EPtalk by Dr. Jayne 4/26/18

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/23/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/19/18

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/16/18

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/12/18

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/9/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/5/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/2/18

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

Challenge #1

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

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

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

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

Challenge #2

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

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

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

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

Challenge #3

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

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

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

Email Dr. Jayne.

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.

Email Dr. Jayne.

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.

Email Dr. Jayne.

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.