EPtalk by Dr. Jayne 7/13/17

I’m going on Hour 8 being stuck in an airport and I’m getting a little punchy. My flight has been delayed a couple of times and I’m now looking at getting to my destination airport at 2:45 a.m. I’ll then have another hour drive to my client, assuming I find an alert taxi driver at that hour since a rental car will be out of the question.

My road warrior readers know what this is like, but for those of you who haven’t spent a good chunk of your lives at the whim of the airlines and the weather, please have pity on the rest of us when we arrive tired and perhaps a little bedraggled. Hopefully the old residency adage that “a shower is worth two hours of sleep” will hold enough to get me through the day.

The airport I’m in has a number of seating areas with electrical outlets, but unfortunately none of them work. Airport decision makers that are OK with that sort of thing should be forced to spend a couple of days stranded at their workplace, left in limbo without charging their phones or using electronic devices yet still being responsible for their daily work.

As long as my battery lasts, it’s a good opportunity to catch up on some vendor updates and try to make a dent in my email backlog. I’ve unfortunately already finished the novel I brought for emergencies, so I may have to break down and go back through security to hit the bookstore, which is bafflingly not in the actual gate area where all the captive people are.

CMS released an article about the “modernized National Plan and Provider Enumeration System (NPPES)” which is used for providers to obtain and maintain their National Provider Identifier (NPI) number. The document is heavy on detail, but from what I gather, they’re making the process around non-individual providers more secure and efficient. Not surprisingly, people responsible for maintaining the IDs of hospitals, nursing homes, and physician groups were sharing credentials, which helped lead to the changes. New fields have been added to PPES to document provider-specific information such as languages spoken, race, ethnicity, accessibility, hours, and the provider’s direct email address.

I’m fine with most of that information being collected since I have to provide it every year on various credentialing applications. Hopefully it will be shared somehow so I don’t have to fill it out over and over. I’m not about to provide my direct email address, however, without understanding how it’s going to be used and who will have access.

CMS also published the 2017 CMS Quality Reporting Document Architecture Category III (QRDA III) Implementation Guide Version 1.0 for Eligible Clinicians and Eligible Professionals Programs. For anyone suffering from insomnia, I highly recommend it as an alternative to the Federal Register or Ambien. For those of you who aren’t familiar with the document or who have never heard QRDA, it’s the recipe for electronic exchange of clinical quality measure data. Vendors must keep expert resources on staff who not only know the material, but who can expertly digest updates to the specifications and deploy them to developers, engineers, and more. It’s incredibly dense information and I admire the people who master it and make the world safe for those of us who need to report quality measures.

I’ve received some feedback on my recent piece on training and adult learning. Most of it has been of the “right on” variety, but one shameless vendor used it as an opportunity to try to guess what hospital system I use and market their simulation software. There wasn’t even a decent introductory greeting, just a link to HIStalk and straight into the sell. Any vendor who thinks that kind of approach works is sad. 

One reader noted, “I have deployed and trained everything from a full EHR to portals to secure messaging to population health. The percentage of clients who let me apply even basic adult learning principles was sadly very, very low. Yet, as we know, the downstream impact of poor and/or incorrect or irrelevant training lasts for years.” I have good data on the costs of retraining as well as the loss of productivity after poor training and I drag it out frequently to convince reluctant practice leaders to do the right thing.

Early bird registration is now open for the AMIA 2017 Annual Symposium in Washington DC in early November. This year’s theme is “Precision Informatics for Health: The Right Informatics for the Right Person at the Right Time.” I like the fact that they used “person” rather than “patient” because we need to continue to understand the impact of technology on the users, not just on patient outcomes. There are days where I feel like I’m a human participant in an unregulated study that some deranged Institutional Review Board approved without regard to the safety of its subjects.

AMIA has also opened submissions for the Workshop on Interactive Systems in Healthcare (WISH) program, which aims to bring research communities together around the challenges of designing, implementing, and evaluating interactive health technologies. The theme for WISH is “Citizen Science: Leveraging interactive systems to connect to our data, our families, and our communities.” Submissions are open through August 7.

There are entirely too many conferences going on during October and November, so it’s going to be a challenge to decide where to spend my travel dollars. In addition to industry meetings, several friends are headed to a patient safety conference in New Orleans and it’s awfully tempting to select that over the technology offerings, especially when gumbo and beignets are on the line. I also have to start thinking seriously about my primary care board certification, which is coming due faster than I hoped, so that will factor into the conference shopping process as well.

One trip I did decide on is my semi-annual pilgrimage to put my toes in the sand and think about little more than whether I am reapplying sunscreen often enough. I’ve got my coverage arranged and am looking forward to being disconnected from my clients, at least for a couple of days.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/10/17

I saw this CPR training kiosk in an airport on one of my recent travels. It got me thinking about how we train people for various tasks, whether in the healthcare IT world or just in general.

There has been a tremendous amount of research over the last several decades about learning styles and individual strategies for education. Part of this has stemmed from the recognition and diagnosis of more conditions that require adaptive strategies. Other forces shaping it include various pieces of legislation, such as IDEA, the Individuals with Disabilities Education Act. Most of the discussion in these areas has been around children and young people, however. The body of knowledge looking at adult workers and adult education is still there, although smaller.

Some people can absorb knowledge readily from printed material and others need to see a demonstration. Some need to learn by doing, and others by doing a task over and over until they feel they have mastery, especially if they work in a high-pressure environment or one with many distractions. Some people shut down in a group environment, where others thrive in that type of collaborative setting. Others need to learn in a very focused environment with few distractions to do their best.

I’ve worked with dozens of healthcare and vendor organizations over the past two decades and have only encountered a couple that seriously considered the idea of different learning styles or learning abilities when creating training for their adult employees. It seems like most training is designed with efficiency in mind – namely, efficiency for those presenting or delivering the content.

Another pressure is the ability to track consistently in training, which leads to more packaged offerings. I can attest to the fact that it’s harder to ensure consistency in training when you’re sitting with a physician in his office eating spicy chicken wings while covering the finer points of the EHR rather than in a classroom environment. Sometimes, however, creative strategies are required to ensure that physician makes it to training at all.

When I was a CMIO, I had to push for approval to offer training through multiple modalities. Let’s face it — some people don’t do well in a classroom setting and others don’t do well with self-directed learning. Regardless of individual learning styles and abilities, others are going to just goof off regardless of how or where you try to deliver training.

I had a boss who loved the idea of conference calls, especially for a geographically distributed organization where managers didn’t want to pull people out of the office. Although some people can learn on a conference call with a couple of dozen people, others find it a recipe for distraction and lack of engagement. My experience is that most adults know what type of training is better for them, and if given the option, they will gravitate towards an environment where they will be successful.

In addition to providing training through multiple modalities, organizations have to work hard to make sure that the people delivering training are strong educators, not just subject matter experts. There’s an assumption that is sometimes made that because someone is knowledgeable, that they have the skill to share information with others in a way that is engaging and effective. I could provide testimony from a good majority of my medical school class that found they learned more efficiently from reading course transcripts than from sitting in a darkened lecture hall. These people are now out in our healthcare IT classrooms, and given other work pressures, are looking for the most efficient and effective way of learning material.

Due to these pressure, many organizations turn to e-learning options. Some of these are little better than recorded webinars with some questions thrown on at the end. Others are fully-baked interactive sessions where attendees are required to replicate workflows and prove some level of mastery before they can advance. I do enjoy the latter kinds of sessions, although they have to be constructed carefully with the emphasis placed on the right portions of the workflow.

I recently QA’d a client training module where the physicians were forced to replicate a complex set of steps around laboratory processing, which wasn’t even part of their workflow. But due to the cost and labor intensity of creating those types of sessions, the organization had settled on a single track for clinical resources, which ultimately wasted the time (and cognitive energy) of many of their end users one way or the other. In all, when you looked at the number of wasted training minutes, it would have been better to put together separate sessions. But since those wasted training minutes fell on the cost centers of the end users rather than the IT budget, the decision was made strictly based on IT resources.

I do a lot of work with organizations that are threatening to switch EHR vendors or who feel that their software isn’t up to par. When we actually roll up our sleeves and assess the clients, we find there are operational or training issues at play the majority of the time. Particularly with stalled EHR adoption, a lack of training and/or proof of mastery leads to reduced schedules that never quite get ramped back up or to features that never quite get implemented.

Often when we look at causality, we find that providers were not required to attend training or show mastery, even when other users may have been held to those standards. I understand dealing with physician attitudes, but letting them take a pass on training isn’t the answer.

The other issue I see frequently is that there has been staff turnover and the new staff hasn’t received the same level of training as others did at go-live, or that they are just expected to try to learn the system during an on-the-job orientation. Often these organizations seem surprised when I recommend what seems like a straightforward solution to ensure everyone in the organization has received an appropriate amount of training.

Another area where we help clients is in formulating training strategies,  not only on what types of modalities they should use, but also how to deliver the training content in a way that is engaging and includes the right kinds of clinical pearls and examples that will keep the attendees engaged. Sometimes when you’re presenting the driest material, having a good story can make the difference. I’m happy to share my tales from the trenches and let the clients take them as their own.

Most smaller organizations (and many large ones) don’t have anyone on staff who is an expert in adult learning and may not have even heard of the idea of differing learning styles, so we’re happy to fill that niche. Like the CPR training kiosk in the airport, we have to strive to meet our students where they are.

What strategies does your organization use to maximize training impact? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/6/17

I’ve been watching a dialogue about medication reconciliation unfold on one of the AMIA email lists. The general consensus seems to be that medication reconciliation is a “wreck” and that there is tremendous variation in how/when organizations apply it.

In the various EHRs that I’ve used, there are many existing choices in reconciliation pick lists, and they may not always apply to a given care setting. For example, “substitute per formulary” might make sense for a hospitalized patient when they may go back on the original medication at discharge. But in the outpatient setting, if you’re doing a formulary interchange, you’re actually going to discontinue one medication and start another, which requires a different set of documentation.

There are also situations where you need to hold a medication because it’s not essential or could lead to complications (for example, oral contraceptives or daily aspirin) but still want it reflected as something that might have an ongoing influence on the patient’s current state (ongoing clotting or bleeding risk), but I have yet to see an EHR medication list that manages this well.

One respondent commented that there are options needed that don’t traditionally appear as choices during the medication reconciliation process, such as “the patient was never on this medication.” There are other choices such as, “patient’s family member says they are taking it, but patient claims they have never seen the pill,” and “patient taking every other day due to cost” that we’ll never see reflected on a reconciliation list but have to be added as a free-text or “other” type comment.

There are many patients for whom medication reconciliation is an impossibility due to dementia, psychiatric issues, or other medical conditions impairing memory and thought processes. Some of these patients have caregivers who can provide the information, but others don’t.

In the urgent care setting, we rely heavily on the medication history information available through our EHR, but unfortunately, it doesn’t always have the information for cash prescriptions since it often feeds from pharmacy benefit managers. The state prescription drug monitoring program helps fill that gap for some medications, but as a provider I often end up looking in multiple places or asking staff to call pharmacies or family members to try to get an accurate history.

For us, every patient is a transition of care for regulatory purposes as well as an opportunity for error when a medication gets lost in translation. The need for a formal reconciliation varies with the patient and their complaint. What if a visit is a transition of care but doesn’t require prescribing? Clinically a reconciliation really isn’t needed for an episodic complaint (laceration closed with glue), but there are challenges associated with saying staff can do it sometimes but not others.

The discussion brought other points about lack of functionality in EHRs in general, including the ability to trend increasing or decreasing doses over time. I know it took the better part of a decade for my previous EHR to get functionality that allowed prescriptions for different doses of the same medication to link, so that you could see the patient who started on 10mg of blood pressure medication and was gradually worked up to a higher dose. This was tricky because the system relied on NDC numbers initially, which are different not only based on dose, but also on how the medication is supplied. Personally, I don’t care whether the medication came in a blister pack or a stock bottle, but that’s how NDC worked. It was only after the system converted to RxNorm codes that things started making sense. Still, it’s hard to track things like when the patient is taking half of a 20mg tablet then starts taking a whole one, etc. That kind of documentation often winds up as unstructured data that can increase patient risk unless that unstructured data is kept attached to the medication list, which some systems don’t allow.

There were also comments about the fact that some providers don’t have any concept of ownership of the medication list. I saw this often in my past life as a primary care physician, when I would receive dictated letters from consultants that were missing most of the medications the patient was actually on. When transitioned to the EHR, these providers still didn’t feel the need to participate with the medication list, let alone try to perform a reconciliation. I saw at one hospital when they made reconciliation the job of the admitting physician of record that the procedural subspecialists (particularly orthopedic surgeons) developed a new habit of having the patients admitted under the PCP with themselves as consultants. In that case, no good policy goes unpunished.

At the same time this discussion was unfolding, I was contacted by a client who recently implemented functionality that allows them to electronically cancel prescriptions. Unfortunately, their local pharmacies don’t yet support this feature, which led to several days of confusion until they figured out what was going on and returned to their phone-based process. Until the pharmacies upgrade their systems, there’s little more I can recommend other than calling the pharmacies and discussing the impact and asking them to lobby their corporate bosses for an upgrade.

This has been the plight of physicians for some time now, as EHR vendors are forced to add functionality that isn’t supported in the real world. Despite electronic prescribing of controlled substances being required in several states, it’s not required in my particular locale. As a result, only a little more than half of pharmacies support the functionality. It’s kind of like being required to have LOINC codes for interfaced lab results but there not being a requirement for vendors to send the codes with the result transmissions.

I’ll be interested to see what comes of the medication reconciliation discussions and whether there is scholarly activity that might push vendors or regulators to change how they hope to steer medication reconciliation in the future. I was encouraged by the number of people willing to engage in the discussion or collaborate in future projects. A group of motivated clinical informaticists is a powerful thing indeed.

How do you feel about the current state of medication reconciliation? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/3/17

No surprise here. A recent survey by the American Medical Association finds that physicians don’t feel they are prepared for quality reporting rules. The survey reached out to 1,000 practicing physicians who have been involved in discussions and decisions related to the Quality Payment Program within their practices. Nearly 90 percent of the physicians find MACRA’s requirements burdensome, with fewer than one in four feeling well prepared to meet those requirements in 2017. Specific areas cited as burdensome included the time required to report performance, understanding requirements, MIPS scoring, and the cost to capture and report data.

The AMA data notes that a little more than half (56 percent) of physicians plans to participate in the Merit-based Incentive Payment System (MIPS) with 18 percent expecting to participate in Advanced Alternative Payment Models (APMs). There were also some interesting statistics on how well physicians feel they understand MACRA and the QPP. Although 51 percent of physicians feel they are somewhat knowledgeable about the topics, only 8 percent describe themselves as deeply knowledgeable.

Although previous participation in quality programs such as PQRS and Meaningful Use seems to have helped physician readiness, only 25 percent of those with prior reporting experience feel well-prepared for the QPP. There were also concerns raised that those who may be prepared for 2017 reporting may not have the long-term financial strategies in place to succeed in 2018 and beyond. Small practices were called out as needing more assistance to be prepared, where large practices were more likely to be concerned about the organizational infrastructure needed to effectively report data.

Where the larger practices were more likely (79 percent) to have previously met Meaningful Use Stage 2, the smaller practices were mixed with 45 percent yes, 44 percent no, and 12 percent not knowing whether they had previously complied or not. Not surprisingly, primary care specialists were more likely to participate in APMs than non-primary care specialists (22 percent vs. 15 percent respectively). Multi-specialty practices seemed to be better prepared than hospital-based, solo, or single-specialty practices with greater participation in Advanced APMs and more optimism around a positive payment adjustment in coming years.

The report notes that its findings support assumptions that although some challenges are universal, small practices will need more assistance in meeting their goals. There is opportunity for CMS, medical societies, and other stakeholders to educate physicians and to help practices prepare for success.

Although the report doesn’t mention them specifically, some of those other stakeholders include vendors and consultants. I’ve seen a pretty significant uptick in messaging from the latter, although nearly all the emails I receive seem to be for clients on Epic. The vendor emails I receive are mostly targeted towards smaller practices who may not be on an EHR or who are looking to switch. These communications make everything look pretty rosy as far as ability to report on their platforms, but neglect to mention the amount of work needed to complete a conversion or bring a practice live on EHR in the first place.

My vendor is actually pretty good at providing information around the various quality and regulatory programs out there, even though it’s a niche specialty vendor and many of its clients have opted out of Meaningful Use in the past and plan to opt out of quality programs in the future. Whether your practice has opted out or not, there needs to be an ongoing dialogue and analysis to make sure that their plan still makes sense. Payer mixes can shift over time, especially with an aging population, and what may have made sense a couple of years ago may not make sense moving forward.

For independent practices, ongoing dialogue is also needed with local health systems or hospitals to determine how their strategy for value-based care will impact everyone else. There are several major players in my area, and none of them seem particularly interested in sharing data with the little guys, especially when smaller groups are potential competitors for procedural volume. It still seems to be less about the patient or controlling costs than it is about market share. I have yet to see any medical staff meetings devoted to helping admitting physicians stay in business by learning how to handle Meaningful Use or MIPS. I do see a lot of attempts to purchase practices, however.

CMS does seem to be trying to do its part to educate physicians, and recently released some new resources on its Quality Payment Program website to try to help us through the maze. At least two of the new resources – MIPS Measures for Cardiologists and Advancing Care Information Measure Specifications/Transition Measure Specifications – are updated versions of previous documentation. This highlights the difficulty in staying up on everything, and the fact that even when you think you have the game figured out and have put processes in place, the game can change. Other resources include vendor lists for Qualified Clinical Data Registries (QCDRs) and Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS. This highlights the complexity of the program, where many participants need to work with multiple vendors to even have a chance of doing it right. The list of new documents is rounded out with an Introduction to Group Participation in 2017 MIPS and a MIPS Measures Guide for Primary Care Clinicians.

I was a little disappointed in the primary care document, which seemed to be overly general and was described as a “non-exhaustive sample of measures that may apply to primary care.” It seemed to be more of a filler to point physicians to the main QPP.CMS.GOV site for more information. Even for those of us who have been steeped in the content, requirements are pretty complex and implementing them is daunting if you haven’t done the pre-work to get all your clinicians on the same page and operating as a cohesive organization. The majority of the consulting work I’m doing these days seems to be in the change management / change leadership space, where I spend a fair amount of time trying to convince reluctant providers that having standardized care plans and office processes really is a good idea and not an infringement on their individuality.

Regardless of our feelings about it, MIPS, the QPP, and Meaningful Use (Medicaid-style, at least) are not going away. It will be interesting to see how physicians feel about their level of understanding a year or two from now.

Are you ready for MIPS? If not, why? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/29/17

Several readers who have ties to consulting or staffing firms have reached out to me regarding my recent Curbside Consult that covered a friend’s layoff following her employer’s migration to a new EHR platform. I am very appreciative of the gesture and it sounds like she has some promising leads.

The piece had several reader comments, with one calling me out for using a full consulting schedule as an excuse to not do business with her former employer rather than telling them I didn’t want to work with them because of how they treated their people.

Like so many large organizations, I suspect here that the proverbial right hand doesn’t know what the left hand is doing, and there is going to be some reorganization that takes place. Eventually someone with their head on straight will be in control and they’re going to need qualified help.

I recall a similar situation with another employer who downsized a division in a way that strongly smelled of age discrimination. Several team members took early retirement. One of the analysts had the last laugh when she came back as a consultant making double her salary while also collecting her pension. She continued working there for another four years. Had her new employer refused to work with them on principle, she might not have had that opportunity for payback.

It’s human to want to sock it to bad people on the way out, but it seldom works out well. I recently coached a former colleague on how to write his resignation letter. He wanted to tell the truth about how the employer was abusive, negligent, and reckless, spurring his decision to leave. I counseled that the standard “This letter serves as my notice, my last day of work will be X” approach would be a much better way to go. He went with the emotional response and ended up being perp-walked through the office without even a chance to pack his cardboard box of personal belongs. His former boss also immediately started attempts to sully his reputation. It’s not to say that the boss might have acted that way regardless, but I don’t think my friend having his say helped the situation.

Even when you’re leaving a job voluntarily, it’s often difficult. Depending on your role and the amount of privileged information you have access to, there are concerns as to whether your resignation will simply be accepted or whether you will be escorted from the premises.

When I left one hospital position, I was fairly confident they were going to do the latter since I had access to their recruiting and acquisition strategies and was going to a relative competitor. I prepared for the resignation for several weeks, slowly moving things out of my office, but keeping enough personal items for it to not appear suspicious. On the day I was planning to deliver my resignation letter, the file cabinets were empty and the medical texts in the book case had been replaced by random binders, coding books, and training manuals.

I had gotten myself to a place where I was mentally ready to be walked out, so it was surprising when they asked me to work through my entire four-week notice period. Several days later they told me that they were going to use my resignation as an opportunity to change the role to a part-time position that would only cover about 20 percent of my job duties. They didn’t plan to continue the kind of change leadership and process improvement work I had spent most of my time doing. They didn’t expect me to perform any knowledge transfer since they hadn’t identified anyone to take the remaining portion of the role.

I spent three weeks doing little to nothing, attending meetings like the walking dead just to have something to do. Finally, they identified someone to take the remaining part of the role and we had three days of frantic hand-offs and a request to extend my employment.

Now that I’m in consulting, I’m constantly in a state of either starting a new job or leaving one. When I really connect with a client, it’s hard to leave, even if we’ve accomplished the goals we set out to meet together. Sometimes, however, the leaving is pretty easy, as it was this week with a client I can only describe as extremely challenging.

They brought me in to do a stakeholder assessment and to look at why they are still struggling with EHR adoption six years after go-live. They’ve got some serious leadership deficits and don’t seem too keen on doing the work needed to move to a place where the physicians have buy-in on what the parent company wants them to do.

Even though I was supposed to be winding things down this week, they spent my last day on site arguing with me about when the physicians should complete their documentation. They allow 10 days for the physicians to finish ambulatory visit notes, which is absurd. They have all kinds of reasons why the physicians can’t complete their notes in a timely fashion and aren’t interested in learning strategies to remediate the situation.

It was like dealing with an argumentative teenager. I think they actually believed I would change my opinion if they continued to badger me. They never seemed to understand that it’s not my opinion that counts — it’s that of CMS, auditors, and their medical liability carrier. I wish them luck defending their policies when an audit or subpoena reveals charts completed more than a week after the fact.

We talk quite a bit about healthcare technology, but sometimes it’s the low-tech solutions that really matter to physicians. I experienced this first hand over the weekend when my stethoscope gave up the ghost. I should have known it was coming since I already had to replace the ear tips and diaphragm. Although I had some spare parts at home, I didn’t have the diaphragm retainer ring that had failed. According to the websites that usually carry spare parts, mine was so old they didn’t stock replacement kits.

I started to despair. I own half a dozen stethoscopes, some of them special purpose (from those neonatal ICU and pediatric rotations) and others that I’ve bought to have a spare or a less-expensive version to take on volunteer trips. But I’ve always been partial to my first stethoscope, my constant companion since the beginning of clinical rotations.

I made a last-ditch effort by emailing 3M about options and was pleasantly surprised to find out that a certain model repair kit would do the trick even though it isn’t officially listed as being compatible. They also sent the handy Amazon link to buy it, so I should be back in business in a couple of days.

What’s your favorite piece of healthcare technology, IT-wise or other? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/26/17

A reader recently reached out with some thoughts on life after a large go-live:

Our large academic medical center went live with ambulatory EHR several years ago. The clinicians and residents were used to many of the system features already from inpatient, but we still had a lot of configuration decisions, setup, training, reduced volumes, then a fair amount of post-live elbow-to-elbow support in decreasing amounts. Though there were a few frantic phone calls with crying and screaming clinicians or administrative staff at the time, it went fairly well all things considered.

However, many post-live optimizations were never completed and it was assumed that new hires could just be trained by existing staff. There is minimal formal training and no discussion of the individual configuration options that we helped people set up during rigorous pre-live training. We lack discussion of workflows and regulatory requirements that have shifted or are no longer tracked, and other changes have been made to the system that have broken prior customizations. Documentation of our individual decisions was by vendor consultants and I don’t think any coherent documentation was left behind at the end of the engagement. We aren’t even alerted to processes that have obviously become broken because the front-line clinicians and staff don’t know any different, assuming that it’s just the poorly designed software at fault. And the further we are from go-live, the worse it gets. It’s like throwing the frog in boiling water or turning the heat up gradually.

Do other systems or consultants do a better job of managing this as they find themselves several years post go-live?

At least in my experience, many organizations struggle with this. However, I see it more acutely in organizations that treated their EHR projects like IT projects instead of operational or clinical projects. The go-live itself is often seen as the endpoint, with little vision around the ongoing efforts needed to maintain a system and its users at a top tier level of performance. There is a lot of money spent to support the go-live, so groups tend to economize on ongoing support.

It sounds like your approach leading up to the migration was fairly tried and true, making the most of existing knowledge from the inpatient system while tending to the decisions that needed to be made specific to the ambulatory system. You had a good amount of elbow support, which many clinicians appreciate. Beyond that, many groups find a greater level of success spending more resources upfront to encourage (and/or force) providers to complete a set number of test patient scenarios prior to the go-live, which potentially makes for an easier go-live with less reductions to the schedule or less elbow-to-elbow support.

I personally like requiring physicians and their care teams to document a good number of patients with their most common chief complaints, along with documenting sample visits on some of their most complicated patients. That tends to prepare them a bit better and they have better mastery than if they try to learn during go-live. I’ve found the stress of the go-live itself tends to make learning difficult.

As you mentioned, post-live optimization is where things often fall apart. Some organizations don’t even budget a post-live optimization program into their implementation, which is a grave mistake. Budget permitting, I like to perform circle-back visits at two weeks, 30 days, 60 days, and 90 days after go-live. This allows the support or implementation team to see what processes are working well in the office and what processes have become ripe for bad habits. Even with the most rigorous training and practice, it’s hard to retain all the nuances of different EHR workflows, especially for patient care situations that you don’t see every day.

For those groups that did budget a post-live optimization program, I frequently see those resources shifted to other initiatives that have taken priority for one reason or another. Maybe the group shifted into acquisition mode, maybe they joined an ACO, but optimizing the EHR and practice operations seems to frequently fall by the wayside.

You mention shifting regulatory workflows and that is an issue I see frequently, especially with practices that participate in multiple grant programs. Once I worked with a group that was insistent that they needed to document the date of the last dental exam on all patients. I continued to ask “why” to every reason they gave until we distilled down to the fact that it was originally mandated for a grant in which they hadn’t participated in more than three years. They had been on the brink of customizing a template to capture that date, not knowing that it wasn’t important except for a sub-group of patients for whom that information was already captured in the system’s health promotion templates.

Institutional memory can be a blessing and a curse in situations like this, the latter when people remember things being one way but not the underlying reason and are so dedicated to keeping things the same that they lose sight of what they are doing. It can be a blessing when you have a stable workforce that can do things like train new workers, but that is certainly the exception in many ambulatory workplaces today.

The idea that workers will just train the new people as part of their ongoing daily duties doesn’t tend to produce desired outcomes. In practices where I’ve worked, on-the-job training has been a bust as trainers don’t have time to focus and trainees don’t understand what is best practice and what is their trainer just making it through the day. Fortunately, in my current practice situation, our version of on the job training actually has a rigorous schedule behind it with checklists and skill proficiency. The trainer and trainee are added to the office schedule on top of the normal staff, so that the training process can be focused. It costs more up front to take this approach, but it’s been more than worth it.

Training of new employees has to include training for user-level preferences and configurations because these are the things that make EHR workflows efficient and personal. When I perform EHR optimizations (or EHR clean-up missions, as the case may be), these are the first elements I emphasize. They’re often the proverbial low-hanging fruit that gets users into a more receptive state of mind for when you come back to cover more challenging workflows.

I cringed when I read the comment about the documentation of decisions being done by consultants who didn’t leave coherent documentation. That’s one of the things that pushes me over the edge. Documentation and hand-off should be part of every engagement, to ensure that your client hasn’t simply been handed a fish, but rather taught to tie his own flies, cast the line, reel it in, fillet it, and cook it over a fire that they have built.

In my consulting engagements, the decisions are documented not only in a spreadsheet-style matrix, but in a corresponding executive summary slide deck. It’s not enough to know that a customization was made, but you need to know why so that you can determine whether it needs to be maintained. Customizations should be reviewed with every major upgrade and evaluated to see if they need to be retained or if they can be retired in favor of new functionality. It’s also a great opportunity to make sure the physicians for whom they were built still work in the organization. Otherwise, as a general rule, the customizations can be put to rest as long as no one else has adopted them.

In those situations, I like to use database queries to determine if the customizations are even used. I once worked with a physician who was ready to fight tooth and nail to keep a customization until I showed her the queries that proved that out of every 100 times she used the template in question, she only used the “have-to-have-it” checkbox one time. In that situation, free-texting would not have killed her.

The comment that users assume the software is at fault rather than looking at the process also resonated. I’ve found that the organizations that handle long-term sustainable process improvements the best do so because they have dedicated teams that continue to work with practices to make sure changes are adopted and incorporated in an ongoing fashion. They make sure users have ready access to training in a variety of formats, whether written, recorded, live, or 1:1. They recognize that users have different learning styles and often crazy schedules and may need accommodation to become truly proficient with an application. And they’re willing to challenge whether it’s a problem with the user, the training, the content, or the technology. They’re not afraid to ruffle feathers getting to a root cause or trying to do the right thing for patient care and user satisfaction.

I work daily with clients who aren’t aware that their vendors have documentation around not only best-practice EHR workflows, but best practices for running the office in general. Several vendors have in-house consultants who are available to help clients with these issues, although I’ve seen come clients give them the cold shoulder because the feel the vendor-employed consultants are inherently biased. I’ve seen them argue with vendor educators who are trying to emphasize well-documented and published clinical best practices, belittling them and dismissing their wisdom just because their paycheck comes from a vendor.

The best example I’ve seen is a group that argued with the vendor about hanging signs to encourage diabetic patients to remove their shoes and socks for a foot exam. They told the vendor it was outside the vendor’s scope, despite the vendor rep being a registered nurse and having citations from articles proving the approach as effective in improving foot exam performance metrics.

The bottom line is that some groups do handle the ongoing maintenance of a system better than others. Those that have a plan accompanied by leadership buy-in and a corresponding budget do best. Others that don’t meet those criteria often become easy prey for vendors trying to sell replacement systems. It’s amazing to me when a client won’t sign a $50,000 proposal for optimization, but ends up paying millions for a new system when their previous system would have been just fine had they maintained it. It’s like never changing the oil in your car and then being surprised when the engine seizes.

How does your organization handle post-live support and optimization? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/22/17

The HUMAN Project calls for New Yorkers to “help power the scientific research and societal solutions of the future.” The initiative is looking for 10,000 participants who are willing to share virtual reams of personal information, including cellphone locations, credit card habits, and blood samples over the next 20 years. Researchers plan to use the data for insights into health, aging, education, and more. Baseline data for accepted participants includes everything from basic laboratory panels to IQ and genetic testing with repeat labs every three years. Participants are eligible for a payment of $500 per family.

The mention of the word “family” made me wonder if they’re going to include children for all of the projects. Although minors are included in research studies, it’s usually for a defined goal rather than for a large set of projects. What happens when minors reach majority and no longer want their data shared? Can they opt out? The website mentions the need for research beta testers and will accept participants age 13 and older.

The project has paid a lot of attention to data safeguards including encryption and firewalls, but as we all know, nothing is non-hackable. They claim outside researchers won’t have access to raw data, but we’ve seen past efforts to re-identify anonymized data sets that have worked. The effort is being coordinated by New York University, and I would love to be a fly on the wall for institutional review board discussions. It looks from the website like they handle the consent process for their beta testing through an online consent portal that allows potential participants to watch videos about consent, which it says are “quicker and easier” than reading the full text of the informed consent document. Personally, I’d want to read every word, but that’s out of the question since I don’t live in New York City and that’s one of the primary screening criteria.

On the other hand, the National Institutes of Health is looking for 10,000 beta testing participants for its “All of Us” precision medicine research program. The beta program is the precursor to a plan to power their research with a cohort of 1 million patients as they look at genomic, clinical, and lifestyle data. The beta program will be coordinated by the University of Pittsburgh Medical Center, which plans outreach at more than 100 locations during the next five months. Ultimately, NIH plans for the program to last for 10 years, and it doesn’t appear to have any geographic restrictions.

Compared to the HUMAN Project, All of Us looks a bit more like a traditional research platform, open to adults in the US who are able to consent on their own and who are not in prison. Participants have to be over 18, although they may allow minors in the future. Also in contrast to the HUMAN project, participants aren’t required to have smartphones to participate. That’s likely to give it a broader cross section, although they’re narrowing it down to English and Spanish speakers currently with a plan to expand to more languages in the future. I don’t have an invitation code so I couldn’t get very far with the website. It’s a little less sexy than the HUMAN project but feels more accessible.

Given the nationwide nature of their 100 beta sites, and the fact that I’m a patient at one of their partner hospitals, maybe I’ll get an invitation. Participating would certainly be an experience. They hope to launch the major part of the national project in late 2017 or early 2018 – once testing is complete. I appreciate a vendor that says their go-live dates are fluid based on the results of testing, because you don’t always get that candor from EHR vendors. Not to mention, the technology isn’t the only thing being tested – it’s the systems, processes, and engagement approaches as well as their ability to build rapport with diverse groups of people in many regions.

All of Us has similar language on its website about data security and safeguards. Given the fact that NIH is sponsoring the initiative, I think it’s safe to say that they understand the implications of a breach or hacking. Thinking back to the HUMAN project and its app, though, it seems that most people don’t give a lot of care to how or with whom they are sharing their data on their phones. Among people I’ve informally polled, most accept all requests for application permissions (and therefore data sharing) because they don’t have the time or interest in determining whether they can use the app they want without allowing permissions. Indeed, we live in interesting times.

I mentioned last week that my EHR platform was experiencing some API issues, and I was annoyed by the fact that they kept sending us emails about the outage that offered no information. A reader responded, mentioning similar struggles and asked what changes would make the communication more meaningful. First, I’d like more information on what stage of investigation the issue might be in. Are they still gathering data? Are they running traces? Are they to the point of troubleshooting? Have they even identified the problem yet? Once the problem has been identified, I’d like to hear about potential timeline to resolution, whether they’re testing a fix, etc.

I’m sure a lot of customers don’t want that level of detail, although it is nice to know whether they’ve even found the problem and are fixing it or whether they’re still digging. I’d also like a published timeline for communication, like we had when I was a CMIO. If it was a critical outage, we provided an update every hour. Major but non-critical outages led to updates every other hour. And minor issues were updated mid-day and at close of business. Finally, I would want notification that the issue was resolved. In the case of the API issues we were having, there was never a notification that they were fixed. We stayed in the application with some workarounds rather than going to downtime procedures, but had we been on paper I definitely would have preferred a notification rather than having to keep checking to see whether things had been sorted. Since the problems were mostly with pharmacy search and e-prescribing, they were difficult to replicate using test patients.

Email Dr. Jayne.

Curbside Consult by Dr. Jayne 6/19/17

I received some sad news from a friend this week whose employer recently migrated to a single vendor platform. She’s worked for her health system’s IT team for years, primarily supporting the ambulatory practices on the practice management application. When the group initially decided to migrate to a new platform, all IT employees were given the opportunity to either transition to the team that would be supporting the migration, or to remain in their current positions with the understanding that following the migration, they would move to positions supporting the new application. She’s developed deep relationships with her customers over the years, and agonized over the decision. She finally decided to stay where she was, keeping the lights on for the legacy application users while everyone else focused on the shiny new thing.

Plans changed along the way, however, but the leadership didn’t give any hints to the support teams. Literally five days after cutover she was given notice that her employment would be ending in two weeks. She of course is welcome to apply for any of the new support positions, however, all of them were posted as requiring current certification on the new system. Having been a CMIO, I understand how these decisions are made, but it seems like a gutless way to get rid of people. I’m not aware of this particular vendor being willing to accept freelance people off the street to train and certify on their products, nor would it be reasonable to expect a full-time employee to try to train on a new system on the side and at their own expense.

It’s not about reducing headcount, because they actually have more posted open positions than the number of people they’re laying off. More likely, it was seen as a way for the health system to get out of paying for training. Not to mention, getting rid of people with 15 to 20 years experience and replacing them with people earlier in their careers is generally cheaper in its own right. The problem, however, is that they didn’t just jettison the employees, but they also got rid of the relationships and history they have built with their customers. They’ve given no weight to the fact that these support workers know their customers, know how the offices run, and understand the dynamics at play. One might think that could be part of the strategy, if they were worried about the “old guard” creating complications with new processes and policies, or being a barrier to effective change.

However, I know enough people at her employer to understand that they didn’t do hardly any work on people or process, but rather treated this migration simply as a technology swap-out. Based on their outreach to me to see if I’m available for some consulting work, I suspect they’re reaping what they sowed as far as failing to use the opportunity for further standardization and clinical transformation. I hate, though, to see good employees negatively impacted by lack of executive strategy and will. Fortunately, my schedule doesn’t allow me to get involved with them right now, because I’m not sure I could do it in good conscience. Although they may think this was strictly a financial decision, when you factor in the loss of “soft skill” expertise, such as knowing how best to handle Dr. Frazzled’s high-maintenance billing team, and the ramp-up time for new technical employees who don’t know the landscape, I bet there is a negative financial impact.

One could argue that there is also a larger domino impact, looking at a health system that provides a large volume of uncompensated care. They’re about to release quite a few workers in their 50s and early 60s, and based on IT hiring needs in the city, they’re going to struggle to find jobs. Eventually COBRA runs out, assuming former employees can afford it in the first place, and depending on what happens with healthcare legislation, they may not be able to afford individual plans. They may wind up needing uncompensated care, with ultimately greater cost to the system in the long run. Although the logic may be a leap, it’s something to think about especially when you’re talking about a non-profit organization that advertises the breadth of their community-mindedness.

Those of us who have seen the balance sheets for those kinds of organizations know the numbers are a little different from what they advertise. They can afford nearly half a billion dollars for an EHR migration, but they’re going to cheap out on training a couple dozen seasoned employees who have been loyal workers, some for decades. They can afford hundreds of millions in capital expenditures but don’t even provide cost of living wage increases to their low-paid clinical employees, let alone to the support teams like IT. Especially for nonprofits, shouldn’t charity begin at home? As a small business person, I understand that businesses need to make money. Even the not-for-profit ones need money to further their missions. Too often, however, that mission is keeping up with the proverbial Joneses rather than being good stewards. It reminds me of when I was in the hospital this winter, when I didn’t get scheduled medications on time due to a staffing shortage. Is it really cheaper to risk a poor outcome? When did people become less valuable of an asset than mammoth IT systems or another outpatient imaging facility or ambulatory surgery center? And do we really need another glass and marble temple to healing when the actual patient care suffers? Every time I think about going back to a health system or large hospital, these are the kinds of issues that keep me up at night.

Fortunately for my friend, there are plenty of opportunities in her area that use the system on which she is proficient. She has a great work history and strong references, so hopefully she will find something quickly. I’d be happy to bring her on to do some projects, but not enough for a full-time position. I’ll help her however I can though, until she finds something permanent. I’m sure her story is representative of those that happen every time a hospital or health system makes a big change. But just because it happens, it doesn’t make it right.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/15/17

Congratulations to the University of Arizona College of Medicine – Phoenix for receiving full accreditation from the Liaison Committee on Medical Education. The school was created more than 10 years ago to help address Arizona’s physician shortage and was originally a branch campus of the UA College of Medicine – Tucson. Now, UA joins the ranks of only a few universities with multiple accredited medical schools. Starting up a new medical school is a daunting process, whether it’s a branch of an existing school or not. I had the pleasure of speaking recently with one of the faculty members at the Dell Medical School at The University of Texas at Austin who shared some of their trials and tribulations. Becoming fully accredited is quite an accomplishment.

While EHR vendors are working on their certification testing, many are expanding the incorporation of user testing. NCQA is also getting into the act with a website usability and navigation study. I appreciate the fact that they’re trying to make the website easier to use, but I wish they’d make their recognition programs less cumbersome and more affordable for primary care practices. I’ve been contacted by multiple clients who are struggling with the transition from their 2014 program to the updated 2017 program. One of my staffers is attending the course in Washington, DC this week, and at nearly $900 for one day it’s certainly not cheap. Tack on some hotel and travel, and it’s a lot for a small practice to spend for training.

Fortune recently released its list of the 500 companies that generated the most revenue in the last year. Multiple healthcare systems made the list, including HCA Holdings, Community Health Systems, Tenet Healthcare, DaVita, Universal Health Services, LifePoint Health, Kindred Healthcare, and Genesis Healthcare. Health insurers made it on the list as well, with UnitedHealth Group ranking at number six. Other payers making the cut include Anthem, Aetna, Humana, Centene, Cigna, Molina Healthcare, and WellCare Health Plans.

A friend sent me this piece about “Perfect Non-Clinical Income Ideas for Doctors.” I had to laugh at some of the suggestions, especially considering the time pressure that many physicians face. I don’t imagine that many physicians would be up for multilevel marketing, peddling insurance, or renting out their cars. Not to mention, the author fails to appreciate the concept of “passive” income. The only side businesses I see my colleagues involved in are in the property ownership realm, and none of them are personally managing their properties.

My practice opened two new locations in the last 30 days, so I’m working more clinical shifts than I usually do. Unfortunately, that increased schedule came right when my vendor is experiencing an ongoing problem with API errors. The impact is worst when we’re trying to use the e-prescribing functionality or when staff is trying to search for the patient’s preferred pharmacy, which means it impacts pretty much every patient when it happens. Although I appreciate the communication, receiving an email every two hours that essentially says “yes it’s still going on, and no we don’t know how to fix it yet” becomes annoying. Even while I scowled at my inbox, however, I did get a kick out of a marketing email that popped in from our friends at EClinicalWorks. Apparently they’re offering an ill-timed promotion called “Make the Switch” that includes free data migration to the system. I wonder how many takers they’re getting.

A reader sent me this piece about workplace wellness programs. It references some interesting statistics that I wasn’t aware of, such as the fact that 50 percent of companies that have more than 200 workers either offer or require employees to complete biometric screenings. Of those companies, more than half offer financial incentives to employees to participate. Others mandate the screenings for employees who elect company-provided health insurance plans. I’m sure wellness programs will continue to expand, as employers try anything they can to try to control rising healthcare costs.

I’ve written about my concerns around wellness programs before, namely that programs often aren’t compliant with screening recommendations. They may require employees to participate in screenings, such as blood glucose and cholesterol, that are not recommended for their age group and that may lead to distress and interventions that ultimately do more harm than good. Another tidbit I wasn’t aware of is the fact that modifications to regulations around employee wellness programs were nestled into the Affordable Care Act, allowing employers to shift 30-50 percent of employee-only healthcare premiums onto employees who fail wellness tests. I haven’t had to participate in biometric screening since I left Big Hospital, although when you compare the hassle, invasion of privacy, and dubious science against the premiums paid by small businesses, it doesn’t seem so bad.

I’m always on the lookout for stories of adventures in healthcare, and today I had one of my own. I was calling to make an appointment for a procedure with a provider who has multiple offices. Even though I haven’t been seen there in a couple of years, they were willing to schedule the procedure without a consultation first, which seemed unusual given the opportunity to not only collect an updated history and physical but to also generate some extra charges in a procedure-based specialty. The scheduler then paused and said, “Let me write all this down” and I assumed that she was going to take my request to a surgery scheduler, who would get back to me for the actual scheduling. She “wrote” for over a minute, and apparently used the information as a reference while she looked at the computerized scheduling system. As a process improvement person, I can’t imagine how that works given an average office’s phone volume. I can’t wait to see it in person in a couple of weeks. Needless to say, I won’t be surprised if they call me back and ask to schedule a consultation first, but you never know.

Email Dr. Jayne.

Curbside Consult by Dr. Jayne 6/12/17

Last week, CMS kicked off a multi-pronged outreach program to help providers prepare for the transition to the new Medicare Beneficiary Identifier (MBI). New Medicare cards, to be issued starting in April 2018, will have a new identification code for each beneficiary, which is not based on the Social Security number. Congress mandated that all cards be replaced by April 2019, and vendors have been working on adding functionality to hold the new identifiers for some time. There will be a nearly two-year transition window where providers can use either the MBI or the old Medicare number, as well as secure lookup tools for both providers and patients. The ID will include both numbers and letters – along with many others, I’ll probably still call it a “Medicare number” regardless of the presence of letters.

There are nearly 58 million people on Medicare, and the goal of the program is to fight identity theft, fraud, and illegal use of SSNs. Unfortunately, this doesn’t help the rest of us who are constantly asked to provide our SSNs across the rest of the healthcare space. I checked with a couple of my clients to see if they have plans to phase out use of the SSN in general and they haven’t really thought about it. I’ve had quite a few adventures in healthcare this year, and every single one has asked for not only my SSN but also had fields on their patient data forms to gather the SSN of a guarantor where one exists.

Even with a Congressional mandate, this process has taken years. It was in the works prior to the passage of MACRA, but that law accelerated the timetable. Although CMS has had a website about the project for some time, it’s unclear how much providers understand at this point. Providers and their office leaders have been through a lot of federally-induced change in the last few years, including the prolonged ICD-10 transition and now the distraction of MIPS, along with continued Meaningful Use pressures for our Medicaid friends. It could be that people just aren’t planning to pay too much attention until it gets closer. The other piece of it is that vendors aren’t entirely ready yet, so it’s not yet “real.” Once the new ID field starts appearing in systems, then perhaps it will be worth thinking about. I searched my email archives and found a notice from our vendor a few months ago, mentioning that it will be added to the system towards the end of 2017. One of the benefits (and sometimes challenges of) a vendor-hosted, cloud-based system is that features just appear after a brief announcement, so we’ll have to see what other communication we receive as it gets closer.

The migration to the new MBI is not just a digital change but one that will require operational and process changes as well. Practices may want to consider proactive outreach to their patients to educate them about the new cards and the need to bring them to the office, as well as to allow for additional check-in time on their first visit after they receive their new cards. Sites will need to educate staff about their cutover plan and the need to maintain both identifiers during the transition, and the fact that they can’t simply remove the old IDs from the system since claims may still be working their way through the system. Everyone should be readying a plan, even if it’s just high level at this point. I’d be interested to hear what organizations of varying sizes are doing at this stage in the game.

In other CMS news, Tuesday is the last day to submit formal comments on the FY18 Inpatient Prospective Payment System and Long Term Acute Care Hospital proposed rule. The rule also includes language around Indian Health Service and other Tribal facilities. Most notably, it modifies the EHR reporting period from full calendar year to 90 days, which many of us are eagerly awaiting. Other nuggets include a new exception from the Medicare payment adjustments for eligible professionals, hospitals, and critical access hospitals if they demonstrate that they can’t comply with being meaningful users because their EHR has been decertified. There’s always a path for no payment adjustments for EPs who furnish all their covered services in the ambulatory surgical center setting. Even if you don’t have any comments to offer, the closure of the comment period is a milestone in the countdown to a final rule, which many of us are eagerly awaiting.

I spent some time this weekend at a continuing education conference at one of the local medical schools. I was looking forward to it, since it was targeted towards community physicians and was an opportunity to engage with some of the leaders in the field about the best ways we can co-manage patients. The content was outstanding, with concise presentations offering real-world advice rather than the more esoteric academic discussions I’ve seen in some of their sessions in the past. However, it was marred by attendees behaving badly. The worst example was a physician who was clearly responding to emails and/or transcribed phone messages, and who was using the voice recognition features on his phone to do so. If you have to multitask, you need to either do it non-verbally or you need to step out of the room.

The first couple of times he did it, I’m not sure people understood what was going on, because it looked like he might be having a sidebar conversation with the person next to him and was just being loud. As it continued, it was more obvious what he was doing, yet no one close to him said anything although there were plenty of people giving him dirty looks. Finally, one of the CME door monitors came forward to address the situation and he quit. Still, you have to wonder in what universe someone thinks that’s OK and how we’ve arrived at a place where people’s need to try to do it all interferes with them being a considerate member of society.

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EPtalk by Dr. Jayne 6/8/17

There has been quite a bit of reader feedback about my recent Curbside Consult addressing the ECW settlement. Several readers agreed with my assertion that multiple vendors have gamed the certification process, with one mentioning “extraordinary actions” taken to pass the testing, but that the product was “replaced by corrected code before the production code was released.” Given the way testing occurs, I bet that type of maneuver occurs more often than we’d like. Technically that would be fraud, regardless of how they try to mitigate it. Unfortunately, other vendors haven’t been caught (yet) and/or didn’t allow the products of their deception to go into general release. Hopefully those companies are on notice and will toe the line.

Other readers called for zero tolerance for ECW and other vendors who cheat, including jail time or outright closure of the company. Some felt I was soft on ECW, even “tender.” Let me go on record as saying what they did was despicable – however, I’m a firm believer in the American justice system and we have a couple of things called the law and due process. Whether you think entering into a settlement is tantamount to pleading guilty, there has not been an admission of guilt and no criminal action has been filed that I can find, and trust me, I’ve been looking. My lack of a torch and pitchfork should not be construed as acceptance or approval of what was done. Still, I was surprised by the number of emails I received that attacked me personally or suggested I don’t respect patients. As much as I believe in justice, I also believe in redemption and this is an opportunity for ECW to make things right. As one reader said, “No one benefits if an EHR is litigated into bankruptcy.” Let’s not forget the vendors who have closed their doors abruptly in the past, holding their clients (and the data of tens of thousands of patients) hostage.

Another reader who is in the vendor space mentioned that his employer has already received calls from clients threatening to file whistleblower actions unless specific defects were fixed, regardless of whether they had anything to do with certification or not. Product liability law is a specialized discipline and I don’t think adding potentially hundreds of suits to the environment will result in positive change. Look at how healthcare has dealt with harm in the past: Until you get past the culture of fear and penalty, people are reluctant to report issues or to be part of the solution. Another vendor reader mentioned his company is considering being less transparent with their “known issues” lists because of fear of escalation to frivolous lawsuits. That would be unfortunate as well.

One reader offered an interesting thought around analyzing the percentage of budget that top vendors devote to R&D. There could certainly be some interesting data there and you could come up with some conclusions from annual reports and shareholder documentation. Unfortunately, privately held companies don’t have to disclose anything, so we’d be relying on their report. We’ve heard self-reported statements about this over the last year and many felt they were inaccurate, so it’s not likely that we will get “real” numbers anytime soon. I’d personally like to see the R&D budget compared to support compared to marketing and sales. There are several vendors I work with who spend entirely too much on the latter while shortchanging the former.

Others mentioned my lack of attention to the potential impact on clients. Frankly I think it’s too early to discuss, as we don’t have a full picture of whether those practices will be asked to repay incentive money. Any mandatory repayment would almost certainly create the potential of a class action suit against ECW. That’s precisely why I advised my colleagues on the system to sit tight and see how it unfolds and what remediation is offered and how it actually plays out. They’re in an incredibly vulnerable position right now and it would be easy for another vendor to try to take advantage of their situation. Anyone who predatorily goes after these practices should be ashamed, and I know they’re already out there. The last things these practices need is a hasty move or a poorly considered replacement decision.

Regardless of your position on the guilt or innocence of a vendor and whether the punishment was appropriate, this event has the potential to change the healthcare IT landscape in uncertain ways. I hope that other vendors take the advice of one reader and revisit their compliance programs. Ensuring a culture of honesty, accountability, and understanding of the fact that you hold people’s lives in your hands needs to be at the forefront of thought as corporate decision-making occurs. It’s unfortunately not as common in the US today as we would like, whether in healthcare, the automotive industry, or just about anywhere people are trying to make a profit.

Other readers offered answers to the question of what they’d do with the whistleblower payment, with several noting that legal fees will consume a good portion of it. One mentioned that he would donate to non-profits promoting expansion of EHR systems to practices serving indigent patient populations and that cannot afford to buy them. Or to scholarship funds for computer science students willing to commit to working with those practices to help them implement those systems. Both are great ideas, although I’d like to see vendors contributing to those kinds of initiatives outright, rather than having someone do it as a result of a legal action. Or how about scholarships for patient safety training to ensure caregivers and technology professionals know how to spot these kinds of problems? The reader also noted he’d reserve a few dollars to buy a good bottle of bourbon as a reward for a job well done. Based on the level of documentation and time spent by the whistleblower, I’d suggest more than one bottle would be in the offing.

I don’t think this is the last time we’ll see something like this, and the problem isn’t just on the vendor side. I’ve seen plenty of “creativity” and shortcuts from hospitals and health systems with homegrown systems or with vendors outside the CEHRT space, and although they won’t be caught for fraud during the certification process, they are eventually going to run afoul of patient safety. The question is whether organizations will find the settlement motivational and will clean up their houses voluntarily, or whether more headline-generating actions will need to occur to move the industry where it needs to be. The other possibility is more consolidation in an already shrinking industry, which could have unpredictable effects on innovation and emergence of new vendors. The one thing I can say for sure is that only time will tell.

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Curbside Consult with Dr. Jayne 6/5/17

Quite a few people called or emailed this week to find out what I thought of the EClinicalWorks settlement. Two of them were ECW users asking for my advice on whether they should change EHRs and, if so, what I thought they should be looking at. For those practices potentially impacted by the alleged wrongdoing, it’s a very uncertain time. My advice was to pause and let the dust settle before making any decisions. Neither of the ECW physicians I talked to this week had concerns about how the system is actually performing based on their scope of use, and felt fairly confident that they’re not experiencing functionality issues that impact patient care.

As for those that reached out simply curious about what I thought, I’ll share what I had to say. There were several allegations addressed in the settlement. I say “allegations” deliberately because ECW hasn’t admitted guilt nor has it been proven in a court of law. Everyone can speculate on the fact that they settled, but given that I have a plaintiff’s attorney in the family, I understand how expensive litigation can be and how $155 million may be a bargain compared to having to mount a defense, deal with the side effects of having half your company (and your customers) deposed, and having ongoing distraction that impacts your ability to keep the lights on and the business running.

First, let’s look at the kickback issue. The suit alleged that it gave kickbacks to customers for promoting its products, including payments for reference site visits. Many of the vendors I’ve worked with would also fall into this category. During my days at Big Hospital System, we regularly received extra attention from our vendor in exchange for being a reference site, and at times we also received credits against our software maintenance payments. I’m sure that could be construed as a kickback, although our site visits were quite “tell it like it is” rather than pure attempts to induce anyone to switch to the vendor. We always insisted that the vendor reps stay out of the discussion and sit in the back of the room or outside the room altogether. It looks like ECW also paid a bonus when prospects actually signed, and paid individual physicians to do references, which is a little murkier.

The way it’s described in the actual filing, any “manufacturers of products paid for in whole or in part by federal healthcare programs may not offer or pay any remuneration, in cash or in kind, directly or indirectly, to induce physicians or hospitals or others to order or recommend products paid for in whole or in part by Federal healthcare programs such as Medicare and Medicaid.” If you take that at face value, then the medical device reps need to stop wooing the cardiologists and orthopedic surgeons, regardless of whether they’re reporting their meals and tchotchkes in compliance with Open Payments. The language also applies to services, so the people from hospice that bring lunch while they explain the services they offer are guilty as well, even though they’re a nonprofit.

Next, let’s look at the issue of cheating on certification. Although some of what they did (such as hard coding the RxNorm codes for the test scripts rather than having the system access the entire library) is pretty egregious, anyone who’s been part of a certification process knows that there’s a gray area between complying with the test scripts and complying with the spirit of the requirement versus the letter of the requirement. There’s plenty of functionality out there that passes the test scripts but isn’t user friendly or sometimes isn’t even usable.

Let’s also look at the allegation that ECW “released software without adequate testing and overly relied on customers to identify bugs and other problems. Some bugs and problems – even some identified as ‘critical’ or ‘urgent’ – persisted on ECW’s bug list for months and even years. ECW lacked reliable version control, so problems addressed in one version of the software or for one particular user could reappear in other versions or remain unaddressed for other customers.” I’m currently working with half a dozen vendors who could fall into that description, and can name a few more to round out the group. Nearly every vendor I’ve worked with is guilty of this to some degree.

As a customer, I’ve been part of beta testing programs that are more like alphas, and have seen code that doesn’t seem to have been tested by anyone conscious. Sure, the coded functionality may have met the technical requirement specifications, so it passed, but when deployed to the field it’s broken or simply useless. I heard from a couple of friends who work for vendors that they were taking joy in ECWs pain. I challenged them to think about their own situations, and whether they’ve ever let a regression error go out the door. It sobered them up pretty quickly. Developers who live in glass houses definitely should not throw stones, because they could be the next ones in the spotlight.

That takes me to looking at the whistleblower component. There was quite a bit of buzz around the fact that the software technician who filed the original suit will receive $30 million. I’m wondering if this is going to be an incentive for individuals to try to prove wrongdoing across the industry in exchange for a potential windfall. Hopefully, this will spur vendors to pay more attention (and devote more resources) to defect resolution as well as defect prevention, since most vendors likely have a backlog of issues needing remediation. On the other hand, it could lead to a lot of rock-turning during which plenty of creepy crawlies will come to light. If vendors have robust systems to manage their issues they’ll persevere, but if not, potential whistleblowers could create a lot of noise that will create distractions that may ultimately harm customers.

Hopefully this settlement will be a call to action for vendors to get their houses in order, and bring greater transparency to the sausage-making that is the certification process. It’s been interesting, though, to see the number of people putting the blame on the certification process itself. The bottom line is that there are rules; if we think they are unfair, we should seek to have them changed in an orderly way rather than just flout them. It will be interesting to look back on this in six months or a year and see whether it’s changed anything or whether it just goes down as another footnote on corporate wrongdoing.

What would you do with a $30 million whistleblower settlement? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/1/17

I took a break from writing over the Memorial Day weekend due to having the privilege of participating in events honoring our nation’s veterans. On Saturday, I assisted with an Honor Flight, welcoming 22 veterans and their families back from a trip to Washington, DC, where they visited the monuments dedicated to their service.

Along with active duty service members, we lined the airport terminal to salute the veterans as they were transported from the gate to the baggage claim area. There they emerged from a tunnel of American flags to greet family and well-wishers in a celebration complete with a USO-style band. These gentlemen, most of whom are in their late 80s and early 90s, helped save the world. I am honored to have been able to work with them.

Three brothers were on the flight, having served in WWII, Korea, and Vietnam. They lifted a beer at the Vietnam Memorial to honor fallen friends. The picture of that moment shares more than a thousand words. WWII veterans are passing on at a rate of 640 per day, according to VA data. Most of the veterans I’ve worked with over the years don’t want to talk about their service, but saying thank you is always appreciated.

Sunday was a little more sobering when I volunteered with a group charged with placing flags at all graves in our National Cemetery as well as on the graves of veterans buried at a dozen Jewish cemeteries. Our local post of the Jewish War Veterans of the USA provided breakfast for over 500 of us before we set out on our task. After the flag is placed, it is saluted. Each veteran’s name is read and they are thanked for their service.

Our small group placed over 1,000 of the 200,000 flags that went out that day. A small commitment compared to what those we honored have given. If you’ve never done this and have the opportunity, I would strongly encourage you to take part. Every one of those flags has a story and it’s something to think about on days when we’re tempted to complain about spotty cell service and slow lines at Starbucks.

I saw patients on Memorial Day itself since many of my partners are former military officers and having the rest of us work allowed them to participate in local remembrances. It was a busy shift due to the three-day weekend.

I experienced something I haven’t seen before, which was having a parent drop off a 12-year-old at the urgent care and then leave him in the exam room to run errands. Of course, we can’t treat a child without a parent there to provide consent, so we had to wait. After an hour, I was wondering at what point it becomes child abandonment when the parent returned, acting like his actions were no big deal. I hope the patient wasn’t too scared about being left alone. We tried to check on him regularly while waiting for Dad to turn back up.

Tuesday sent me fully back into the healthcare IT fray, mopping up after a client who decided to try to install an upgrade over the weekend despite their vendor’s support desk being closed for the holiday. While I was re-running and monitoring the upgrade scripts, I had a chance to catch up on some articles that friends and readers had sent my way.

One caught my attention with its headline that “Patients Fare Worse with Older Doctors, Study Finds.” It cites research from Harvard Medical School looking at Medicare data for over 700,000 hospital admissions. The patient mortality rate rose for each decade of physician longevity, ranging from 10.8 percent for physicians under age 40 to above 12 percent for physicians over age 60. However, physicians who saw large volumes of patients didn’t seem to have a change in mortality rates due to age, rather those rates remained consistent for higher-volume physicians. Seeing more patients may force physicians to stay current, but it could also be that lower volume physicians see fewer patients because they are less knowledgeable.

The article offers some other interesting conclusions, but I’d be interested to hear what readers think. One 74-year-old physician keeps current by reading multiple medical journals each day. That kind of volume would be hard for me to do, so I applaud him for being what he describes as “addicted to keeping up to date.” He’s a medical school dean, so I’m not surprised.

Another piece from Boston’s NPR new station chronicled one burnt-out doctor’s decision to leave medicine. The author notes that while many people ask why she left, virtually no physicians ask her that question. They instead ask how the transition worked.

I’ve had numerous physicians approach me over the last few years asking about clinical informatics as a potential way to get out of clinical practice but still be able to positively impact patient care. I would be dishonest if I didn’t acknowledge that I leveraged the move to full-time informatics as a way to get out of paying for supplemental liability insurance (so-called “tail coverage”) as well as a way to get free of a restrictive non-compete clause. In my situation, those were beneficial side-effects of the move, however, rather than incentives.

The article was sent to me by a former residency colleague who is trying to formulate her own exit strategy. She was one year behind me in training and we caught up recently for drinks. Out of the 13 family medicine residents in our two classes who we’ve kept up with:

1. Clinical informatics: 1
2. Residency faculty: 1
3. Retrained in another specialty: 1
4. Cosmetic/age-reversing medicine: 2
5. ER/urgent care: 2
6. Concierge practice: 1
7. Left medicine to care for family: 1
8. Part-time practice: 1
9. Incarcerated: 1
10. Full-time primary care: 2

Those are some sobering statistics for physicians who aren’t even 20 years out of training. They also paint a different picture of the primary care shortage, one where lack of training slots are not the problem.

I hate to see my friend consider leaving medicine, as she practices in a relatively underserved area and also serves as the medical director for a home hospice organization. Those vital services aren’t easily replaced. She has already stopped delivering inpatient care and next week marks the end of her hospice practice. Her eight-year plan gets her children nearly through college while letting her only sit for Board recertification exams one more time. I’m glad that she’s designing a strategy that lets her keep seeing patients while trying to address potential burnout. I will be supportive no matter which way she decides to go.

Are you thinking about leaving healthcare or healthcare IT? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/25/17

I’d wager that 99 percent of people who have worked with me wouldn’t classify me as a delicate flower, a special snowflake, or someone who is easily offended. I’ve spent the majority of my academic and professional careers in male-dominated fields and have been on the receiving end of sexual and other harassment.

I take issue, however, with organizations that pay lip service to diversity and inclusiveness when their actions say otherwise. Not everyone has a thick hide, however, so when one of my consultants reported that a client was behaving badly, I wanted to gather some evidence.

I spent a good chunk of today listening to recordings of conference calls, which unfortunately demonstrated everything my consultant said was going on and more. Boorish and unprofessional are the mildest adjectives I could come up with as I prepare my letter terminating our professional relationship.

We had been hired to assist a small practice with their workplace dynamics and to help try to correct some issues they’ve had with staff turnover. Our first onsite assessment revealed countless sports and gambling analogies (in nearly every conversation) that had a tendency to alienate members of the staff who might not find stories about betting at the dog track to be amusing or in harmony with their religious beliefs. Based on our findings, we agreed that you can coach your way through a lot of that, and we persisted because they seemed willing to participate in making things better.

Many of their issues were process related, with staff being frustrated by lack of policy and procedure documents that would explain why they were constantly being told by one partner or another that what they were doing was wrong. My consultant worked on getting an employee handbook together and at standardizing their office workflows knowing that reduced variation would make things less stressful and perhaps increase retention. She did some stakeholder assessments that identified many of the issues being attributed to a couple of the physicians, with the rest of the providers being highly respected.

The two physicians who needed the most work have been abrasive to my team, but within the realm of what the team felt they could handle. Plus, they were treating both male and female consultants badly, so we chalked it up to boorishness rather than discrimination.

Over the past few weeks, though, the behavior has escalated. One consultant (who happens to be a man) never complains about anything, so I knew that there was more to the story when he described some of the behavior as “unseemly.” We discussed strategies for discussing it with the managing partners and office manager and that we’d monitor how things were progressing.

At this week’s management meeting, however, some comments were made about certain office responsibilities being “women’s work” and one of the managing physicians told a young female physician to stop bringing her complaints to office meetings and maybe bring some cookies or cupcakes instead. It may have been meant in jest, but I doubt he would have said the same to a junior male physician. In fact, after reviewing the recording of the meeting, he didn’t say anything of the sort to a male peer who was also complaining. He listened to the same types of concerns from one while chastising the other for hers.

It wasn’t just that. The meeting ranged all over the place, with outright mocking of the regional dialect of one staff member and some snarky commentary about various ethnic groups and international political conflicts. There was also some talk that could be graciously referred to as “locker room talk” that was pretty rough.

Listening to some of the banter, all I could picture in my mind was an episode of “The Three Stooges.” Some of the comments were so bad and so highly inappropriate that I felt like the physician in question was trying to sabotage himself. I don’t care who you are, or where you are, or what your beliefs are, some things are just not OK and there are lines that should not be crossed.

I transcribed some of the dialogue and scheduled a call with the head physician to address it. Although he was apologetic, he wasn’t willing to address his partner and essentially told me that since Dr. Lawsuit-Waiting-to-Happen was the top biller and we needed to stop making waves.

At that point, I let him know that I was unwilling to put my team in a hostile environment and that we were done since the entire point of the consulting engagement was to help them get to the root of (and hopefully fix) their office turnover issues. If he wasn’t able to assist with the process, there was little more for us to do. He seemed to take it in stride, said he understood why I was canceling our agreement, and asked me to send a formal written termination notice so he could release us from the rest of the engagement.

It was at that point that I realized the extent of his partner’s bullying. He knows he has a problem and he knows he’s not ready to take on his partner, so he is going to go along with it. I hope he comes to his senses before they get slapped with some kind of lawsuit, but I’m not holding my breath.

For practices struggling with the transition from fee-for-service to value-based care, or dealing with shifting payments and increasing patient responsibility, or all the other pressures, having a physician behave like this is the last thing they need. You need your office running as a finely-tuned machine. But until they’re willing to address it, or let someone else address it, they’re going to get what they get.

Like I said, I’m not easily shocked, but this guy took the cake (regardless of whether a man or a woman baked it). I didn’t have the opportunity to shadow him with patients, but I wonder how he is on the other side of the exam room door and why patients continue to flock to him. He has to have some redeeming value, but after this week I am challenged to figure out what it might be. It makes me more grateful to be in my current practice situation, where this sort of nonsense would never be tolerated.

Since most of us can’t fire our colleagues or co-workers when they act like this, how does your organization handle boorish behavior? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/22/17

I ran across an article about the impact on multi-tasking and memory. We’ve known for a while that the idea of multi-tasking is a myth. What really happens when we try to do multiple things at once is rapid switching of attention, which sometimes doesn’t work very well.

In my experience, trying to tackle two tasks simultaneously only works when one of them is significantly less critical and the majority of attention is paid to the more critical task. This is how we can get away with browsing Facebook while on conference calls, or reading the newspaper while eating breakfast.

When people try to do equally critical tasks at the same time, that’s when things start falling apart. I’ve had a couple of instances where people tell me they’re on two conference calls at the same time, and based on their participation on my side, it’s clear that they’re probably not paying adequate attention to either.

The article specifically looks at the impact of multi-tasking on memory. Research has showed that when people don’t fully attend to an event, they’re less likely to be able to create a strong memory of the event. One of the people interviewed in the article, Anthony Wagner, is a neuroscience researcher. He intentionally avoids having a smart phone, and has found that without it, he’s not lured into surfing the Internet or being constantly connected. As a result, he’s more focused on the activities around him. According to research coming out of the Stanford University Memory Lab, this means he’s more likely to remember the activities he’s watching.

There’s something to be said about just saying no to technology, although most people would be reluctant to give up their smart phones. Unfortunately, it then becomes a matter of discipline, where you have to consciously leave your phone in your pocket or bag rather than give in to the need for constant connection. That seems to be getting harder and harder for many people. I’ve had several uncomfortable conversations recently with employees who cannot pull their noses out of their phones long enough to pay attention to even a brief conversation. Fortunately, these people are not my personal employees because they wouldn’t last long.

Still, I’ve been increasingly asked to help teach people how to work in the new world of technology. People sometimes assume that because younger employees have grown up with technology, that somehow they know the best practices. I’ve found this challenging as workers struggle with prioritization of work, distraction, and follow through. Some of them are not aware of seemingly straightforward work habits, such as how to assess and prioritize an overflowing inbox when time is limited, or how to carve time out of the day to look at that inbox when you’re assigned to train end users or support a go-live.

The research shows that abilities such as attention and recall can be trained. It’s human nature for our minds to wander, but some of us definitely go walkabout more than others. One study mentioned in the article looked at brain function in heavy multi-taskers vs. that in light multi-taskers. The heavier multi-tasking group did worse on certain tests, and brain activity showed they were having to work harder to focus on the task at hand. It’s not clear whether this is a chicken or egg phenomenon – whether this was caused by multi-tasking or whether people with more fluid attention were more likely to multi-task.

Other research has looked at whether using technology causes our cognitive skills to atrophy. One study mentioned looked at those who used Google Maps for navigation vs. using landmarks. Those who used landmarks built better mental maps than those relying on digital assistance. Another looked at people taking pictures of museum pieces vs. those who simply looked at them. Those with cameras had worse recalls of the details. Anyone who has ever been to a school program, assembly, concert, or recital in the last decade has to wonder about the people who are experiencing the entirety of their children’s lives through the screen of an iPhone. Are they really seeing what is going on or are they more focused on getting the perfect video? Regardless, I long to attend events without people holding phones and tablets in the air, blocking everyone’s view.

The article also mentions a 2011 paper titled “Google Effects on Memory: Cognitive Consequences of Having Information at Our Fingertips.” It showed that people are more prone to think of how to find information than to be able to remember it. As someone who deals with tremendous volumes of complex information, the ability to look things up instantaneously is a great asset. On the other hand, if it’s making us somehow less able to retain and recall information, it might not be so great.

One researcher talks about being selective regarding the use of technology. For tasks that are going to be done multiple times, it’s better to learn the information. For one-and-done type work, it might be OK to leverage technology. A non-tech example would be for those of us from the days of the dinosaurs, where we had to memorize our multiplication tables and regurgitate them on 60-second “timed tests” rather than calculating out the numbers each time. No one wants to have to use a calculator to figure out 7×6.

You can easily identify people who haven’t figured out how to successfully leverage technology. They’re the ones who repeatedly ask you questions that fall into the “let me Google that for you” category. They’ve been habituated to need external resources to figure out even small things. Frankly, I’d be glad for some of these folks to use technology as their primary resource rather than waste their employers’ consulting dollars asking me for basic information because it’s easier to ask someone else than to leverage your company’s Intranet, personnel manuals, and policies and procedures.

These are the kinds of basics I’m having to work on at some of my client sites. I recently taught a class on the successful integration of instant messenger into the clinical office to improve patient care rather than detract from it. People don’t inherently know when they should use IM, when they should use email, or when they should simply talk to one another. They need to understand the right use of each modality and then solidify it with documented processes for patient care. Unless you address it head-on, it will continue to cause chaos. I never thought I’d be teaching these kinds of skills, let alone teaching them to physician peers. It’s part of the evolution of technology and healthcare, though, and if a practice is savvy enough to ask for help, I’m certainly glad to provide it.

What’s the most egregious example of multitasking you’ve ever seen? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/18/17

The National Patient Safety Foundation is holding its annual Patient Safety Congress this week in Orlando. This is the first meeting since NPSF merged with the Institute for Healthcare Improvement at the beginning of this month. I’m a big fan of both organizations, not only because patient safety is such a big deal, but because they both offer accessible and cost-effective training for practices and organizations trying to improve their safety culture.

Awards programs recognized NYC Health + Hospitals/Bellevue for their primary care diabetes program and recognized Christiana Care Health System for a care coordination program aimed at reducing readmissions. For all of us who complain about EHRs, we need to remember how hard it was to pursue these types of initiatives with paper charts. If you missed it, next year’s Congress will be held in Boston from May 23-25.

Although telehealth continues to be promoted as a way to increase access to patient care and reduce costs, it isn’t being widely adopted in the primary care trenches. Researchers from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care queried family physicians to understand their use of telehealth and what barriers exist that prevent expansion. The results were published in the Journal of the American Board of Family Medicine and indicate that although many of us are interested in providing these services, few of us are actually doing it. The survey is somewhat limited by its 2014 data; it would be interesting to see whether adoption has been driven forward given changes in technology and payment policies. At the time, however, only 15percent of respondents had used telehealth services during the year, with many using it only a handful of times throughout the year.

The most common uses of telehealth services included diagnosis/treatment (55 percent), chronic disease management (26 percent), follow up (21 percent), second opinions (20 percent), and emergency care (16 percent). I always shudder when I hear about virtual care of emergency problems, but many of the “emergency care” situations aren’t truly emergent in reality, so perhaps this number isn’t as shocking as I originally found it. Those using telehealth were more likely to be rural, have an EHR, and be in a smaller practice that was less likely to be privately owned. Respondents cited lack of reimbursement and lack of training as obstacles to use – both among those who used and did not use services. The authors recommend that residency training be expanded to include telehealth services and that payers should expand coverage.

Personally, I don’t see the latter happening. As we shift towards value-based care, it’s more likely that physicians will explore telehealth as a relatively low-cost care option, at least compared to office visits. As physicians receive bundled payments and operate under payment systems that are tantamount to capitation, they’re going to look for alternatives to bringing people in.

What remains to be seen is how well telehealth vendors will be able to integrate their solutions into mainstream EHRs and how clunky the arrangements are. I’m working with a third-party care management vendor with one of my clients and the technology itself is a major barrier to use. They actually partner with the primary care office to provide telehealth chronic care management services, which the primary care practice bills for under the Medicare Chronic Care Management codes. The vendor has nurses and care managers who review patient-generated data such as daily weights, blood pressures, blood glucometer logs, and more.

The vendor’s employees meet with patients and document care plans and progress, then send the information back to the EHR. In principle it sounds great, but in practice it’s a tangled mess.

First, the vendor offers a standalone patient portal and wants the patient to submit all their data and conversations that way. This directly competes with the practice’s patient portal and creates confusion for the patient on what kinds of questions should be sent to the office and what should be sent to the care management portal. Although the practice sends data to the vendor discretely, what is pushed back to the office to document the virtual visits and care plans comes back as an image. That means it lives in a separate place in the patient chart from all the other data that physicians are reviewing when they see the patient.

Apparently the root cause of this disconnect is the fact that the third party wanted to quickly partner with multiple EHR vendors to sell its chronic care management services, but the EHR vendors were too busy building certification requirements into their products to be able to build the kind of integration that needs to happen. Unfortunately, my client (the practice) didn’t pick up on this during the slick sales demo, and now is stuck with this hybrid approach, at least until their contractual obligations end.

They’ve stopped enrolling new patients in the service in the meantime and are struggling to stand up their own care management team, which is how I came into the picture. Their EHR has great care management content but just couldn’t handle the billing piece, so we’re working through that gap. They will fully separate from the third party in a few months and I’m confident they’ll be able to ramp up their own program. The practice may not have the same slick videoconferencing capabilities that the third party had, but they can practice telehealth the old fashioned way — via phone. This approach can still help with access issues and cost issues as well as reduction of readmissions. We’ll see how it goes.

As a side note, I’m waiting for the EHR vendors I work with to get through all their regulatory certifications and mandatory releases so they can get back to the business of enhancing usability and coding features that their users actually want. Of course, I’m not delusional enough to think that there won’t be some other burdensome pack of regulations coming right after, but there might be a window of opportunity to do some good work before it hits.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/15/17

I had a rare opportunity this month to do something I haven’t done in a very long time: support a go-live. A friend who owns another consulting company reached out to me to see if I could help her out with the launch of a new EHR client when one of her consultants had to back out due to a family emergency. I had a bit of a lull in my schedule, so I was happy to oblige, especially since it happened to be one of my favorite cities. The idea of grits made by people who actually know what they are doing was enough to seal the deal.

I’ve supported the EHR in question before, but not for a couple of versions. She sent over her training documentation as well as the training records for the users at the location where I’d be covering. The end users had been through quite a bit of training along with role play and simulated patients with real-time coaching for eye contact. They also were planning a soft go-live the week prior, where end users (including providers) would be entering their visits after they left the exam room.

The plan was that by the time the actual go-live occurred on Monday, everyone would have documented at least 30 patient visits and would be ready to go. Each user had to not only attest to the fact that they did the visits, but my friend had consultants going through the charts to ensure that it was done correctly and to remediate anyone who appeared to be struggling.

I arrived Monday morning to a very calm office where everyone seemed comfortable with what was about to happen. Patient visit schedules had been adjusted, giving a 15-minute break after every three patients to allow the staff to catch up. Charts had been abstracted for upcoming visits based on a rolling schedule, and for same-day and next-day appointments, they were being loaded in real time.

Of course, the providers had spent some time cleaning up the charts for patients seen in the last six months so that abstraction could be simple data entry rather than a complex game of “hunt the data.” The practice also spent the last year adjusting their scheduling processes and panel sizes to ensure they were not trying to operate way above capacity. Some physician panels were closed and others shifted to move patient volume to where there was capacity.

The practice had been live on the practice management side of the application for a few months and also had been scanning all inbound and internally created paper (including visit notes) as well as receiving lab results via interface since the first of the year. There was very little reason to need a paper chart at the time of go live, although the practice planned to pull the chart for three patient encounters (whether in person or by phone) before archiving.

After the first couple of patient visits, I began to wonder why I was there. Although some might think the pre-live activities were grossly over-engineered, they did exactly what they were designed to do, which was to make the go-live successful.

At the end of the day, the providers were asked how they felt about their schedule and the amount of blocked time and they felt they could open some additional patient visit slots for Tuesday. Tuesday also went off without a hitch, with nearly all providers opting to continue to reduce the number of blocks on their schedule for documentation time. By Thursday afternoon, everyone was running a full schedule and seeing patients reasonably on time.

Overall, providers lost very little volume during go-live week because they were extremely well prepared. The workflow I saw in the exam rooms was good, with providers being able to interact with both the computer and the patient through reconfigured exam rooms or other adaptations. It was about as textbook of a go-live as you could ask for.

I was able to spend some time debriefing with my friend on Thursday night before heading home on Friday. My big question was how much time was spent up front to ensure the smooth go-live, especially considering the amount of training, role play, patient simulations, chart clean-up, etc. She had been tracking it pretty thoroughly and the average time commitment per provider was around 60-70 hours. That included 14 hours of system training, time needed for soft-live chart notes, time spent resolving data issues during chart clean up, additional role playing/coaching, and other activities. The only thing she didn’t have an accounting for was time spent in regular staff meetings where the EHR project was discussed.

Depending on how you think about it, 60-70 hours may or may not seem like a lot of time. When you talk about losing nearly two weeks of potential patient-facing hours, it seems like a lot. But when you hear about practices that “never got back to full productivity” despite years on an EHR, it seems like a small investment.

I think the more unquantifiable factor here was the smoothness of the go-live. There were very few chaotic times and no moments of terror at my site, and by report, none at other locations, either. Things were extremely smooth and you can’t put a price on the value of that when you’re talking about the mental health of your providers and frontline staff.

My consulting buddy, who prides herself on her “white glove” service, has follow-up assessments scheduled weekly by phone for the first month and then onsite at the 30-day, 60-day, and 90-day marks. If the practice starts to struggle, she’s going to know about it.

I look at some of the EHR vendors out there offering go-live within a week or two and I wonder how well that really goes in practice. I imagine that if the practice was fully optimized and the paper charts were all in good shape, it might be possible. But for practices that are going live on EHR this late in the game, I would think that’s less common since many net new purchases are from practices that are only being dragged into technology adoption through penalties.

I’d be interested to hear from readers in the implementation space. What do your experiences look like at this stage of the game? Can you really get practices live in a couple of weeks and have the adoption stick? What happens when you leave?

Have a good go-live story? Email me.

Email Dr. Jayne.