach me at 888-555-1212 or by email at DaveSmith@hotvendor.com and we thank you for your time.” That message is more likely to get filed for the next client I run into that needs your particular solution.

A few other vendors have called but all have left reasonable messages, so no complaints about those. Also, plenty of emails even from vendors I don’t remember talking to or visiting. Those are interesting, because I almost always visit their website to play the “what was I thinking” game to try to remember if they caught my eye with their advertising, booth presence, or product. Even with the website, sometimes I can’t figure out what a vendor really does. That always makes me chuckle, so it’s a good mood booster.

Speaking of websites, Mr. H mentioned the announcement of Canvas Medical entering the primary care EHR fray. I had mentioned them a few weeks ago, but not by name. I received a mailing from them pre-HIMSS, but they didn’t mention HIMSS and weren’t there. I thought the timing was odd and would have wanted to look at their product. I’ve checked their website a couple of times in the last few weeks because they did get my attention and found it not ready for prime time, with the blog page having several “lorem ipsum” type placeholders. It looks like they cleaned it up in preparation for yesterday’s actual launch, which is good, but makes me question why they did a direct mail piece directing users to the website if they weren’t ready to roll.

I pulled out the original mailing that I had filed in the “keep an eye out” category. I noticed that they use “EMR” rather than “EHR” to refer to their product. Not sure if that is intentional, but might be since it doesn’t look like they offer a patient portal or maybe they just don’t mention it. They’re up to six practices mentioned on the website,  but one is using the Medfusion portal (along with “non-secure email and Skype”), three appear to have no patient portal, one kicked me over to ihealthinterview.com, and the remaining practice doesn’t seem to have a website. The company is very small and I don’t see anything about certification, which makes it a no-go for many practices. They do offer a MIPS guarantee, stating “if you receive a negative adjustment, we will cover it,” but it’s not clear how they’re executing this. Having worked with a startup EHR that died a rapid death due to lack of certification, I wish them well.

Another item that reached the end of the line was the proposed merger between Providence St. Joseph Health and Ascension that would have created the largest hospital operator in the US seems to be over. It appears the organizations will work independently to restructure, feeling that a merger would have taken attention away from the need to restructure as health care deliver moves away from hospitals. Both systems also appear to want to continue to grow, with Ascension acquiring Chicago-based Presence Health earlier this month, even as its CEO told employees via video last week that it will focus on outpatient care and telemedicine.

Ascension has already slashed spending over the last couple of years and plans to save more money by “aligning its pay practice,” which I can tell you from experience at other health systems won’t involve bringing underpaid workers up to the level of their peers. The employee communications mentioned that executives have already taken pay cuts and hinted that employees would be asked to do the same. I touched base with one colleague in an IT-related department and people are already buffing their resumes.

I read with interest Mr. H’s comments on privacy and security and figuring out how much Facebook and Google know about us. I’m relatively “off the grid” despite my being immersed in the tech industry. The fact that I don’t use location services on my phone unless absolutely necessary and rarely identify where I am makes it trickier to know where I’ve been. Since I got new Internet service, my PC thinks it’s in Wisconsin for some reason, so that adds to the mystery as well. If Facebook really wanted to understand our preferences and make sure we saw marketing, maybe they’d give us features such as “hide posts about recipes even if they’re from people we like” and “hide pictures of abused animals.” I have a couple of people I dearly love, but they post so much in these two categories, I worry that I’ll miss something important from them.

Speaking of missing something important, I had the unsettling experience this week of learning somewhat via Facebook that a colleague had passed away. Someone had posted earlier in an email group that we’re part of that he had no-showed a meeting on Monday, which was unusual for him, and wondered if anyone had heard from him. I had corresponded with him last month about an upcoming meeting, but hadn’t heard anything since. One group member had met with him on Friday and things seemed fine. A few hours later, another email popped up with a screenshot from his Facebook page, where someone posted “Can’t believe the news, RIP.” Since he joined the gig economy as an independent contractor, it’s not like there was a corporate office that would notify his customers, so I guess finding out this way makes sense. Emerging technologies and scattered social networks make for some uncharted etiquette waters at times. My condolences to his loved ones, wherever they may be.

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Curbside Consult with Dr. Jayne 3/26/18

I received quite a bit of feedback on last week’s piece that mentioned the concept of moral distress. Someone experiences moral distress when they know there is a “right” thing to do, but are blocked from pursuing it by institutional constraints. It was previously spoken of in clinical circles and can contribute to burnout. We’re seeing more and more people experiencing these symptoms even if they’re in support roles as opposed to being frontline clinicians.

One reader noted:

Spot on. Having been in the vendor side of the house for over 40 years, I’ve seen the challenges of performing daily duties grow exponentially, especially in the clinician environment. Volume over value is one direct contributor to this headache. As long as earnings per share remain king in the mind of the C-suite (indirectly, but this is how the folks on the carpet think if you ever have a meaningful discussion with any of them) and maintaining decent margins is the most important focus, the system will never be people-centric. Empowering mid-level leadership has been the nemesis of success for many, many years. We have a disease management system in that generates $3.7 trillion annually; makes this system the largest employer in the domestic US (outside of the US government); and is trying to transition to a true healthcare system. Until the right entities and people are brought to bear and focused upon, status quo will remain king.

With the push towards analytics and true disease management (capturing the most expensive patients and figuring out how to care for them in a way that is less expensive) we’re starting to see some movement, but not enough. Many primary care practices are caught in the chicken-or-egg situation where you have to have money to buy software and hire care coordinators to manage complex patients to get paid for care coordination. Even the “incentives” available as CMS payments don’t cover the overhead of actually performing the care coordination for many practices, and unless you’re involved in full risk contracting, you’re not likely to see that money returned to your practice as “savings.”

On the software front, I see many vendors pushing slick-looking analytics platforms, but they’re not able to deliver the education needed to help practices actually move the needle. It’s one thing to learn how to identify the patients and document on them, but it’s another thing entirely to learn how to interact with those patients and come up with creative strategies to work around their barriers to care. Most of the care coordinators I know are magicians, pulling from a bag of tricks to fight complex situations involving lack of financial resources, unemployment, neglect, depression, anxiety, abuse, trauma, food insecurity, and more. When the frontline team caring for these patients doesn’t have enough “tricks” in that bag, it really doesn’t matter whether you’re working from the shiniest application or from the much-maligned Excel spreadsheet to track your patients.

Still, people are working hard to try to minimize the problems that care teams face. A reader on the Informatics side of the house had this to say:

We implemented quarterly release cycles. We first defined what we considered support and maintenance (change a price on a fee schedule, update a med on an order set, add a new employee to a work queue, etc.) with specific turnaround times. This was ongoing work that was on a daily o rweekly basis. Everything else, including optimization enhancements and projects, were on a strict quarterly release cycle. Originally, we implemented this as a way to achieve economies of scale with our build, testing, training, updates to policies and procedures, etc. For example, prior to release cycles, we ran the same test script multiple times to test a variety of build items for different projects. With release cycles, we streamlined this so we only had to run the script once that would test the build for those same projects. We found that we gained a significant amount of capacity back to those same teams.

In an employee engagement survey conducted approximately nine months after the implementation of release cycles, we noticed an almost 40 percent improvement in scores related to stress, burnout, and anxiety. It was the best improvement across the entire survey. Because of the significant increase, HR conducted many follow-up surveys and focus groups to try to better understand the increase. One of the major contributing factors was the implementation of the release cycles. When asked why, people (nurses, physicians, IT, etc.) almost universally said that the predictability of the release cycles (we started a new cycle the first Monday of a calendar quarter and would go live on the last Tuesday of the quarter) allowed for better change management and to plan their schedules accordingly. Part of their stress levels was that people felt everything changing constantly on them from a day-to-day basis. The release cycles allowed them to better understand the changes to their workflows and adopt the new change before introducing additional changes. We never thought about release cycles in those terms, but it became a significant factor in its continuing success. In fact, when we had to deviate from our cycles for ICD-10 implementation due to external factors, it created significant pushback from operations. I just wanted to share my experience for a potential strategy that other organizations might find useful.

Well said, and solid concepts. I continue to see organizations (and vendors) who don’t have a well thought out release strategy. Or perhaps it’s well thought out but poorly executed. From an end user standpoint, I see the best adoption when break/fix is separated from enhancements and new features, even though that might mean a bit of overlap in training strategies. It’s tempting to say lump it all together, but that can mean users spending more time on broken platforms while trying to save a buck.

Employees are more resilient than we think as far as being able to compartmentalize different types of change. In my CMIO life, we rolled out “urgent fixes” such as new drugs or charge changes after hours on a relatively real-time basis, with notification to those who had logged the issues. The rest of our fixes were deployed monthly, with communication of the emergency items added to that communication so that we weren’t bombarding general users with all the “urgent” items. The monthly package was always deployed the same night as the physician IT advisory board meeting, so that we could re-communicate the changes (and because the analysts were already staying late, so we could save on the catering by feeding both crews at the same time).

Major upgrades to the application happened twice yearly and we opted to hold some workflow changes until those releases — even though they may have been patched earlier — in the event that we thought more intense training was needed for successful adoption. Those major releases included Web training, in-person training, and 1:1 training where needed, whereas the monthly patches were basically described in newsletter format.

It worked well for us and seemed logical, so I was surprised when I went out into the larger world and saw the mess that some groups make of application change management. One organization just threw patches on the system every Thursday night, regardless of whether the patches addressed issues of record. There was no communication to end users. Another communicated every little thing, whether it was relevant or not, causing the users to miss important issues.

Of course, if you’re on a vendor-hosted platform, you might not have the choice to identify how and when you’ll be updated and upgraded. In my clinical world, I often come in to some surprises regardless of how well the team has tried to communicate them. Usually they’re small, though, and our clinicians are adaptable, so not having that level of control isn’t as major of an issue as one might think. Of course I might feel differently if this was software for the operating room, the ICU, or another high-stakes environment, but for urgent care, it works.

I always appreciate hearing from readers, especially when there is concrete advice involved. How is your organization working to reduce burnout? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/22/18

It’s been a wild week of post-HIMSS email madness, with most of the vendors that I asked to “give me a week to recover before we connect” having complied with my request. It’s a new strategy I tried this year and it seems to have worked, although a couple of companies did call or email the first business day after HIMSS.

You have to give them credit for working their leads, but one company’s contacts have bordered on the obnoxious – every two days with escalating language about our need to connect, and by both phone and email. You can bet that I’m not eager to connect with someone who doesn’t understand that people don’t always respond right away and that getting frantic about it isn’t going to build a potential business relationship.

Over the last two weeks, I’ve visited a couple of long-term clients to check in on their strategic planning for the next year. Organizations vary in how good they are at this process. Some that I’ve worked with do an outstanding job, with a major annual planning retreat each year and then quarterly or monthly follow-ups. They’re a joy to work with since they set their dates a year in advance to ensure everyone can attend and that agendas are productive, since they typically pull key provider stakeholders out of productive clinic time to meet their objectives.

Others are pretty bad at it, with last-minute attempts to pull people together and slapdash agendas. The worst don’t do any strategic planning at all and then wind up in a frenzy as they struggle to meet regulatory or other deadlines.

I was contacted by one of these organizations this week, who is looking for last-minute help with clinical quality measures reporting which is due very, very soon, as in “nine days from now” soon. I have a handful of groups reach out to me every year and all are in the same dire straits. One version of the tale of woe has the person who used to be responsible for it leaving the practice, out on medical leave, or something similar. Another version has someone running the reports regularly, but not telling anyone the numbers are bad until the end of the year and it’s too late to correct workflows. When the physicians find out, they go ballistic and I get the call. The third version has a group who knows their numbers are bad and workflows are problematic, but wants someone to “move” the data because it’s all somewhere in the EHR but just not in the right fields for reporting tools to pick it up.

I’ll help the first group as much as I can, but the rest are on their own for this reporting cycle. I’m happy to contract with the latter two to try to remediate them for next year, but I’m not going to tackle their dumpster fire (which incidentally was added to the Merriam-Webster dictionary) this year.

I enjoy reading posts by the rest of the HIStalk team, especially those that mention startups. I was baffled, however, by this piece sent to me by a reader, where startup SteadyMD refused to comment on $2.5 million in funding. Maybe they’re going for an “International Man of Mystery” vibe, but as an industry follower, it seems unusual.

In the “truth is stranger than fiction” category, I ran across this NPR piece about a reporter who had an interesting experience while working on story featuring Theranos. I’ve heard of people going off the rails during an interview, but the alleged pulling of a fire alarm to force the evacuation of a pharmacy and stop the interview is a new one.

April 16 marked Match Day, where tens of thousands of medical students are herded into auditoriums to learn their fate for the next three to five years in front of classmates and loved ones. It’s a variable experience, with some people whooping for joy and others seeing their dreams crushed. Many of us have mixed feelings about it. My medical school had a keg delivered to the auditorium lobby, so you were either celebratory or partially anesthetized by the time the envelopes were handed out.

This year’s Match set a new record, with over 37,000 applicants participating. The match results are always telling as far as physician workforce and the popularity of specialties among US medical school graduates. Programs filling with more than 90 percent US grads: interventional radiology, orthopedic surgery, integrated plastic surgery, radiation oncology, neurological surgery, and otolaryngology. The three main primary care specialties were in the “programs that filled with less than 45 percent US grads” category: family medicine, internal medicine, and primary pediatrics. The fact that US grads don’t want to go into these specialties should be very telling. Congrats to my neighbor who matched in a highly competitive specialty, even though he will be wading through lots of snow for the next six or seven years.

The highlight of my week was being on a conference line today with the funniest hold music I’ve ever heard. UberConference allows account owners to select their hold music, with one of the options being a song about being stuck on hold on a conference line. I’m sure it might have the potential to become annoying, but today it was just what I needed after having spent hours and hours on the phone yesterday. The worst hold music I’ve experienced was a current events news program that unfortunately was giving updates on a mass casualty situation that didn’t set the stage for a productive call, since participants were still in shock from what they had been hearing. The second-worst was music sounded like it was better placed in an adult film.

Apparently I’m not the only person with an interest in hold music, because a quick Internet search brought up several articles. I had forgotten the quirky Cisco default hold music – if you’re looking for an hour-long recording to jog your memory, you can find it here. I got my hopes up for an article that claimed to have 11 recordings of terrible hold music, but the links were broken so I missed out on that particular hall of shame.

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Curbside Consult with Dr. Jayne 3/19/18

Many of the physicians and other health professionals I work with during consulting engagements are suffering from burnout. As I work with troubled organizations, I am finding an increasing number of non-caregivers experiencing symptoms of burnout as well. I’ve recently partnered with an executive coach to work on strategies that we can use to better assist these organizations. It used to be that teams became stressed during times of change or times of institutional uncertainty, but we’re seeing teams that are now under stress all the time. Budgets have been cut, positions have been eliminated, and remaining workers are expected to absorb the work of others regardless of their capacity for additional tasks.

Healthcare informatics work is becoming more high stakes as systems are more deeply intertwined in care delivery. It’s not just about keeping systems in a state of high availability anymore. Now, healthcare IT teams are expected to monitor clinical quality calculations, enable reporting that has significant financial ramifications, and monitor updates and patches to ensure there are no changes to critical business processes or reporting processes. At one hospital where I have worked, there is no budget for clinical informatics, so the IT team is handling everything from system maintenance to ensuring physician adoption, with little support from medical leadership. The analysts are stressed all the time, caught between a mandate to ensure clinicians use the system properly and not having any authority to actually get the physicians to come to training. The turnover rate in the IT department is high, and leaders don’t seem to understand why people don’t want to stay.

The executive coach I’ve partnered with works with organizations to try to build resilience. The American Psychological Association defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, or stress – such as family and relationship problems, serious health problems, or workplace and financial stressors. It means ‘bouncing back’ from difficult experiences.” The people we’re working with are adaptable – they’ve watched the evolution of healthcare IT systems and some of them have worked on everything from basic billing systems to complex enterprise applications. They’ve watched the growth of technology at the bedside, and have seen the need for more transparency in the IT organization as the number of departments using technology has grown. They’ve coped their way through the rise of E&M coding, Meaningful Use, MACRA, MIPS, and ACOs.

Even with those changes under their belts, we see people struggling with the day-to-day stressors that impact their work. People are double booked for meetings and more than once I’ve been confronted by a conference call participant who appears to be inattentive who responds by saying he’s on multiple calls. (I still don’t understand how that works, but people do it, so it’s definitely a thing.) Workers are reluctant to take much-needed time off because they don’t have adequate coverage or feel that they’ll be buried when they come back. Others don’t want to burden their coworkers with the extra work that might shift their way if someone takes off. I see IT analysts that are continually frustrated by buggy software and delayed release schedules, who feel it acutely when they can’t deliver solutions to their customers. They’re caught between the vendor and the end user and may feel powerless to remedy the situation.

We’re working with groups in this situation by helping individuals analyze their individual work styles and better understand their own strengths. We help them identify situations they find challenging and develop strategies to work through them. Unfortunately, learning new strategies and figuring out how to incorporate them in the workplace takes time, and already-stressed teams struggle with finding the time to do this type of contemplation and reflective work. It’s often the management level that is feeling the most stress, because they have little control over budgets and priorities but are expected to deliver results regardless. When working with managers, one of the first steps we take is to help them complete a 360-degree evaluation, where they understand how they are seen by supervisors, peers, and direct reports. In one organization, we struggled with even getting the team to find time to respond to the surveys required to complete the evaluations.

There’s a concept that’s referred to in clinical circles called Moral Distress. It’s defined as the state of knowing there is a “right” thing to do but there are institutional constraints present that make it impossible to pursue the correct course of action. We typically talk about this when discussing nursing shortages and clinical staffing issues, when clinicians have to make difficult choices on how they deploy scarce resources. It’s thought that being unable to care for patients properly creates a particular kind of stress that increases the risk of caregivers quitting. A study of nurses performed in 2014 found that 20 percent of nurses surveyed intended to leave their current position due to moral distress.

Although it’s not quite as severe as moral distress at the point of care, we’re starting to see similar levels of stress in the teams that support front-line caregivers. Those support teams feel it acutely when clinical staffers can’t complete tasks or don’t have the technology they need to care for patients. I watched one IT analyst tear up as he tried to help a nurse figure out a documentation issue, when he understood that problems in the EHR were directly responsible for errors in care that negatively impacted a patient. He had reported the issue to his manager previously and they had been working with the vendor to try resolve it, yet he was told to move on to other priorities. He feels personally responsible even though there wasn’t anything he could have done, other than not follow the instructions that his leadership had given him. This isn’t the first time he’s been in a situation where patients were impacted by system issues, and he’s actively pursuing a job outside of healthcare.

As leaders, we need to figure out how to make sure our teams have the resources they need to do their jobs properly and ensure that the ultimate customer, the patient, is taken care of. We’re often between the proverbial rock and a hard place figuring out budgets and staffing while we prioritize projects. Maybe we need to be more forceful at saying no to implementing an on-demand meal ordering platform when our laboratory and radiology orders platforms aren’t at peak performance. Maybe we need fewer 70-inch TVs in patient rooms and more functional desktops and mobile workstations so documentation can occur quickly at the point of care. Maybe we need to stop adding bells and whistles to our systems when we haven’t fully implemented the basics. These are issues that the C-suite deal with regularly as our hospitals try to keep up with the Joneses across town.

I’d be interested to hear from any healthcare IT leaders who are taking a back-to-basics approach and trying to refocus energies on reducing stress while helping workers be more resilient. Have you found the recipe for the secret sauce? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/15/18

Theranos CEO Elizabeth Holmes is charged with fraud and has agreed to a settlement without admitting guilt in the matter. People were eager to believe in the promise of new technology without proof. Various family connections and their endorsements added to the investment frenzy.

I see dozens of startup proposals every year and have a high degree of suspicion for vaporware or vaportech. I’m happy to sign non-disclosure agreements with organizations that legitimately want my opinion, but they have to be willing to show me what they’re doing before I’m going to get on board. I think some folks have lost their ability to perform due diligence given the constant hype around innovation and being the Next Big Thing. I feel sad for the lower-level investors who were caught up with Theranos and its deception.

This article from The Guardian was a hot topic in the physician lounge today. Physicians took immediate exception to the comparison of US physician salaries to those from other nations, noting that in other countries, physicians do not have to incur significant debt to complete medical training as they typically do in the US. No one disagreed with concerns around the cost of prescription drugs or administrative costs.

One member of the hospital administration noted that some of the starting administrators at Big Health System make more than starting physicians, which is a sad state of affairs since starting administrators often have minimal experience beyond their MBA coursework. Similarly, there was no disagreement with the US having worse population-based outcomes.

Every time I have to argue with a patient about unneeded tests, there is typically a comment from the patient along the lines of, “We have the best technology in the world and I deserve this test,” or, “I’m paying a lot for my insurance and it’s covered so I want it.” Patients often don’t see past their individual situations and don’t want to have decisions made based on populations and statistics rather than their own personal feeling about what should happen.

Culturally, we have issues with desiring invasive care, often to our detriment (take a look at some of the childbirth data) and not understanding the need to pursue lifestyle changes rather than medicating everything. We don’t want to wait things out. We want medication now whether we need it or not.

Also culturally, we make it difficult for people to access care. Many of my patients come to urgent care after 6 p.m. because they can’t take off work or have no sick days to seek medical care. Very few primary care offices in my area have evening hours, so the more expensive urgent care begins to fill the primary care void.

Having the worst maternal mortality rates among other “developed” nations is embarrassing and should be avoidable, but we’re not tackling it very well. Infant mortality is also nothing to be proud of. I’m shocked by how many Americans keep up with the Kardashians and a host of other celebrity or social media personalities, but can’t name things they can do to keep themselves healthy. Prevention isn’t sexy, nor is doing the hard work needed to lose weight or stay in shape. Insurance plans often don’t cover preventive treatments or put hoops in place for patients to jump through when they want to pursue non-invasive or non-surgical treatments for some conditions that might improve quality of life.

I had a patient recently who switched insurance plans and her new coverage won’t allow for replacement of her custom shoe inserts, which had broken down over time. The patient had previously been active and now has constant foot pain, which has limited her activities and probably has contributed to her weight gain. She was in to see me about a cortisone injection, and even just looking at the cost of my visit plus the cost of the injection and potentially a follow-up visit, it would have been cheaper to just pay for new orthotics than to treat the foot pain. The patient had lost her job and is working as a restaurant server, which isn’t helping her pain either. She’s diligently trying to save for a new set, but that’s hard to do when you’re living paycheck to paycheck.

HIMSS may be in the rear-view mirror, but the onslaught of emails and cold calls is just beginning. I’ve finally learned to link my HIMSS registration to a dummy email account so that the contacts can be sorted out. I used a burner phone number as well. A couple of the post-HIMSS emails have been personalized greetings from a specific resource thanking me for the interaction at the booth and making note of our conversation. Others follow a formula that doesn’t help me at all: Thank you for your visit to X Vendor, we are hoping to help your organization, we will be reaching out to you directly. A link to the company website or an attached product portfolio PDF might be helpful memory jogs and might be less easily deleted than the form email.

The best outreach I have received so far was from Formstack, with the subject line “Have you worn your green Formstack socks yet?” and asking for a follow-up. It definitely caught my attention, and yes, the socks were perfect for coming back from HIMSS. I’m sending my VMWare socks to my favorite engineer, so I can’t comment on their comfort. I wasn’t lucky enough to score Google Cloud socks. Socks were certainly on the menu this year. I did finally score some #pinksocks this year and they got some looks wearing them around town.

I’m still recovering post-HIMSS, most likely because I landed, unpacked, repacked, and immediately went cold-weather camping, which probably wasn’t in my best interest. From there, it was on to client work and clinical shifts. The 12-hour days are becoming more and more difficult. Maybe the longer daylight hours in the evening will lift my spirits. I don’t mind it being dark in the morning since I can sleep without the birds trying to drag me out of bed.

I’m putting together the list of meetings I want to attend the rest of this year and also planning for 2019, when I get to take my board recertification exam. What’s on your list of can’t-miss meetings? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/12/18

Based on some networking accomplished at HIMSS, I’m about to begin work with a new client. The nature of the work requires me to have a medical license in their state, so I jumped right in Friday morning to get the process rolling. The licensure process can vary from state to state and I haven’t completed an application in years, so I wanted to get going quickly.

The first place I visited was the Interstate Medical Licensure Compact website to see if that might be a pathway to speed things along. When the Compact was introduced several years ago, it was touted as a way to increase delivery of care to underserved areas as well as to better enable telemedicine.

Unfortunately, the state where I primarily practice doesn’t participate in the Compact, nor do any of the states where I’m secondarily licensed, so that was a bust. Even if it had panned out, there is a $700 application cost plus the cost of the license in the target state. I have the luxury of being able to pass this on to my client since it’s their requirement, but that fee is far from pocket change.

I then investigated licensure directly with the state and found that they have an online portal. After creating an application, I learned that if I’m licensed in a state with similar requirements, they have an attestation pathway, where it should be easier to credential than if I were applying from scratch. This state borders my own and I have many colleagues that practice across state lines, so I thought it might be fairly easy.

Unlike a paper application, the online application directs the user through a rigid pathway of data-gathering. You can’t even see what the subsequent requirements are until you supply the preliminary data, which wasn’t close at hand. I found an instruction sheet PDF through an online search, but it had an older date on it and I wasn’t sure whether it was still relevant. Although I was sitting with copies of all my board certification information, medical school and college diplomas, and more, I became hung up because I couldn’t supply the date of my high school graduation or the date that enrolled in college.

I pawed through some boxes in my basement for a bit to see if I could come up with the high school diploma, but that wasn’t fruitful. I visited my high school website to see if they had an online request form. They don’t, but I was able to download a paper form to mail or scan back, which allows them to send me an unofficial transcript by email.

In my subterranean digging, I found my final college transcript, but of course it didn’t have the enrollment date on there, so I’ll be requesting that from my undergraduate institution as well. The application also requires my dates of attendance at medical school, but I was able to figure that out from my first tuition bill, which I must have saved as a memento.

I have no idea what kind of information they will want from residency. Probably similar information, and it should be a little easier to find because it’s more recent. Still, it will require either some digging or sleuthing to get it done and I’ll be in a state of curiosity until the rest of the application is revealed to me.

The bottom line though is that this “by attestation” pathway seems about as complicated as trying to apply for a license from scratch, minus having to submit USMLE scores. (For the first-time applicant, they have a nice current instruction sheet that spells out everything you need to apply.)  Fortunately, when I packed up my diplomas and certificates in leaving my corner office at Big Health System, I had scanned all those documents so that information is at least at my fingertips. Hopefully they won’t want anything too unusual.

I will have to travel to the state in question and be fingerprinted by their state police organization. I’m not sure why I can’t be fingerprinted by my own state police and submit that, but I’ll be sure to factor that travel into the contract for my new client.

For a physician who has been in practice the better part of two decades, certified by two different medical boards (one of them multiple times), and possessing multiple unrestricted licenses to practice medicine, this process seems a little cumbersome. I’m not sure why it’s relevant to document what date I began high school in order to be licensed to practice medicine. But it is what it is, and if you want to practice in another state, you have to play their game (and pay their fee, which in this case is more than $700 plus a state controlled substance license, and I haven’t even started that process yet). Once you are granted the license, you have to pay to keep it up even if you’re not sure you’re going to continue to do it because it is such a cumbersome process to be re-licensed.

It seemed like the Interstate Compact was the answer to all of this, but the reality is that only 22 states participate, leaving the rest of us in the cold and completing lots and lots of forms if we want to change where we practice. Several other states have passed legislation and the implementation is delayed and other states have introduced legislation. But it looks like those of us in the other 22 states are stuck with the traditional process. I’d be interested to hear from physicians who practice telemedicine or from those who practice as locum tenens in multiple states – are there any secrets, tips, or tricks to make this easier? Certainly there has to be a better way.

In the meantime, I’ll be watching my email for that high school transcript and my postal mailbox for the college information. At least I can use the Postal Service’s Informed Delivery to see what is headed my way when I’m out traveling. Nothing says road warrior like stalking your postal mail from the other side of the country.

Have secrets for multistate licensure? Leave a comment or email me.

Email Dr. Jayne.

Dr. Jayne at HIMSS 3/6/18

As is usual when I go from East Coast to West Coast, I woke up insanely early compared to local time. It allowed me to head out to the strip for a good walk to check out all the changes that have happened since the last time I was here without a crush of people and without having to deal with people handing out stripper cards. Back in the room, I tried to log into my EHR to check messages and see if there were any charts from mid-level providers that needed signing, only to find that the system is down. I’m sure they’re having heart failure at the office since we’re still in the throes of flu season.

My hotel room has a lovely view of the roof of the expo center and I was glad to see some solar panels as well. After my usual HIMSS breakfast of a Clif Bar and Diet Coke, it was off to sessions. I hate fighting the coffee and breakfast lines at most conferences and HIMSS is always the worst. I’ve learned to bring my snack stash and especially so for this conference, since there won’t be any MedData scones.

I waited until the expo hall opened and it was still gridlocked when I headed down the escalator from the faux St. Mark’s square. Claustrophobic people should not attend HIMSS since the aisles were packed today, even in Hall G. I did spend a fair amount of time there today, mostly because the vendors were more enthusiastic and actually acted like they wanted to talk to you rather than seeing you as a distraction from their internal conversations.

Not every vendor was avoiding customers, however. I had some issues with vendors upstairs being overly aggressive, straying way outside their booth boundaries and actually stepping in front of attendees and blocking their way to try to talk to them. There were also lots of people shooting video in the aisles, even up on ladders taking pictures of their booth, which didn’t help the crowding.

Cheers to sponsors that had their signs out front and center: Aprima, Dr. First, Elsevier, Forward Health Group, Health Catalyst, and Fortified Health Solutions / Santa Rosa Consulting.

Jeers to Imprivata’s scrub-clad demo team, members of which were also wearing lab coats. No one is fooled by the fact that you’re not actual clinicians. I was surprised to see how many people were watching their demo.

I had a great chat about Office 365 with this gent from Tech Data, who humored me with a photo of his cloud suit. He promises a shorts version for next year in Orlando. There’s so much going on at HIMSS that you really have to have something to grab attendee attention – I’m not sure the “same old, same old” attention-grabbers in the booths such as golf swing analyzers and cheap giveaways are cutting it. NextGen showed off in Booth 3821 with a four-panel screen printing machine making tote bags on demand – for every bag given away, they’re donating food to needy youth.

In Touch Health had a soft serve bar, but they’re located in a far corner of the hall. I only ran across it because I was turned around and couldn’t figure out how to get out of the hall. Juniper Networks had their oversized Operation game. MedData had a vintage candy shop complete with Wax Lips, which I haven’t seen for decades. Kudos to them for finding something to (hopefully temporarily) replace the scones we all love. Edifecs had some super cute pink shoes on display as part of their #WhatIRun campaign.

I found these folks painting away in Hall G, in a mostly-anatomically correct way. You never know what you’re going to see at HIMSS, and so far, this is the weirdest thing.

I was gifted with some pink socks today and must say I am thrilled!

Towards the end of the afternoon, I ran into an old friend outside the Logicalis Healthcare Solutions booth in Hall G. We were chatting away and they were kind enough to let a couple of weary travelers enjoy their comfy chairs late in the day. We talked about marketing campaigns and sales tactics with one of their client executives, who was gracious and engaging. They seem to have a lot to offer, so stop by and check them out.

From there it was off to visit various booths for cocktails and then head to the Holon Solutions reception at the Venetian. I was excited to learn about their success at Banner Health, surfacing gaps in care within the EHR. I joined some old friends for dinner, and by the end, my feet were giving out, It’s going to be a relatively early night for me.

EPtalk by Dr. Jayne 3/1/18

The countdown to HIMSS18 is reaching its end and I’m in my final stages of preparation. I’ve developed some strategies over the years for making the meeting productive without being too exhausting. I was talking with a colleague who is attending his first HIMSS this year and he made the comment that what I was suggesting sounded a lot like the strategy he used when taking his small children to Disney World. I have a fondness for the chocolate-covered Mickey-shaped ice cream bar, but I don’t think I’ll be seeing any of those on the floor of the convention center. I guess I’ll (hopefully) have to settle for some fresh-baked scones.

My first general rule for HIMSS is to plan travel to arrive a day early if possible. This allows me to get settled in and possibly squeeze in a couple of social-style meetings on arrival day, such as a lunch or coffee, drinks, or dinner. It’s nice to be able to connect without all the hustle and bustle of the exhibit hall and sessions. It also makes it easier to meet with people that might have booth assignments during the show and who would otherwise be working the floor or too tired to get together.

I’m breaking my own rule this year for a couple of reasons. First, because we’re in Las Vegas, where the shift in the start/end times that happens when the meeting is there always throws a wrench in things. We also recently opened several new locations in my clinical world, so we’re a little thin on physician coverage and I have to see patients Sunday. I’ll be heading out before the sun arrives on Monday, though, so I should have time to meet with a couple of people and get settled.

My second general rule is to choose a hotel that doesn’t involve a significant commute, or if it does, that I’m OK with it. In the past, I’ve stayed at places that are a bit of a hike from the expo center, mostly due to cost, with varying degrees of shabbiness. I learned from experience in Orlando that you have to book early to get the hotel you want for the dates you want, so I book as soon as the room blocks open up.

The last time HIMSS was in Las Vegas, I stayed at TI due to closeness and cheapness, but I wasn’t thrilled with having to walk through the smoke to get to the elevator tower. This year I’m splurging and staying at the Venetian. I’m sure there will be smoke I’ll have to walk through, but the proximity to the meeting should be a bonus. I know Mr. H is a fan of staying off strip and you certainly can get more value for your money that way, but I don’t want to hassle with figuring out transportation. It’s kind of like staying on property at Disney – it’s more expensive, but it might just be worth it.

Planning what to wear always requires some thought, although this year I’m eerily relaxed because I don’t have to figure out what to wear for HIStalkapalooza or feel the pressure to find the perfect dancing shoes. The black cocktail dresses are staying at home, which also makes packing easier. I generally dress for exhibits and sessions in layers since the climate control at most convention centers ranges from arctic to subtropical. Since I’m not representing anyone other than myself (and HIStalk anonymously), I skip the suits and go for comfort. I’m not going to surf the hall in jeans, but I don’t think suits are mandatory. Unless you’re job interviewing, which a lot of people do at HIMSS.

Planning shoes is always a big deal and becomes more important as my feet get older. My favorite trade show shoes gave up the ghost last year, and despite having been comfortable for years, they became a liability because they were a little stretched out, resulting in blisters. This year is all about comfort, with some dressy clogs and cozy loafers. Usually I worry about being able to go day-to-night with whatever I’m wearing and throw an extra pair of shoes in my bag, but I’m hoping that being closer to the action will reduce the need to haul around a spare pair of shoes. If I get too tired, I’ll wear running shoes to the exhibits on Thursday, because by that point no one cares what you’re wearing.

Also like Disney, it’s important to plan what attractions (or booths in this case) are must-see, want-to-see, or just possibilities if there’s time remaining. As I hear about different vendors and products throughout the year, I keep a list of them and use it to create my HIMSS to-do list. I make appointments for the most critical things I want to see, but the rest are just drive-bys, partly to see how the booth team interacts with a random CMIO that walks in. I do also take a peek at all the mailings that arrive, to see if something catches my eye.

This year was slim on the mailings, with fewer than a dozen pieces arriving at the house. The Imprivata goodie box that I mentioned a few posts ago was an attention-grabber, but the rest of the mailings have been largely post cards, with only two of the “bring this to our booth and see if you’ve won” or “first 50 people to the booth get a prize” type of offerings. That’s way down from the past. Usually there is at least one vendor that sends a playing card or poker chip promotion when we’re in Las Vegas. Of course, that’s not to say that those mailings won’t arrive after I leave, which also happens. I typically find at least a handful of vendor marketing pieces in my held mail when I return.

Speaking of marketing pieces, the one mailing I received that really caught my attention is from a vendor that won’t be at HIMSS but didn’t acknowledge that in their mailing. Vendor advice: if you’re doing a mailing to launch a new product in February, you might want to mention “although you won’t see us at HIMSS this year, we’d love to hear from you, here’s how” or something similar. To not even acknowledge it makes you seem like you don’t know what’s going on in the industry. Even if you’re not a fan of HIMSS, it does exist and sucks up a lot of people’s attention.

My last piece of Disney advice is to be flexible. Sometimes you arrive to something you want to see and find a long line that you don’t want to deal with, There is no Fastpass available at HIMSS. Sometimes your attention is grabbed by an attraction you didn’t know existed and you rearrange to accommodate it. You never know what you’re going to see at HIMSS or who you’re going to run into, but there is always plenty to look at and learn.

I’m putting together my final lists today. I’ll see you in Las Vegas!

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/26/18

I spent a good part of last week trying to help a client sort out their strategy for Patient-Centered Medical Home. The client is a mid- to large-sized multispecialty group, which started as a mostly primary care group that was forced to take on specialists as it acquired smaller multispecialty groups. They didn’t really think much about having to integrate the specialist documentation with the primary care documentation until they decided to enter into some risk-sharing contracts. They’re also trying to attest for just about every incentive program out there, including smaller, payer-centric contract bonuses, and trying to navigate from the older NCQA Patient-Centered Medical Home requirements to the redesigned program and are really struggling.

Their EHR vendor supports both primary care and specialty workflows, which are often siloed because of how the content was developed. For example, there’s a completely separate “urgent care module” that some of the primary care physicians have taken to using for the half days when they are assigned to see only acute patients. They like the separate module because the documentation is faster and easier than what they typically do for “regular” primary care patients, but the problem is that the data doesn’t always flow to the same tables used by the rest of the documentation screens. This is creating a problem with their Patient-Centered Medical Home reports, which were custom built by a third party that didn’t know the application and so only designed them to use data from a single workflow.

This isn’t the first EHR I’ve seen that works like this, with different pieces being built at different times and not being fully integrated with the rest of the application. In addition to the urgent care workflow, there are separate streams for documenting OB/GYN and GI procedures that account for integration with different ultrasound and imaging devices. This is frustrating to the client as well, since of course the supported devices aren’t the ones they use in their clinic. When they talked to the vendor about it, they were told that the specialty flows were built as contractual requirements for specific clients. When vendors enter into those kinds of agreements, it’s more likely to result in workflows that don’t necessarily meet the needs of the entire client base, but work well for a unique client.

As we began to dig deeper into the needs for Patient-Centered Medical Home, it became evident that the client had entered into some agreements that were going to cause challenges for designing an ideal documentation path. They recently agreed to work with embedded care managers from insurance companies, who will be documenting in two separate systems depending on the insurance coverage of patients selected for the care coordination program. The IT team decided that they would bring the documentation from those systems back into the client EHR as a PDF, which would then be inserted into the document management system. Of course, that means no discrete data and no availability for the Patient-Centered Medical Home reports to make use of the information that represents the work that has been performed.

Situations like this always lead to discussions of governance and a need for greater understanding of how this client’s situation evolved to put them in this place. The chief medical officer is apparently the one pushing the Patient-Centered Medical Home agenda, but the director of nursing lobbied the group to engage in the embedded care management programs. The nursing side of the house saw participation in the program as a way to get some flex on staffing since they were struggling with care management services, but didn’t understand the ramifications of having those coordinators documenting outside the EHR. To their credit, nursing worked with the IT team to make sure the patient contacts made through that program were represented in the EHR and IT found a relatively easy solution, but neither of those groups understood the impact on PCMH.

The CMO didn’t do a great job helping the rest of the team understand what was going on with Patient-Centered Medical Home and its requirements or that they were having customized reports created to meet those needs. IT wasn’t involved with the creation of the reports since the CMO outsourced them at a time when he perceived the IT team to be too busy implementing newly-acquired practices. And while the third party that built the reports did a great job creating really nice reports, they didn’t understand how the different specialties work together and just built what the CMO had described in a broad-strokes overview. It’s one of those situations where they built exactly what was requested but didn’t know that the request wasn’t completely formulated. As a result, IT is doing a lot of finger-pointing at the third party, which is defensive and doesn’t understand why their beautiful reports are being questioned.

The other wild card here is the group’s understanding of the redesigned Patient-Centered Medical Home program. They’re trying to make the transition from being at a low level of recognition under the previous program to being more robust participants in the new program, but haven’t identified sufficient resources to learn the new requirements and figure out how to mesh them together with what the group needs. They brought me in specifically to deal with the new requirements, but as is common with organizations like this that are trying to dive into many different pools at the same time, we’re peeling back the layers and finding out there are many more issues that need to be addressed.

My task for this week is to bring together the administrators and to lay out the various initiatives and how they interact and/or compete. The goal is to get them to prioritize which programs they want to lead with, along with getting them to all start moving in the same direction. No one has infinite resources and they’re not likely to be successful if they continue to try to do all of this at the same time and all of it in a way that is under-resourced and doesn’t really fit in with a long-term strategy.

Although it sounds easy to lock everyone in a room and lay things out, I’ll be particularly challenged by the fact that this group just came out of their annual strategic planning retreat and thinks they have a master plan and a strategy. Either these items weren’t discussed at the retreat (which I’d say makes it less than strategic) or they weren’t discussed in a way that had meaning for everyone and led to actionable decisions.

Sometimes these conversations can turn towards the consultant with a bit of hostility or there can be a lot of finger-pointing, so I’m readying my strategies to try to wrangle this meeting. I haven’t been working with them long enough to know if they’re open to some give and take, or it’s going to be a turf battle, or I’ll end up the bad guy. Consulting is like a box of chocolates – you never know what you’re going to get.

How does your organization prioritize initiatives? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/22/18

The pre-HIMSS madness has started, with companies starting to churn out press releases that try to act very important but don’t actually say much. More than a few vendors save up even the smallest tidbits to try to release them for HIMSS, but miss the fact that their news is just going to get lost in the shuffle. The buzz words are out in full force, so for those of you playing along at home I offer up a HIMSS18 Buzzword Bingo card for your enjoyment:

Some vendors are sending out sneak peeks of what will be in their booths, but quite a few others are sending cold-call type emails that are sometimes registering as spam. One arrived today thanking me for my interest in a particular company and asking me to click to verify my email address. It was a mainstream vendor, so I didn’t think a lot about it, but on the other hand, it sounded more like phishing so I decided to take a pass. Vendors need to think twice about the wording in their messaging (or hire public relations people who will think about it) if they want to truly get attention and not be accused of spamming people.

Other vendors are going for the “wow factor,” with Imprivata shipping this HIMSS survival kit. In addition to protein bars and 5-hour energy shots, it has both plastic and metal water bottles, along with lip balm. The red survival kit has tissues, hand sanitizer, vitamin C supplements, and lollipops. The cutest part is the little black trinket stuck above the Imprivata logo – it’s a camera cover for your laptop, that slides to cover or reveal the lens depending on your needs. Usually I keep a piece of tape over my camera, but I’m going to test drive their slider and see how it does. I had some accidental camera exposure on a call several weeks ago, when I had to switch laptops at the last moment. It was one of those “crazy ponytail” days with an unmade hotel bed in the background, and the person I was talking to wondered why I covered my camera abruptly.

CMS announced its Annual Call for Measures for Eligible Hospitals and Critical Access Hospitals participating in Medicare EHR incentive programs. They’re looking for measures to be included for rules that are made during 2019 and would be optional in 2020 and required starting in 2021. CMS is looking for measures that build on Certified EHR Technology and increase interoperability, along with those that might improve program efficiency, effectiveness, and flexibility. Last on their list (although most clinicians might say it should be first) are measures that address patient outcomes and emphasize patient safety.

Much as there is increasing research into distracted driving, I’d like to propose some evaluation in the latter two categories that would look at distracted practicing. It’s increasingly hard to focus on the patient when you’re busy with data gathering, finding the right fields for documentation, and fielding clinical decision support popups. As systems become more sophisticated, I sometimes feel like I’m in the cockpit of a fighter jet rather than trying to care for patients.

CMS is also eager to find measures that would reduce reporting burden, avoid duplication of previous measures, and include an “emerging certified health IT functionality or capability.” It’s sexy to focus on new features, but how about allowing physicians to focus on the technology they already have and learn to use it well? I see numerous physicians who are underusing features such as order sets and clinical decision support, which should be able to drive clinical outcomes, reduce inappropriate ordering, and improve efficiency. They also tend to under use features that would make them not only more efficient but more satisfied with their systems, such as personalization features and individual preferences. Those features take time to set up on the front end but pay dividends on the back end, Shortsighted physicians who skip the pre-work wind up with many more clicks down the road.

Speaking of CMS programs, physicians continue to vote with their feet, not only opting out of the incentive programs, but by opting out of Medicare altogether. Based on data from the Provider Enrollment, Chain and Ownership System (PECOS) as of the end of the year, more than 16,000 physicians have filed affidavits to opt out of Medicare. The number was down in 2017 from a peak of more then 7,000 in 2016, but the overall trend is concerning. I recently received my letter from the Department of Health and Human Services detailing the penalty I’ll be taking this year. Since I’m in an employed situation and my practice isn’t participating in the incentive programs, there’s not much to be done. But if I were back in private practice, I might start thinking twice about CMS participation vs. moving to a practice that doesn’t have a payer-based compensation system. Nearly 40 percent of my residency class is now in practices that are either retainer-based or offer substantial savings through cash-only services.

I’m in a no-travel zone leading up to HIMSS, which I desperately need after my most recent travel experience. After a flight that included some turbulence that felt a bit like the prelude to astronaut training, I made it to my hotel and found this little guy in my bed. Fortunately I spied him (or her) right when I came through the door and not after I had gotten settled in. I’m not sure what it is (it seemed too large to be a bed bug and not quite the right shape), but I am waiting to hear back from an entomologist friend. Although the hotel was apologetic (and moved me to a top floor corner suite), it’s unsettling. I’m hoping the only living thing in my room at the Venetian is a CMIO with tired feet, although a plant would be OK too.

What’s the weirdest thing you’ve found in a hotel room? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/19/18

From time to time, I contemplate heading back into the CMIO trenches full time. Although I do a lot of CMIO work in my consulting practice, it’s usually episodic and I miss seeing projects come full circle. I also miss being part of the strategic planning team, helping lay out the vision for an organization and how it plans to support patients and providers.

When I serve as an interim CMIO, I’m usually charged with keeping the ship afloat rather than deciding where the ship is going or what kind of cargo it will be carrying. Or perhaps I’m brought in as a consultant, tackling projects that the CMIO should be doing but doesn’t have the bandwidth to handle. There are some times where maybe the CMIO wants to do the project, but it’s politically charged and leadership feels having third-party assistance will help steer them through a rocky course. Those are challenging but often fun, although they can be stressful.

As I’ve talked to recruiters and looked at various job postings, I’m seeing some trends in CMIO job descriptions that I’m not sure I’m fond of. It might be a function of the duration clients have been using clinical systems, but I’m seeing more “maintenance” type job responsibilities and fewer “leadership” elements. Organizations are recruiting CMIOs to manage systems and data and people, but not necessarily for the ability to shape mission or to help architect strategies for delivering care in increasingly complex environments.

It feels like the role is being diminished somewhat, and the salaries are commensurate with that change. Of course, I have to remind myself that the positions I am looking at are sometimes in organizations that have struggled with even having a CMIO, let alone keeping one. If they were a great place to work and had found the right person, they wouldn’t have a vacancy.

Regardless of the situation, though, and the reason for the vacancy, it’s difficult to look at positions that are less C-suite and more director level, regardless of the title. Usually those positions have a salary range that is also less C-suite and more middle management. I recently spoke with a recruiter about a position with a salary range that was closer to that of a new graduate fresh out of residency than to an executive-level position, and certainly far less than one could earn in clinical practice. When asked about how they see the range as being supportive of the position, they mentioned that it was less than they pay their staff physicians “because it doesn’t have all the stress that comes with clinical medicine.”

When you hear comments like that, you know immediately that a position isn’t going to be a good fit. I would argue that anyone who thinks that being a CMIO is less stressful than other physician roles probably doesn’t understand what typically falls under a CMIO’s responsibility. I also didn’t like the fact that they were comparing the roles like that, because frankly being a physician is stressful and being an executive is stressful, but in different ways on different days. I don’t think that comparing stress levels across the organization as a means to justify salary shows that an organization is very progressive. It also highlights the risk that they might be in the habit of pitting various constituencies against each other in the hospital, which again is not a good sign.

I’m also struck by the lack of diversity in some organizations’ leadership profiles. At one organization, a large community health center that sees a very diverse population, the entire leadership team was composed of Caucasian males over age 55. I try to judge a potential job based on the job, but given the fact that I didn’t feel welcome during the interview, I didn’t think I’d feel welcome on the leadership team. Having grown up around many hunters and fishers and being fairly outdoorsy, I can talk hunting and fishing in a passable fashion, but it was nearly impossible to steer them away from conversations about who had the better deer lease and whether the wives would be coming to hunting camp this year or not. There were also conversations about how much money their stay-at-home spouses spent that were entirely inappropriate for an interview situation and made me concerned about how my potential peers viewed women in the workplace since none of the wives discussed work outside the home.

Another organization had an interviewer that asked me directly whether I had children. Although it was offered in a folksy tone under the banner of “help us get to know you,” it’s irrelevant to the job and role and was an immediate turn-off. It also said that this is an employer who doesn’t even understand the basics of employment law. As a seasoned people manager, that’s not something I want to sign up for. Given the desire of employees to have work-life balance along with the challenges of a graying society, rather than asking those kinds of questions, potential employers should be trumpeting whatever provisions they have in place to allow people to have children, build families, and participate in the care of aging family members.

Other organizations have been much more welcoming and have been proud to showcase provisions they have in place to keep their workforce healthy and productive. I’ve seen some fairly generous sick leave policies and concepts such as floating holidays to ensure that employees get time off on days that are significant to them and to their families. Vacation tends to still be a bit of a sticking point, though. Although I understand having people “earn” multiple weeks of vacation as they build tenure with a company, offering a senior-level applicant two weeks of vacation with the option to have a whopping three weeks of vacation after five years of service is a bit of a non-starter. We know the US lags behind the rest of the world with vacation days, and as a potential applicant who’s well established in the workforce, it’s a concern.

The issues I describe aren’t unique to finding CMIO positions and they apply to many other situations I see in the workplace. Potential employees want to feel valued and they want to feel like they’re moving to something better that offers more opportunity and/or rewards than their current situation. They don’t want to feel like they’re making a lateral move, let alone a downward move. I’ll be meeting up with some of my CMIO colleagues at HIMSS and will be interested to see how they feel about where they are in their careers or what the future holds. Until then, I’m off to the airport on my next adventure.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/15/18

Lots of people are catching Olympic Fever. I’d much rather see that in the community than influenza. I’ve been catching some figure skating and snowboarding on the TVs in the patient rooms, which I much prefer to the omnipresent HGTV.

This Winter Games marks the debut of GE’s Athlete Management Solution, which sounds like a cross between an EHR and a clinical data repository with a side of SNOMED. GE Healthcare’s CTO noted, “Olympians train for many years to represent their nations at the games. Their Herculean efforts must be matched with superhuman clinical speed and quality.” I’d like to see some superhuman clinical speed in my own EHR, but would settle for seeing what GE has in store for both these games and those upcoming in Tokyo in 2020. If any readers are at GE, let me know if you can refer your favorite anonymous blogger for a demo.

Gallup and Sharecare recently released the “2017 State Well-Being” rankings. I’m not surprised that well-being is on the decline given the political turmoil we’re exposed to on a daily basis along with the pressures of social media and an unpredictable economy. No states showed a statistically significant improvement in the score, and 21 states experienced decreased well-being. The declines were driven by decreased numbers in social well-being and purpose along with the mental health aspects of physical well-being. The highest score was South Dakota with a 64.1 out of 100, followed by Vermont at 64.09. Louisiana and West Virginia rounded out the bottom. I’ll be taking a trip to the latter next summer and will let you know if the beauty of the New River Gorge improves my wellness and sense of purpose.

A reader asked me to further clarify my recent Curbside Consult comments regarding information blocking. In my travels, I frequently encounter major health systems that are guilty of information blocking, throwing up barriers in the way of patients who want to share their information. Examples include telling patients that outside physicians aren’t in the EHR directory for sharing records, refusing to send records by Direct protocol, citing HIPAA as a reason for not sending records to a consulting physician, failing to release specifically requested portions of the record, and downplaying the known interoperability features of their respective systems. Unaffiliated (read independent) providers are blocked from accessing clinical data repositories unless they sign cross-marketing agreements.

People are quick to blame EHR vendors for so-called information blocking, but in my experience, there are plenty of tools available but too many policies and procedures that discourage their use. I guess the theory is that if you make it harder for an independent consulting physician to receive your patient’s data, maybe the patient will be frustrated and choose an employed physician who documents on the shared hospital EHR, therefore solidifying the hospital’s market share.

Failing to accept labs sent from “outside providers” because of perceived compatibility issues and forcing patients to endure duplicate tests is also something I’m seeing more and more of as well. I’m proud to be an independent provider, but given my history in the world of big healthcare, I wish we could all just get along and put the patient at the center of what we do.

The Medicare Quality Payment Program attestation season is in full swing, with practices starting to realize that perhaps they weren’t as prepared as they thought. Organizations have until March 31 to submit their data for the 2017 calendar year reporting period. I’ve already gotten a couple of calls from organizations asking me to do the EHR equivalent of cooking the books, claiming that providers had the right information but just documented it in the wrong place in the EHR or maybe documented it incompletely. We’re 45 days into the new calendar year and I’m not about to manipulate someone’s database regardless of how well-intentioned they act or how much they beg.

The bottom line is that practices need to be monitoring their providers and their respective documentation habits (or lack thereof) throughout the year and catching problems early enough so that a mitigation plan can make a difference. I’ve had a couple of practices complain that their vendor didn’t have their 2017 measures packages ready at the beginning of the year, so they had nothing to run. I remind them that they could have kept running the 2016 packages to at least get an idea of the numbers since some of the measures didn’t change much, or that they can always create their own reports or use a third party to create interim reports. I know there are consultants out there that will help these clients massage their data, but I’m not eager to become one of them.

I spent Valentine’s Day with the good folks at the Marriott, but at least I had some time to read #healthpolicyvalentines and feel the love. This one from California ACEP is my favorite. I also want to give a shout out to Alexander Gaffney @AlecGaffney for sharing the best FDA labeling letter ever:

Misbranded Food:

• Your Nashoba Granola and Whole Wheat Bread (wholesale and retail) products are misbranded within the meaning of section 403(i)(2) of the Act [21 U.S.C. § 343(i)(2)] because they are fabricated from two or more ingredients, but the labels fail to bear a complete list of all the ingredients by common or usual name in descending order of predominance by weight as well as all sub-ingredients, as required by 21 CFR 101.4. For example,
• Your Nashoba Granola label lists ingredient “Love.” Ingredients required to be declared on the label or labeling of food must be listed by their common or usual name [21 CFR 101.4(a)(1). “Love” is not a common or usual name of an ingredient, and is considered to be intervening material because it is not part of the common or usual name of the ingredient.

There you have it, folks. Beware of foodstuffs made with love! In other news, chocolate is under scrutiny for its purported health benefits, with critics alleging bias through industry-funded studies. I see their point, but I do know that dark chocolate makes me smile, so I’m counting on it to help raise my personal well-being index.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/12/18

I was heartened this week to see the American Academy of Family Physicians engaging with ONC in an attempt to “reduce clinician burden from health information technology.” AAFP has been meeting with CMS and ONC as part of the Patients over Paperwork initiative, and submitted what amounts to a wish list of items to discuss at a follow-up meeting later this month.

The letter opens with commentary about the regulations that physicians are subject to are “daunting and often demoralizing.” AAFP cites lack of standardization among payers, whether public or private, as a significant challenge.

The letter cites family physicians as possibility participating with 10 or more payers, which is a significantly smaller number than what we see in our community. In my family medicine heyday, I was contracted with nearly 35 payers, including Medicare and Medicaid for two states. Just the credentialing paperwork alone was mind-numbing, and the actual paperwork that needed completion to actually care for patients was soul-crushing. Every plan had a different pre-authorization form, certification process, and appeals framework. Although I was part of a large health system, my personal office staff spent a significant amount of time dealing with it since we had no centralized resources to assist.

AAFP refers to their wish list as “consensus principles on administrative simplification” and many of them seem like common sense measures. First, they call for CMS and ONC to work with Congress to reduce the reliance on healthcare IT usage measures. Their point is that programs such as MIPS are already measuring quality, cost, and practice improvement, so measuring the usage of IT systems is no longer necessary. AAFP calls for policies that mandate health IT use to be assessed to identify “evidence of benefit and burden in real-world practice prior to their implementation.”

I agree with this request wholeheartedly. Many of the requirements found in these programs seemed like a good idea to the people who designed them, but when they’re placed into practice, they fall flat. An example is the requirement that physicians send certain percentages of prescriptions electronically, including controlled substances. There was no corresponding requirement to mandate that pharmacies update their systems, resulting in delays for physicians who wanted to use the technology and frustration for those whose service areas didn’t have adequate pharmacy adoption. Requiring certain numbers to be met also doesn’t take into account the preference of certain patient populations who want a hard copy of the prescription to take with them.

Many of my older patients didn’t trust electronic prescribing or had experienced delays or misadventures with it previously, and simply wanted paper prescriptions. Even if I tried to e-prescribe and then print a backup copy for the patient, the way our EHR calculated the transactions, I would still be on the hook for a printed prescription. Meeting my patients’ needs and preferences for care put me at risk for a penalty, which just seems wrong.

One of the more hot-button requests in the AAFP letter is a request that the CMS Documentation Guidelines for Evaluation and Management Services (E&M Coding) be overhauled. It notes that, “adherence to E/M Documentation Guidelines consumes a significant amount of physician time and does not reflect the workflow of primary care physicians.” They cite the creation of the Guidelines for the paper world as being part of the problem, and that the Guidelines don’t take into account how EHRs support care and documentation.

They go as far as asking that guidelines for new and established office visits be eliminated for primary care physicians. That’s certainly a big ask and personally I don’t see it happening, but I’m glad they’re trying. I’d love to see the guidelines at least modified to allow for different types of documentation to “count” for coding points. For example, when my patients come in with rashes, I’d love to be able to drop in a couple of pictures of the rashes and call it a day rather than trying to find the right checkboxes to click to try to describe a rash in a way that may not convey what I saw. Under the current requirements, I can drop that photo in, but I still have to use words in order to get billing credit.

My favorite request in their list is a request that the Medicare Program Integrity Manual be updated “to allow medical information to be entered by any care team member related to a patient’s visit” and that it be changed across the board for all Medicare contractors, Medicaid programs, and private payers. We’ve been living in a world with arbitrary boundaries where staff can document the Review of Systems but not capture any History of Present Illness (HPI) data, even if the patient volunteers it. Of course, this is if your employer follows a strict interpretation of the rules, which many do. Other practices may allow staff to collect HPI data and have the rendering provider review it, which saves time and effort, but I see that less commonly.

The original E&M guidelines also don’t fully address the requirements of patient documentation when scribes are used, and whether documentation can be performed differently depending on the training and education of the scribe. For instance, if I have a registered nurse scribing for me, I may get more detailed documentation than if I have a less-trained scribe, because the nurse may pick up more specifics from my descriptions. A patient care technician might enter my statements verbatim (I often speak in lay terms to patients when I explain their exam findings) where a nurse may translate these descriptions to accepted medical terminology.

AAFP also calls on CMS and ONC to go after those who are guilty of information blocking. Administrators, listen up: when you’re ready to go after some major health systems, give me a call. They’re the biggest offenders in my metropolitan area and the EHR vendors don’t have anything to do with it. It’s all about controlling your referrals and managing your ACO and not about enabling patient choice or sharing of clinical data. Too bad there’s not a whistleblower clause since  maybe I could retire early.

The letter evokes the myth of interoperability, where many of us are exchanging reams of irrelevant information that we don’t have time to wade through. Even though I haven’t been a family physician for years, I still appear in many patients’ records and receive C-CDA documents on a frequent basis. Most of them are unintelligible, and one local hospital is guilty of including every medication the patient has ever been on, which I imagine makes medication reconciliation nearly impossible for the receiving party.

The letter notes the need for consistent data models created by clinicians rather than by legislators or software engineers. I deal with several EHR vendors that don’t even really have a data model of their own, which is amazing to me in this post-Meaningful Use age. When data comes in from another vendor, it creates a mess that is hard to sort out and adds considerable junk to the patient chart. It also notes the need to continue to harmonize clinical measures, so that physicians don’t have to report data that is similar but not identical to different payers.

Other factors mentioned should be no-brainers in this day and age, such as removing the need for physicians to fill out new forms for items like diabetic supplies when a patient switches brands. Especially if we are trying to allow patients to be empowered and make choices about cost of drugs and supplies, having to write for “WonderGlucose Harmonious Precision Extra” as opposed to “glucometer test strips” is silly.

The letter closes with a request for CMS and ONC to reach out to Steven Waldren, a family physician who is the Director of the Alliance for eHealth Innovation. I had a chance to meet Dr. Waldren a couple of years ago at HIMSS and he’s a knowledgeable physician with a good head on his shoulders. For some reason, however, I don’t suspect that his phone is ringing off the hook with regulators asking how they can help. I’m interested to see if other specialty organizations follow suit and whether we see any changes.

What would you do with your free time,should E&M coding be eliminated? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/8/18

We’ve heard a lot of stories lately about people behaving badly (not to mention criminally), and frankly there are too many stories of harassment to count. The AMIA Board of Directors released a new anti-harassment policy that applies to future meetings. I was pleased to see that they called out the unacceptable behavior of “real or implied threat of professional or personal damage.” Fear of retaliation or professional retribution are powerful forces that keep people from reporting harassing and unprofessional behavior. Simply having a policy isn’t going to stop abusers, but it may make them think twice about their actions. Regardless, I’ve seen too many institutions sweep inappropriate behavior under the proverbial rug, so kudos to AMIA for providing leadership.

In the current climate, organizations need to get serious about educating their employees about problematic behaviors and reducing situations where harassment and abuse can occur. HIMSS is coming and it will be interesting to see if the parties are any less alcohol-fueled than in previous years. I was harassed by a vendor sales rep the last time HIMSS was in Las Vegas and didn’t say anything because I just wanted to get away from the situation and forget about it. Thinking back, I’m still disheartened that the other sales folk that witnessed it didn’t say anything either, because they were people I had known for many years. I’m hoping that both victims and witnesses are increasingly empowered to say something and make sure that abusers know their behavior is not OK.

Speaking of HIMSS, if you’re planning your wardrobe, too bad you can’t get a pair of Intel’s new Vaunt smart glasses yet. A worthy successor to Google Glass, they don’t look too different from typical spectacles. The main feature is retinal projection, which makes you feel like you’re looking at information on a screen. The glasses don’t have a speaker or a microphone, which saves on weight and adds more normalcy. An early access program will launch for developers later in the year. If they’re looking for any sassy physicians to give it a try, I’m definitely game.

I was beyond disappointed to hear of Jamie Dimon’s comments that walked back the Amazon, Berkshire Hathaway, and JPMorgan Chase healthcare venture. Apparently now it’s only going to be targeted to benefit employees of the three companies, and are sounding more like a group purchasing arrangement than the lofty endeavor we heard about last week. We need someone to shake up healthcare, but to do it in a way that includes a rational business plan rather than hype. I had hoped that these companies would be the real deal, but they’re already sounding like a fizzle.

In actual news that might help patients deal with the high cost of care, the FDA reports that 2017 was a record year for approval of generic drugs, with 843 medications receiving full approval. I haven’t seen any statistics on “formerly generic drugs that we let manufacturers re-brand and drive up the cost” such as Colcrys, but I’d like to see what that category looks like over the last several years. Despite a generic being available again after the three-year period of exclusivity for Colcrys, prices haven’t dropped anywhere near the historical price of generic colchicine. It was around 10 cents a pill prior to Colcrys, then went to $5 per pill, and even the generic still sits near $4 per pill ($2.50 if you can find a really good coupon). I get that it’s capitalism at its finest, but for patients, it’s terrible.

Even though we’re seeing a spike in flu cases, we have many patients coming in with severe illness because they’re trying to avoid medical costs. Patient deductibles reset on January 1, and with many more patients using high-deductible plans, cost of care is right in front of them rather than months later when the explanation of benefits arrives.

My practice’s cost of care is higher than it might be at a primary physician, but still significantly less than the emergency department, so patients are often pleasantly surprised at the end of their visit, especially if we’ve had to do a significant procedure such as a laceration repair or a CT scan. Our physicians are very conscious of our charges and how we fit into the overall healthcare expenditure scheme, so we can educate our patients as they make choices.

I wonder how many physicians truly understand how much the care they’re delivering costs and what value it does (or does not) bring. Every day I meet physicians who are having quality metrics data entered on their behalf and reported behind the scenes so they can check a box to avoid payment penalties. They have no idea what their actual numbers look like and aren’t using them to change how they deliver care. Now that is truly a waste of time, money, and effort.

The best thing I did this week was rearrange a meeting to be able to watch the Falcon Heavy live stream on Tuesday. Many kids dream of being an astronaut, but I took it one step farther and wanted to be the first doctor on a permanent space station. I figured by the time I finished medical school and residency, certainly we’d have civilians living and working in Earth’s orbit. That dream wasn’t to be, but I still find the idea of space travel fascinating. In some ways, my generation became somewhat spoiled by the seemingly “routine” nature of the Space Shuttle program even with its tragic accidents. Movies like “Apollo 13” and “Hidden Figures” gave us a new appreciation of what it took from a STEM perspective to make space travel possible. I still can’t believe we put people into orbit and later went to the moon with human computers and slide rules making it possible behind the scenes.

Hopefully a new generation of kids will be inspired by what they saw this week and will do some deeper digging. The Tesla may have been the first midnight-cherry roadster launched into space, but three other electric cars went before it on Apollo 15, 16, and 17. The story of our journey up to this point, both manned and unmanned, is inspiring. We need many more young people to be as fascinated by science and engineering as they are by pop culture and social media if we’re going to solve some of the biggest problems we’ll face in the next hundred years. If you didn’t have a chance to watch the launch, I highly recommend viewing the video, especially when the side boosters re-enter and land, starting around seven minutes into the flight.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/5/18

I receive quite a few requests from readers wanting to pick my brain about various topics. This week brought questions about Apple’s new Health Records. There are concerns that patients can change or hide information, which makes them less reliable should patients want to show them to physicians. A reader asked what I thought about it.

Frankly, hiding or changing information is nothing new. Patient-provided medical records of the past (mostly from memory) can have dramatically variable reliability. Sometimes people don’t remember a procedure or lab they’ve had done or don’t think a piece of their history is relevant. Other times patients intentionally alter the facts, leaving out details that they think might negatively impact their interaction with the physician or that might make it into records for potential release.

One of the best examples of this is asking patients about their alcohol intake. In medical school, we often joked about the rule that whatever the patient says should be doubled. The advent of EHR documentation has forced our questions to be much more detailed, so it’s difficult to tell whether that still holds true.

Does asking for more detailed information make the data more reliable? Do patients just round down because they’re tired of answering so many detailed questions? I would be interesting to study, although I don’t see such an exercise being funded any time soon. Patients also tend to intentionally leave out other confidential information such as sexual history, drug use, incarceration, and more. This happened in the paper world, and whether it’s worse in the digital world or not remains to be seen.

Then there are situations where patients might want to remove information because it’s inaccurate. I’ve had it happen to me, where an erroneous diagnosis was entered into my chart. Once that happens, it becomes nearly impossible to remove it. I’m surprised by how many ambulatory organizations don’t have good records correction policies. As long as an audit trail exists, erroneous information that hasn’t been acted upon should be able to be removed from the chart in a way that it doesn’t continue to haunt the patient. Of course, it’s a different story of the erroneous information has been acted upon, and it might need to remain in the chart in a modified fashion to document a decision process or an adverse event.

In many instances, a patient-curated chart might be more accurate than some of what we inherit from other physicians, especially if the patient is engaged and has a high degree of health literacy.

In short, I don’t think the fact that Apple will let people edit their records is a big deal. I personally don’t see the app getting a huge amount of traction, but we’ll have to see what the coming months bring once people start downloading and using it.

Another reader wanted to pick my brain about why I still attend HIMSS. As the cost of attending continues to rise, it’s something I weigh each year. So far, the benefits continue to outweigh negatives, and as long as they do, I’ll likely attend. What do I find beneficial?

• It’s an easy way to pick up 20 of the magical LLSA Credits that those of us who are board certified in clinical informatics need. Many of the sessions are actually relevant to what we do as informaticists, unlike some of the other LLSA-eligible coursework out there such as undersea / hyperbaric medicine and occupational health. Even though some of the sessions can be stale, there is often lively discussion and I’ve met a good number of people with similar interests in sessions that I correspond with.
• Meeting people face-to-face is valuable and HIMSS is an easy place to do it. Many companies don’t send people to the conference and don’t exhibit, but they know that there is going to be a critical mass of people wherever the conference is held. Last year, I had at least a handful of vendor meetings with people who weren’t registered for HIMSS but came to town to do business. I was able to use the opportunity to make decisions on products and strategy for my clients.
• Some of the less-flashy parts of the meeting are good opportunities to talk to people in the trenches. I spent a fair amount of time in the Interoperability Showcase over the last couple of years, talking with the people who actually build the solutions that are in the field. Once you get past the demos (which can range from engaging to lackluster), people are eager to talk about the work they’re doing and how it’s behaving in the real world. Presenters seem willing to talk about what they’ve seen go wrong as well as what has gone well, and that’s where real learning happens.
• The exhibit hall, in its own crazed, deranged, over-the-top way. It’s interesting to see what companies decide to put front and center. Sometimes it’s something truly interesting, and sometimes it’s just a smokescreen for the fact that they really don’t have anything new to talk about. It’s a decent way to check out comparable products from different vendors without having to schedule people to come to the office, and to be able to go back and forth and make purchasing decisions. I did this a couple of years ago with workstation carts. The time it would have taken to try to do real comparisons while meeting with vendors in the hospital would have been untenable, but having all the competitors on the same show floor was a timesaver.

I have to admit, I have a love/hate relationship with the exhibit hall, though. The excess makes me nauseated, as do the reps that can’t engage and the companies that think prospects aren’t smart enough to figure out that they’re showing vaporware. I’m tired of the luxury cars, jet skis, and Vespas, yet I’m entertained by the magician. For someone who spends most of their day being cool, collected, and logical, the fact that it’s so overwhelmingly overdone makes me think in a different way. And then there’s the scones — can’t forget those for putting a smile on your face.

I also have a bit of a love/hate relationship with the parties and social activities, of course with the exception of the late HIStalkapalooza. I enjoy the networking and meeting new people and learning what’s going on elsewhere in the industry, but attending both as me and as my alter ego can be tricky. I think the kind of event that a company throws says a lot about their strategy and how they see themselves, as well as how they’re trying to position their products. Are they the wild and crazy party guys? Are they the quiet trip to the symphony? Are they the people that invite you and then un-invite you? If the latter happens, that’s a huge red flag for a company you do not want to do business with.

I do love some of the social media meet-ups, even though I attend incognito. It’s good to talk with people who face some of the same challenges that I face in writing every week and trying to keep things fresh in an industry that sometimes feels like it has a deadly undertow. There’s no one in my real life that I can talk to about blogging or how to navigate the industry.

Last but not least, HIMSS is the one time of year I get to see my HIStalk family. What we do is usually a solitary activity, so it’s great to be able to spend time together and get to know each other as people rather than just lobbing columns and articles and “hey, did you see this?” messages back and forth.

I’d like to see HIMSS dial it down a little and work on providing a better value proposition for more attendees, but I’m not too hopeful that they’re going to change the recipe (or the venues, for that matter, since we’re likely permanently locked into the Las Vegas-to-Orlando death march).

Now that my brain has been thoroughly picked, let’s hear from some readers. Why do you attend or not attend HIMSS? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/1/18

Lots of chatter among my clinical colleagues about two main topics: Amazon getting deeper into the health space and the State of the Union address.

The Amazon topic definitely got a lot more traction, namely because of comments that the Amazon, Berkshire Hathaway, and JPMorgan Chase venture would be “free from profit-making incentives and constraints.” Many physicians blame the current healthcare crisis not only on hospitals trying to make a buck, but on payer executives focused on shareholder profits and their own career advancement. Healthcare industry stocks declined, including Express Scripts, CVS Health, and UnitedHealth Group.

The new company was also quoted as planning to center on “technology solutions that will provide US employees and their families with simplified, high-quality, and transparent healthcare at a reasonable cost.” There is an incredible amount of waste in our healthcare system, with estimates of up to 35 percent lost through several categories. Don Berwick broke the categories down in his 2012 piece on “Eliminating Waste in US Health Care” and I don’t know that they’ve changed significantly since then:

• Clinical waste (14 percent). Could be improved with high-quality care, use of cost-effective treatments, or standardization of best practices.
• Administrative complexity (9 percent). Could be improved through standardization of billing and collections, credentialing, and compliance.
• Fraud and abuse (7 percent). Payments for services not provided or billed by deception.
• Excessive prices (5 percent). Could be improved by tying prices to efficiency, outcomes, or fair profit.

There are some interesting findings in those numbers. Many of the laypeople I encounter assume that the entire problem with healthcare is with excessive prices, because they see the prices that hospitals and healthcare providers charge and the dramatic reductions through allowable charges and other adjustments. The higher “list” prices are often billed directly to patients without insurance if they don’t know to specifically request a cash price or adjustment.

Health-related businesses should be able to earn a fair profit, I don’t dispute that, but then there are the stories of price gouging, particularly in the drug industry. There are games that manufacturers play, such as purchasing a generic and finding a way to get a new patent so they can raise prices and control the market. Then there are unconscionable acts, such as grossly inflating the prices of medications that cost modest amounts to produce.

Those sources of waste, even coupled with the nefarious category of fraud and abuse, still pale in comparison to the losses via administrative complexity and clinical waste. I spent a good chunk of my clinical day trying to talk patients out of treatments they don’t need even though they think they do because they heard about them on TV or read about them in an article about “things your doctor doesn’t want you to know.” I also watch patients pay urgent care prices for treatments that should be performed in the primary care office, where they can’t get an appointment because we have a serious shortage of primary physicians in our community. I watch our practice spend incredible amounts of money on the billing and collections process, dealing with rejections, denials, and other attempts by payers not to actually pay. We experience these things on a daily basis while we work with patients who lack the resources to get the care they need. I can’t help but think the disconnect between waste and need contributes to the burnout that many of us feel.

When we hear that someone as upright as Warren Buffett wants to get into the fray, we can’t help but be hopeful. And despite what one may think about Amazon and their takeover of the marketplace, the company does seem to get things done and provide excellent service, which people crave. And when it sounds like they’re going to try to take down payers, which many of us find cocky and distasteful, that makes it even better.

The devil is in the details with an endeavor like this one, and it remains to be seen if they can make a difference where others have not been successful, or where they have failed to appreciate the complexity of healthcare economics.

Failure to grasp the complexity of healthcare leads us to the State of the Union address, where much was promised. Addressing drug prices will be a priority, with lowered costs and improved access to breakthrough drugs. Anytime someone talks about breakthrough drugs, many of us are skeptical – precision medicine sounds sexy, but the costs are substantial. The real savings may lie in figuring out to incent manufacturers of generic drugs and reducing the need for drugs through prevention and lifestyle change.

The State of the Union address also covered “right-to-try” legislation that would expand access for patients with terminal conditions so they can try experimental drugs that have not been approved by the FDA. It’s dramatic to talk about patients going “from country to country to seek a cure,” but in reality, the number of patients impacted by this would be much smaller than the number of patients who could benefit from basic, affordable healthcare. In some circles, right-to-try”is spoken of as cruel since treatments themselves may cause suffering with little promise of improvement. I’ve seen my colleagues in hospice care in tears while they care for patients and their families who have been given false hope.

The speech also touched on the need to address widespread opioid misuse. Since my practice just began a groundbreaking partnership with our local sheriff’s office to try to better support opioid addicts as they attempt rehab, I’m all for efforts to stop this serious epidemic. I don’t see big increases in government funding in the future, however. That’s one reason why our practice started this new protocol – addicts in our area have a high risk of relapsing before they can even make it to rehab because there are so few rehab beds available, and those that are open come with a great cost. We help bridge patients through opioid withdrawal while they try to stop using during their wait. The strategy has worked in other communities and we’re happy to bring our resources to bear.

There’s a lot going on in the industry today and frankly it’s been refreshing to hear providers talk about something other than how much they hate their EHRs and how much they think they’ve been meaningfully abused. I’m interested to hear what non-providers think about these recent developments.

Ready for Amazon to get in our business? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/29/18

We talk quite a bit in the health IT world about efficiency strategies such as muscle memory, use of order sets, care plans, and team protocols. Those strategies and solutions are mandatory if you’re going to try to get through a day filled with dozens of patient encounters while keeping your sanity and trying to finish your documentation before you go home.

In my office, the clinical team works in an open area in the center of the clinical suite. Patient rooms, procedure rooms, the laboratory, and radiology areas are wrapped around the outside. In many ways it’s good, because you can see what’s going on with patients – whether they’ve gone to x-ray yet, whether they’re back from the restroom, etc.

In some ways it’s a challenge because you’re always “on stage” when patients walk by on their way to an exam room or another destination. You have to manage your own positive or negative energy in that situation, and avoid scowling at the EHR or expressing your frustration when patients roll in the door 10 minutes before closing time with a chief complaint they’ve had for weeks.

Our practice is a high-touch, high-service environment where we work hard to make patients feel that we appreciate their business and are invested in their well-being. You get used to wishing patients a “feel better” or “thanks for coming in” as they walk by on their way out.

At times, the muscle memory becomes a bit reflexive, though. My staff had some laughs at my expense this weekend. I was heads-down documenting and a couple of patients had gone by with the usual comments – “Thanks for coming in, we’ll call in a few days to check on you” and “Let us know if you’re not getting better” and so on. Another figure headed my way and I was on autopilot as I thanked him for coming in and said that I hope he feels better. He looked at me a little quizzically but smiled. As he went around the corner, my staff erupted in laughter — he was the evening pickup driver from the reference lab and I completely missed his uniform and the fact that I had not seen him in the exam room.

It was a good lesson that sometimes our quest for efficiency can blind us to the details of our day and that we have to stay vigilant to make sure we’re doing the amount of listening, data gathering, and synthesis of information that we really should be doing. Being on auto-pilot is not necessarily a good thing. I’m sure it’s not the first time the lab rep has encountered someone who commented as I did, but it certainly made me think twice about being more attentive as people are walking by the clinical work area.

The weekend was super busy and confirmed that influenza is not yet on the wane. We’ve had to temporarily shut down our online check-in system because of the patient volumes we’re seeing. The automation was allowing large queues to build without the ability to intervene. When we have people arrive at the office instead, we can let them know what the wait time is at their location as well as where the next-closest location with a shorter wait time might be. I have four days to recover before my next clinical shift, and after tonight, I definitely need it.

I’m starting to do my HIMSS planning and happened across this graphic along with encouragement from HIMSS for people to join in order to save on registration. Even with the “member discount,” HIMSS is still an expensive proposition, with some of the more convenient hotels that are close to the convention center being some of the most expensive. I’ve stayed in enough budget hotels that are hike from the convention center to have earned a little splurge this year, which should be good for trying to rest and refresh between the conference and evening activities.

I tried to eyeball the session schedule, partly in response to some teasers in the HIMSS18 Preview edition of Healthcare IT News. Unfortunately, the one session I wanted to put on my calendar was advertised as being on “Wednesday, March 8” which unless I’m missing something, isn’t a date on this year’s calendar. I searched for the session on both Wednesday the 7th and Thursday the 8th and couldn’t find it on either, leading me to believe that perhaps it’s in another space/time dimension.

I’m also starting to put my evening plans together and there are openings in the social schedule. If you are interested in having Team HIStalk drop by your event, send along an invitation. We register anonymously so you won’t know exactly whether Dr. Jayne or anyone else will be in the house, but we’ll be sure to mention your event in our daily HIMSS recap. If your event is open to HIStalk readers, let us know and we’ll include it on HIStalk as we prepare for the big show. I love meeting new people at events and hearing their impression of HIMSS and the industry as a whole. Plus, I’ve got some new dancing shoes and am looking forward to being out on the town.

One of my medical school classmates reached out to me over the weekend knowing I’m in touch with the EHR industry. He’s trying to figure out how to attach his practice to the class action suit that was filed against Allscripts, alleging that the company “intentionally, willfully, recklessly, and/or negligently” failed to take precautions to prevent or minimize the recent SamSam ransomware attack. The filing is actually an interesting read and provides a primer on ransomware and previous similar attacks.

I explained to my colleague how a filing is laid out and that the responsible attorney is listed at the end. I’m not sure how serious he is about joining the Class or getting involved, but if he does and provides updates, I’ll certainly pass them along. Allscripts has tens of thousands of physicians using its platforms, but it’s unclear how many of them were on the impacted systems.

Are you ready for a ransomware attack? If not, why? Leave a comment or email me.

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