EPtalk by Dr. Jayne 12/28/17

I’ve been following the reader comments regarding the recently-opened $1.2 billion Stanford Children’s Hospital. There is plenty of cynicism about whether the expenditure will lead to better outcomes or a healthier community. I see this in my own community with several multi-state health systems competing to have the most beautiful and indulgent facilities, with far less advertising of their actual patient care.

My own hospital experience earlier this year was in a lovely private room with a flat screen TV four times larger than what I have at home, along with on-demand dining in a brand-new hospital wing. It was also accompanied by lackluster nursing care, delayed antibiotics, and failure to use bar-code medication administration systems as required to ensure patient safety. There was also a missing pathology specimen and a weeks-long delay in seeing my discharge summary in their patient portal. At least the hospital in question was spared a penalty under the Hospital-Acquired Condition Reduction Program. 

Although I received belt-and-suspenders prevention against deep vein thrombosis with both heparin injections and pneumatic compression devices, I’m not sure whether it was as effective as my early-morning ambulation, as I got dressed and packed up as quickly as possible to avoid staying any longer than absolutely necessary.

I caught up with some grad school friends who were in town for the holidays. A summary of our get together reads like the opening line of a bad joke — a doctor, a drug rep, and a hospital administrator go into a bar… All of us have worn many different hats over the last two decades, so it was interesting to hear each other’s perspectives on the evolution of Meaningful Use, the current state of this mess we call a healthcare system, and whether physicians are hanging in there or readying themselves to retire or pursue second careers.

I go back and forth in the latter category. Although my work is rewarding when I can help organizations make meaningful change, it can be depressing as frontline primary care groups struggle with trying to deliver more to sicker patients with fewer resources. Although value-based care is supposed to “fix” this, the learning curve can be steep and it’s hard for many organizations to figure out how to spend money they don’t have to make money they may or may not actually receive.

Many of the physicians I work with experience less satisfaction in their work lives than even a few years ago. Some of my former family medicine colleagues have moved into niche practices such as cosmetic treatments and vasectomy reversals. I know already that a couple of my favorite clients are planning to pursue early retirement in 2018. I’m sorry to see them go since they’re not even in their sixties, but given the diminishing returns on their professional labors, they feel backed into a corner.

As solid members of Generation X, we did have some common thoughts on what we think we’ll see in healthcare’s next decade. First, practices, hospitals, and health systems will continue to compete with each other to some degree even when it would make sense to collaborate. We see health systems that refuse to participate in collaborative ventures that would help not only patients but their own bottom line, out of fear of losing control. At least in our respective parts of the country, we don’t see this changing.

Second, there will be continued focus on profitable service lines despite the push to steer patients to enhanced primary care models. Community-based exercise and weight loss programs aren’t profitable, but knee replacements certainly are. It’s challenging for primary care physicians in the trenches to motivate patients for the months and years needed to solidify lifestyle changes (assuming the same provider even continues to be in your network) and the US population will continue to ask for high tech interventions where there is a possibility for a quick win.

There isn’t any excitement around funding the major cultural changes needed to truly transform how we live, what we eat, and how we manage our health, although we will continue to see glimmers of hope with greater patient engagement and patient empowerment.

Third, the cost of healthcare will continue to be a hot button issue. When left with the individual decision of investing in their health through preventive care or to purchase insurance against major health expenses, many people will lack the money to fund those choices. Others will choose to spend their money on other priorities. Since healthcare isn’t going to get any less expensive, this will continue to cause medical bankruptcies and significant hardship. The cycle of unfunded care and cost shifting to insured patients will continue.

As we chatted, we wanted to be hopeful about things such as machine learning, diagnosis algorithms, and predictive analytics, but it’s difficult to support the bluster from the reality in many cases. The next year or so will be very telling for these technologies and I think we’ll get some real data for how they’re going to play on a broader scale.

The reality, though, is that non-sexy interventions such as public health projects and simply getting people to move more and eat less are going to be increasingly important as we continue to try to reduce the burden of chronic disease. I think often of one of my favorite shows “Call the Midwife” and the untapped potential of community health interventions. At least one health system in my city is working towards greater community outreach, establishing new school-based clinics that not only provide healthcare, but serve as food pantries and distribution sites for clothing and other necessities.

Hopefully the New Year will bring continued focus on corporate stewardship as we continue to figure out how to make something sustainable out of dysfunctional systems that seem constantly on the brink of collapse. Healthcare impacts such a great deal of our economy and daily lives, so I was excited to read about a large health system that was willing to look at issues outside their “normal” areas of activity and consider other impacts such as water use, greenhouse gas emissions, and plastic waste. Healthcare organizations employ an increasing percentage of the US workforce and may be uniquely poised to transform workplace culture over the next decade as we evaluate how we care for aging Baby Boomers and whether we will put systems in place to reverse some of the negative health trends we’re seeing.

What challenges do you think we’ll see in the New Year? Is your organization looking to lead change? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/21/17

Usually things in the healthcare IT world are relatively slow from Thanksgiving through the early part of the New Year, as vendors save their best efforts for HIMSS. At the same time, hospitals and health systems make sense of new federal regulations and changes to insurance contracts while patients try to figure out new coverage along with new deductibles, networks, and more.

This year, the early November release of CMS updates to the 2018 MACRA Quality Payment Program, along with the Physician Fee Schedule, seem to have energized the provider community to ensure that they understand the rules that they’ll be operating under in 2018. Healthcare organizations are scrambling to make sure they are ready for initiatives such as the Comprehensive Primary Care Plus (CPC+) program and year-long reporting for various quality programs.

On the vendor side, there has been increased activity supporting clients in the above areas. I’ve seen a handful of vendors announcing their required APIs along with their plans to support the transition to new Medicare beneficiary identifiers. Others are highlighting enhancements to CCD exchange.

Compared to the last several years, vendors seem more likely to publicize the changes they’re making to their systems. Where some focus on enhancements and updates, others are increasingly transparent about defect identification and fixes. In the wake of the Department of Justice action against EClinicalWorks, one has to wonder whether vendors are hoping that transparency will save them from potential whistleblower actions or client claims.

In addition to supporting their clients, vendors are well into the pre-HIMSS run-up. They are refining their messaging and getting ready to put their best feet forward as they work to recruit new clients and to retain existing clients who are constantly looking for the next big thing to solve their workflow woes. I’ve heard from several firms that conduct marketing research – they’re looking for physicians to participate in projects that sound like they are being conducted on behalf of EHR vendors. At least two of them seemed to be for new product launches and I hope I’m able to see what companies are planning before we get to the HIMSS exhibit hall.

I had the opportunity to learn about a startup’s product this week and was impressed by what I saw. The company’s founders come from an industry far away from healthcare. Although many “outsider” companies have thought it would be easy to crack the healthcare nut and have received a rude surprise, this group comes from an extremely data-intensive industry and they have a fresh approach. I’m looking forward to seeing how they prepare for HIMSS and whether their approach to patient engagement will play to healthcare purchasers in the way they hope it will.

A reader emailed after my last Curbside Consult that talked about the challenges patients face when trying to figure out prescription pricing and whether they should use their insurance coverage or pay cash for prescriptions from us. He asked if I had ever seen GoodRx. Although it provides real-time information and price comparisons across pharmacies, it has some of the same issues that make patients question whether they should get their medications from us – namely that GoodRx doesn’t run prescriptions through insurance.

For patients who are looking to meet a family deductible or get out of the Medicare donut hole, it’s not going to help with the bigger picture of those expenses unless their payer allows them to submit receipts and credit the cash expenditures towards the deductible. I also failed to mention that our home grown cheat sheet in the office includes data on pharmacy hours, which is indispensable for any patient trying to get their medications filled after 4 p.m. in our area. I haven’t used GoodRx in a while, but will make it a point to give it another go during my next clinical shift.

It will be challenging to predict how the patient cost curve will bend following changes to the provisions of the Affordable Care Act once the current tax legislation makes it through the process. Although supporters are trumpeting the repeal of the individual mandate for insurance coverage, that doesn’t appear to happen immediately and some subsidies will continue. I would expect costs to rise as people opt out of individual coverage, leaving only sicker people in the pool.

Additional challenges will come to families who receive funding for child healthcare through the CHIP program, whose federal funding stopped September 30 and hasn’t been reauthorized. This is a popular program with bipartisan support, and states are running out of reserves with a forecast of half being out of money by the end of January. Alabama is no longer accepting new patients into the program and Colorado and Virginia have told parents to start looking at private insurance options. Of course, there’s also the threat of a government shutdown looming, so when this will all be untangled is anyone’s guess.

For many organizations, this is the time for holiday greetings and service projects. InstaMed launched its “10 Days of Giving” program, running a toy drive for patients at the Children’s Hospital of Philadelphia and delivering 930 toys.

I looked for blurbs from other vendors and was surprised at how little I found on public websites. One vendor detailed their efforts to collect clothing for the earthquake in Haiti in 2010, and another had a corporate philanthropy blog that hadn’t been updated since 2016. A couple of corporate responsibility webpage links returned “page not found” messages.

I know vendors are out there doing good things and would love to report on them. Many hospitals (especially pediatric facilities) have wish lists for gifts in kind and would be happy to receive your donation. My local hospital is looking for not only toys, but things like ear buds and sports team shirts for teen patients. If you’re looking for an opportunity to give, please also consider Mr. H’s Donors Choose program. I’m amazed by the generosity of our readers, and as the daughter of a retired teacher, I know how much those donations mean not only to the students, but to the educators.

I would love nothing more than to have my next piece be full of stories of holiday giving.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/18/17

I worked my last clinical shift of the year this weekend. We had several families come in for care and nothing stresses the system like trying to work up two parents and four preschoolers at the same time, especially when vomiting is part of the picture. There’s a nasty gastroenteritis going around (aka “stomach flu”) along with actual influenza, so I spent most of my day in a mask and cover gown, marinating in alcohol foam every free minute I had.

I had a scribe for a couple of hours during the worst part of the surge, and although we had never worked together, we felt like old friends by the time the shift was over. He’ll be headed off to medical school next summer and was interested to hear about my clinical informatics work in the couple of blocks of downtime that we had. He had spent a couple of years in West Africa, first doing economic development work and later working in a rural hospital, but had never heard of the specialty.

He had some great stories (and even better pictures) of his time with a general surgeon whose skills spanned everything from plastics to OB/GYN due to lack of colleagues. My scribe had spent some time as a first assistant during multiple surgical procedures and figured it would give him a leg up when he gets to medical school. Since he’s been accepted to several highly-competitive schools, he’ll have to fight off dozens of fellows, residents, interns, and students to get to the operating table, but hopefully his knowledge will get him noticed. If there are any cases involving hyena attack victims, he will definitely be able to contribute.

Having a scribe during a record-breaking shift is more than just having someone to help click the boxes. It can mean reminders to include directions you didn’t happen to verbalize when talking to the patient or having an extra set of hands to call around to pharmacies to see who has any Tamiflu left.

We did see several situations where the cost of that particular antiviral medication was out of control, with one family being quoted $750 per patient to have a script filled that typically retails for $120 in our area. The use of Tamiflu is somewhat debatable, but many patients want it in hopes that it will shorten the course of influenza or help protect them from a contagious family member. Most of the local pharmacies were out of pediatric formulations weeks ago, so trying to find it for a child was nearly impossible.

Since we have in-house, cash-only medication dispensing, we’re pretty savvy to the price of drugs because patients typically ask whether it’s going to be cheaper to get it from us rather than using their insurance. Depending on co-pays and deductibles, we’re largely competitive. Often patients who pay cash for their prescriptions are better off getting their medications from us – for one common generic pneumonia drug, we’re nearly $25 cheaper than the local big-box store.

Price transparency is important for many of our patients, and we found over the past year that trying to get the information through our EHR was a nightmare. The cost information, which was scaled by number of dollar signs, wasn’t detailed enough for our patients to make decisions. It was based on average wholesale pricing and didn’t take into account co-pays, deductibles, or pharmacy benefit manager incentives. We keep our cost information the new-fashioned way, on an intranet document that’s basically the equivalent of taping up a cheat sheet at the care team pod.

It would be great if we could get real-time cost information for our patients and then they could make the decision whether they want to purchase their prescription from us because it’s cheaper, or whether it’s worth paying a little more to have it immediately and not have to make another stop.

Sometimes they choose to have the script sent to the pharmacy and then call us back a few hours later, asking if they can come back and pick it up at the cheaper price. This illustrates the challenges we face with patient engagement – we’re empowering them with more information than they’ve had in the past, but sometimes it’s not all the information they need or it might not be correct. I know as a patient having had multiple arguments with providers about the fact that I shouldn’t be paying co-pays the rest of the year and few of them being willing to honor the payer letter that I carry around, that it’s not just about prescription coverage. (Incidentally, I hope the practices that refuse to trust my “don’t charge this patient a co-pay” letter enjoy processing my refund requests, because I make them as soon as I see the Explanation of Benefits.)

If we aren’t able to provide good information on the smallest decisions, it’s a leap to expect people to make decisions on larger health concerns without experiencing stress and uncertainty. I think this is why some patients trend back towards the old days of physician paternalism, where they want a provider to tell them what to do. Or better yet, what the provider himself or herself would do when confronted with the same situation. Having those kinds of conversations requires rapport, which requires interaction over time and the building of trust, which are difficult to do in this era of six-minute visits and fragmented care.

Although the care team approach should theoretically help, in some cases I’ve seen it make things worse as the patient has to now build trust with multiple care team members rather than just with the provider who they’ve chosen (or been assigned) as their primary care physician.

I did have a couple of patients this weekend who specifically said they were at the urgent care because their insurance companies sent letters saying that emergency department visits would no longer be covered for non-life-threatening issues. Fortunately, none of them were emergencies and we were able to handle them. On the flip side, we had patients whose definitive care was delayed by choosing urgent care over a higher-acuity setting. We’re not the best place for actual heart attacks and we just increased your time from symptoms to angioplasty. Same for stroke, when the golden hour really is golden.

I didn’t get a chance to get into the psychology of why they came to urgent care rather than the ED since I was too busy taking care of their ambulance transfers and ED handoffs, but I’m always suspicious about cost being a factor.

I’m hoping that the New Year brings wisdom to our policymakers and greater patience for everyone in our healthcare system, from patients to providers to payers to politicians. I’m skeptical about the last group, but after all this is the season of hope, so I’ll send happy thoughts their way.

What are you looking for in the New Year? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/14/17

When we think about healthcare IT systems, I think most of us probably overlook some of the quasi-healthcare vendors that patients have to deal with to handle their medical bills. A friend vented to me about his company’s choice of a new benefits administrator, which needs to use to access his flexible spending account. This is the same company his employer used in the past, but switched to another benefits administrator last year, and is now switching back to the first one.

He received a message to establish his account to be ready for 2018, but when he tried to execute on it, he received a duplicate warning and was referred to customer support. The site then generated a password reset link, which didn’t help him due to the duplicate accounts. After opening a second help ticket, he received a secure message notification in his employee email, which required him to create a secure messaging account on the benefits website, using his work email as the user name and creating a new password.

Despite having the same login as the benefits site (as well as the same look and feel) the secure messaging portion of the site is entirely independent, and the messages he had been sent were not useful. Returning to the benefits site, he tried again to have his account unlocked, and four days later, finally received a secure message that his duplicates were resolved.

Once he was able to access the benefits site, he discovered there is no linkage to the secure messages from that side either, so users have to go in and out of two different systems if they need customer support. I’m going to go out on a limb with the idea that maybe this is intentional, since money left in flexible spending accounts is forfeit if not used. If the system is difficult to navigate, there’s a chance it will prevent employees from using their benefits.

Speaking of difficult to navigate, I tried to complete my HIMSS18 registration today since the early bird discount is ending. It kept replacing the name of my company with “DX” for no apparent reason, forcing me to log in and out a couple of times. I also had trouble getting the name badge fields to correctly show my city, since I wanted it to display Big City instead of Nameless Suburb in the field. I finally gave up and will try again tomorrow. It looks like my hotel of choice is sold out, so I’m glad I made my reservations a couple of months ago.

I’ve already started building my agenda for the week, including at least one BFF Booth Crawl. Although I’m not fond of Las Vegas, I do enjoy catching up with my healthcare IT friends. For the third year HIMSS is hosting a reception for Millennials. I’m tempted to sign up just to check it out and see how the conversations differ from the other events such as the Women’s Networking reception. I’m too old to pass for a Millennial, but I bet I could pass for a hip older coworker.

It’s the time of year when holiday cheer abounds. I was surprised to receive a notice about the American Medical Association’s “Joy in Medicine” modules and the fact that the American Board of Family Medicine is going to provide Performance Improvement Credit for providers who complete them. I’ve focused most of my Maintenance of Certification and Continuing Medical Education activities on being a competent, compassionate, and culturally-sensitive physician and have completed more than enough credits for 2017. The idea that physicians need to complete coursework to learn how to find the joy in medicine again is a sad commentary on healthcare today. The course is promoted as having tools “to guide the executive leadership teams in creating a joyful practice environment and thriving workforce.”

I gave it a glance, and it does touch on physician burnout but not on the high rate of physician suicide – I guess that wouldn’t be very joyful, but it is a reality. I’ve lost two colleagues with bright futures to suicide and agree that we need to have better support structures, not only for physicians, but for all caregivers and people trying to work in our crazy healthcare system. The module advocates creating a “wellness infrastructure” with a chief wellness officer reporting directly to the CEO or equivalent to other leaders such as the COO or CMO “and is resourced accordingly.”

It goes on to say that “this leader should ensure all leadership decisions consider the potential effect on workforce wellness.” Even though it offers a calculator to estimate the true cost of physician burnout, I don’t see this playing in most of the arenas where physicians are employed. Especially in the under-20-provider practice, it’s going to be hard to create that infrastructure. I’m working with a five-doctor group now that can’t even agree on how overnight call should be distributed, so getting them to have a conversation on workforce wellness would be quite the trick.

Speaking of pipe dreams, Aetna wants to create a healthcare hub at CVS pharmacies to help patients navigate the healthcare system. Likening it to Apple’s Genius Bar, Aetna CEO Mark Bertolini explained it as a cross between the Patient-Centered Medical Home model and a retail establishment where people can walk in and get help.

It’s this kind of over-simplification of patients’ true needs that gets my blood pumping. The infrastructure required to truly make this work is vast, and although CVS trots out its MinuteClinic retail clinic sites as part of the solution, it’s more complicated than it seems. My practice sees many patients who are beyond the narrow care protocols in place at MinuteClinic, and the referral of their patients to a second visit at Urgent Care actually adds to the healthcare system. Do we really think that CVS is going to triage customers away from its clinics to competitors, or are they going to try to expand into the primary care and urgent care space? Or do as they do, and see the patient first, then refer to a higher level of care? Will they send the patient to their primary care physician or offer to sell over-the-counter remedies? I’m hoping the former, but since retail profits are important, the balance might be tricky.

The simplicity of comparing healthcare to the Apple Store also masks the complexity of patients. Where Apple offers service on a set number of products, the number of “models” walking into a healthcare environment is infinite. Although basic processes can be put into place to handle subsets of patients and conditions, I hope CVS and Aetna folks truly engage with their stakeholders to create the model. First and foremost, this needs to be about doing what’s right for patients rather than shareholders. I’ll remain skeptical until I see drafts of their pilot plans. Or, if they’re looking for an anonymous physician blogger to give them advice, I’m available.

What do you think of the Aetna/CVS merger? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/11/17

At times, being a consultant feels more like being a therapist than a business person. We see clients at their best and at their worst and try to help them figure out how to replicate the good times and how to avoid repeating the bad times. Some days, I really feel for the vendors trying to work with these clients.

In recent engagements, we seem to be increasingly leaned on to try to mediate between vendors and clients or at least mitigate situations that are starting to turn bad. These situations tend to illustrate a variety of organizational pathologies, whether it’s the client and vendor not being able to work well together or the client (or vendor) having internal dysfunction.

Case in point: one of my clients hired their EHR vendor to build some content for custom clinical workflows in a specialty that the EHR vendor doesn’t support. There were plenty of meetings to define the scope of the project, outline the proposed build, obtain stakeholder signoff, etc. The vendor’s team performed the build and delivered it to the client environment for testing. While the build was occurring, the client re-prioritized its projects and failed to provide any client-side resources to perform user acceptance testing on the delivered work product.

There were a lot of back-and-forth communications that were fairly ineffective and some loud chatter at the client about whether the work was authorized or whether they were going to pay for it. The vendor was at the mercy of the dysfunctional client, with time spent creating templates and the vendor now wondering if they were going to be paid.

I worked with some of the client core team to explain that their counterparts on another team had authorized the build and had generated a work order to the vendor, based on leadership requests to enable documentation tools for that specialty so they could retire their paper charts. The core team members didn’t seem to understand that the initiative was even going on, and once they were pulled in to be a part of it, they took their anger at their peers out on the vendor. It didn’t seem like the different teams at the client site were able to realize that there might be more to the story, and my team had to step in to get them talking.

The ensuing conversations revealed that probably the not all the stakeholders were included in the project and that the templates might not meet the practice’s needs. Word on the street was that there was a good likelihood that the vendor was going to have to go back to square one.

What was really disturbing about this situation was the client’s assertion that it was the vendor’s fault and that the vendor should perform the re-work for free. The vendor’s customization team provided all kinds of documentation, meeting minutes, build specification signoff, etc. that showed client approval of the project as it moved through various process tollgates. But the people signing off weren’t the “right” people and the client failed to see that the problem was its own fault and not the vendor’s mistake.

The vendor tried to meet the client in the middle and offered a 50 percent discount on the services needed to restart the project and ensure the newly-identified “right” resources were involved, as a gesture of their partnership, but the client dug its heels in and refused to participate until the vendor agreed to perform the as-yet-undefined future services for free.

I can’t fault the vendor here. What the client did is tantamount to ordering something at a restaurant, eating the whole thing, and then deciding it wasn’t what you wanted or that it wasn’t any good. Even worse, instead of asking for a different entrée, you ask for the restaurant to agree to give you however many items you might want off the menu to make up for your decision, without boundaries.

From a business perspective, it doesn’t make sense, but the client continued to push it despite the vendor’s willingness to meet them halfway. The client continued to behave badly, trotting out the threat that maybe they should consider a different vendor since their current one didn’t offer the specialty in question. The vendor reacted as expected, explaining that they’ve never claimed to support that particular specialt, and had worked diligently to meet the client’s needs. The client wasn’t having any part of it, though, and continued to assert that everything was the vendor’s fault.

Since my team was hired to implement the new specialty, I had a vested interest in getting the client to get on board with what the vendor had proposed as a remediation strategy. There were several 1:1 conversations with various client leaders and managers to try to get them to understand what had happened to date in a neutral conversation without the finger-pointing and blame-laying that we might see in a group discussion. Then I tried to bring them to the table to discuss it as a team and to figure out how to move forward.

Meanwhile, the implementation timeline continued to slip as did the practice’s confidence in the ability of anyone to get them onto the system with the rest of their colleagues. The group meeting was a lesson in coaching angry people how to have a productive conversation to move an initiative forward, regardless of how they felt about it or whose fault they thought it was. I was having flashbacks to the behavioral therapy components of my residency training. We would agree to baby steps to move the project forward and then someone would say something that inflamed someone on the other side of the table and we would take two giant leaps backwards.

Eventually we agreed to have the physicians in question take a look at the workflows that had been created and identify how far off they were from the mark. Since at least one of the physicians was involved in signing off on the build, I hoped they were at least partially usable. It turned out they just needed a few tweaks and the creation of one additional workflow for a clinical scenario that wasn’t represented in the original set, and due to the small amount of work needed, the vendor offered to do it for free just to get things back on track. Still, it was a tense four weeks as we tried to work this out, and previously decent relationships were damaged without good reason.

As painful as situations like this are, as a consultant, they are our bread and butter, not only because we can help resolve the situation, but because they identify future work that needs to be done. In this case, there clearly needs to be a review of how they want to onboard new specialties and how stakeholders will be identified when custom content is requested. There also needs to be discussion about how these projects will be socialized by the leadership team to the management team and whether certain criteria need to be met for them to move forward.

We’ll see if they want to engage with a formal project in this area, but due to the budget constraints many organizations face, there’s usually not a lot of money for process initiatives because they’re sometimes considered “soft skills.” I guarantee that what they would spend on a small process project would still be less than the cost of the delays, wasted time, and loss of forward momentum exhibited here.

A new fiscal year is coming, so we we’ll see if it makes the budget.

Have any stories about “soft skills” projects your company needs but continues to avoid tackling? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/7/17

A new survey from the University of Utah looks at how different healthcare stakeholders define value by querying physicians, employers, and patients. Working with Leavitt Partners, they’ve assessed how those groups view quality, cost, and service. I’m not surprised by the findings that nearly 90 percent of physicians equate quality and value, since we’ve had the importance of quality metrics drummed into us for years.

The survey found that employers focus more on cost and patients are most often looking at whether out-of-pocket costs are affordable. That’s not to say that physicians don’t consider cost – it found that more than 75 percent of us consider cost when they make treatment decisions. Unfortunately, we don’t always have an idea of what some of the procedures or medications we recommend might be billed at, let alone how 20 or 30 different payers are going to handle them and where a given patient is on his or her out-of-pocket or deductible limit.

I ran into this recently when trying to have new orthotics made. I know my insurance doesn’t cover them, so wanted to wait until January to order them when I have cash in my flexible spending account again. The physician swore my payer had changed its plan, not realizing that even though I have Big Payer’s name on my card, that I’m part of a self-insured group that uses the network but has a number of carve-outs. Needless to say, they now have my measurements on file, but I’ll be calling back in January to put the order through. They also insisted on charging me a co-pay even though I had documentation that I had met my out-of-pocket maximum this year and no longer needed to pay it, but that’s another story.

Road warriors beware: the New York Times ran a piece last week looking at the health problems of frequent travelers. It’s not just colds and jet lag any more, but obesity, high blood pressure, and more that we have to worry about. The article mentions a 2015 Harvard Business Review article that looked at frequent business travel as a cause of early aging and increased risk for cardiovascular events with more than 70 percent of business travelers reporting unhealthy lifestyle symptoms such as stress, mood issues, digestive problems, lack of exercise, and excess drinking. I’ve seen plenty of the latter in other business travelers, including a consultant who no longer does work for me due to his submission of a lunch receipt that contained four martinis while he was on site with a client.

One of the benefits of working for yourself is making your own schedule. Of course, that schedule is largely driven by the needs of my clients. I’m generally able to accommodate them, but this year I made the tail end of November and all of December a “no fly zone” in an attempt to stay home for longer than two weeks in a row. I’ve been successful, but the consulting karma has caught up with me as I’ve been inundated by clients expecting me to pull a rabbit out of the hat at the end of the year. Usually these requests are around things such as HIPAA Security Risk Assessments, when organizations realize that either they didn’t know they had to do one, they knew they had to do one but just didn’t, or the person who normally does it has left the practice. I subcontract with two vendors who are willing to handle these folks well into the eleventh hour, so I can’t complain.

This year’s end-of-year rush brought me a couple of twists. The first was a client who has decided they need to stand up a Health Information Exchange “or something like it” by the end of the year to comply with the requirements of a grant that they’ve already spent on other things. Of course, they want this done cheaply and quickly, but don’t have any resources to do it and aren’t familiar with their vendor’s current solution offerings. We spent several hours on the phone discussing the options, including secure messaging, which would be slam dunk given their vendor’s built-in workflows. They came back with the traditional excuse that their practice is so different from anyone else’s that they couldn’t possibly make that happen with the prescribed workflow. We discussed other solutions that would cost much more money and be more risky from a timeline perspective, and in the end, they couldn’t make a decision because one of the key stakeholders is out of the office for the next week. But when he comes back, they want to start immediately even though no one has his proxy or signatory authority for a contract.

The second twist was a potential client who hadn’t looked at their quality metric tracking reports for several months following the departure of a key employee. They didn’t fully understand what her role and responsibilities were, and everyone assumed that someone else was picking up the reporting. Now that they’re in the bottom part of the year, they have run the reports and the performance of several physicians is well below the benchmark. The practice determined that several workflows were in error and were shopping around to see if someone would help them modify the database to “correct” the erroneous workflows. I feel their pain, but I’m not one to putter around in someone’s database, especially where an attestation is on the line, so I took a pass.

The next twist was a rescue mission for a new client who recently upgraded their EHR. Despite warnings to the contrary, they elected to retire 100 percent of their custom workflows in favor of out-of-the-box functionality. They failed to perform any kind of user acceptance testing and didn’t require the providers to attend training, so when Monday morning arrived, it was a total calamity. They were initially looking for someone who would revert their database to pre-upgrade shape, but since they had three days of partial patient documentation in the system, that was a no-go.

I martialed some consultants and a couple of trainers to join me in an after-hours training marathon, where we tried to get the providers up to speed before Thursday hit. I’ll be in command center mode all day Thursday and Friday, so wish me luck. The staffers I brought in are delighted to have the extra hours and bonus pay in the weeks before Christmas, but I’m exhausted, and if I have to listen to one more physician complain that they hate the upgrade but they didn’t go to training, I’ll scream. On the bright side, they had already committed to some extensive governance and change leadership work starting after the first of the year, so I know I’ll have a receptive audience if they’re still standing after this week.

Seeing any end of the year madness at your workplace? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/4/17

I occasionally do some work for EHR vendors. Sometimes I help with usability studies or provide an opinion on workflows. Other times it’s more straightforward marketing and communications work. I may have even ghost-written a blog or two for a company who was experiencing some clinical leadership challenges.

Given my background helping practices with system selection, one of the things I enjoy most is helping companies look at acquisitions or potential partnerships. I recently had the chance to evaluate a potential solution for a mid-tier EHR vendor looking for a patient engagement partner, and it was quite the experience.

I’m definitely a process kind of gal, so the first question I usually ask is whether I will be asked to sign a non-disclosure agreement and whether there are any agreements in place between the vendor parties that I should be aware of. Since my business is fairly vendor-agnostic, we need to make sure that anything new we take on doesn’t come into conflict with existing clients.

In this situation, the companies had been talking for some time and had been doing some work on what seemed to be a handshake basis. They seemed surprised that I would even be asking about a NDA and the fact that I thought we should have one in place. Although neither vendor is a publicly-traded company, both of them have multiple external funding sources and should see protecting their intellectual property as a priority. Once they agreed to create the needed NDA, it took several weeks to get it drafted.

In evaluating the discussions that had taken place to date (and which continued despite the lack of NDAs) most of them had been of a technical nature. There was plenty of understanding on how a potential integration would take place and the best ways to leverage interfaces vs. APIs and how to handle discrete data. There was a striking lack of discussion on whether the EHR vendor’s clients would even be interested in such a solution or how they would use it in daily practice operations. The potential partnership was being driven almost entirely by the secondary vendor, who was clearly looking at this as an opportunity to catapult their solution to the next level.

I recommended some facilitated conversations between clinical leadership of both companies so that everyone could adequately understand what a partnership might bring to the table for both companies and how the EHR vendor’s clients and their patients would benefit. I also asked for reference sites that we could contact and see how the solution was working with other EHR vendors.

As we were working to get both of these sets of discussions scheduled, someone mentioned that a pilot was already in place. Since we still didn’t have a signed NDA, I was shocked to hear that the EHR vendor had identified a client who would agree to install an unproven solution with questionable value that not only had the potential to disrupt their workflow, but also to push data into their EHR database. Even if the solution was being provided for free, just because something is inexpensive doesn’t make it a good idea.

I pushed again for the reference calls to be scheduled. The first call was less than stellar, with the provider stating that they had difficulty adopting the solution because patients didn’t want to work with people outside the practice. In a small family medicine practice, the patients generally know all the staffers, so I understand their skepticism at talking to people they didn’t know and who weren’t part of their small-town community.

My biggest takeaway from this less-than-stellar reference call was that this client should never have been put forward as a reference site. They only had a handful of patients using the solution and the process wasn’t working, to the point where the vendor was considering changing its model altogether. Why would anyone think that is a good idea to use this practice as a reference site? The second reference call was scheduled and canceled twice, and then the reference site became unresponsive. Again, not a good sign.

The potential partner continued to push us to have conversations with its clinical leadership, who continued to talk about their vision but couldn’t answer many of our questions on actual strategy and deliverables. The EHR vendor team responsible for vetting the potential partner continued glossing over the third party’s shortcomings, minimizing the clinical concerns and focusing on the idea that, “We need to strike while the iron is hot.” I was part of more than a few discussions about needing to lock in with the partner before another EHR vendor started talking to the company. However, when the conversation was steered to the actual commercial potential of the solution and the ability to deploy it to the EHR client base in a sustainable fashion, those concerns were also minimized.

The partnership continued to move forward in a nearly-unstoppable fashion, with a plan to bring pilot sites live that didn’t have support from the clinical leadership committee, the VP of implementation, or the VP of client support. There was zero documentation on the actual ROI and value proposition for clients, and the EHR vendor began to lock in on the fact that the sales team thought it was a cool solution. Since logic wasn’t giving people pause, I tried to use automotive industry examples to show the difference between “cool” and “useful” and “valuable,” but that didn’t work either.

Meanwhile, the pilot project (again, done on a handshake) was failing and it didn’t feel like there were resources on either side to try to save it. The lack of strategy was obvious, and the finger-pointing began with each vendor accusing the other of not being fully invested. The poor client was caught in the middle, with a half-implemented solution held together by duct tape and Band-Aids.

I tried to appeal to the EHR vendor to stop the madness, but the project had by now taken on a life of its own. The sales team had already gone out and identified additional prospective pilot clients who had received demos and offers of free installations, but the implementation team had withdrawn from the discussions due to lack of clarity on the project. It’s hard to implement something when you can’t figure out what had been promised or how to make it a reality.

At this point, the NDAs were finally complete, but the initiative was falling apart due to lack of leadership on both sides. Another external consultant and I continued to encourage the development of an actual business plan and commercialization strategy, but we both agreed our recommendations were being ignored.

I was glad that I had made this a time-limited contract, allowing only 120 days to work with this vendor. I was left with a sense of frustration and disbelief that two organizations could operate like this and not change course when confronted with expert recommendations if not outright failure. It felt like everyone was racing to the endpoint without a plan, which is never a recipe for business success.

When the EHR vendor asked me to extend my engagement and to help rectify issues with the pilot, I respectfully declined. I didn’t want to continue down this maddening path and am beginning to question whether I will even consider working with this vendor again.

Watching seemingly savvy business people run headlong into a mess was difficult, even though it was fascinating from an organizational psychology perspective. It made me wonder whether living in the world of speed dating and Internet hookups has spilled over into the corporate world, with the focus being on a quick connection rather than a longer courtship with appropriate discovery. At the end of the day, both companies spent time and resources on something that fell apart and probably shouldn’t have been contemplated from the beginning.

As my contract expired, they were continuing to try to patch things up. I’ll have to check back in a couple of months and see if they figured out how to take things forward or whether they continued to throw good money after bad.

Have any good stories on due diligence? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/30/17

I enjoy following startup companies, especially those that are looking for novel or improved ways to manage complex conditions. Diabetes is not only a killer, but a significant drain on our already overloaded healthcare system, and many physicians feel there has to be a better way to engage patients to participate in the lifestyle-related parts of their care. I’ve been following Diasyst for a couple of years now and it looks like they’ve actually launched. Their approach uses a patient-facing mobile app to monitor blood sugars coupled with EHR integration to get all the data in the same place. They then use clinical algorithms drawn from work at Emory, Georgia Tech, Grady Memorial Hospital, and the Atlanta VA Medical Center to provide clinical decision support. The loop is closed by sending custom patient plans back to the mobile app. I haven’t seen a demo yet, but hope to catch one soon.

My laugh of the week was and email from the communications and marketing team at a hospital where I haven’t worked for a number of years. They were asking me for a new head shot for my profile on their find-a-physician website. They’re switching systems and my old picture apparently was too low of a resolution to be compatible. I replied and told them I was no longer affiliated with the facility and they sent an email again asking for a head shot and telling me it was my right to be included in the directory because I have “referral privileges for diagnostic testing” and that it would be free advertising for my practice.

In all the years I’ve filled out medical staff credentialing forms (both as an applicant and as a department chair), I’ve never heard of that class of privileges. When was the last time you saw a hospital refuse a patient who arrived with an order for diagnostic testing because the ordering or referring physician wasn’t on staff? Personally, I’ve never seen it, and I’ve received reports from many hospitals where I wasn’t on staff but where the patient had arrived with a radiology or lab order form. As long as the insurance card is valid and/or the preauthorization is in order, you’re usually cleared to receive services.

I asked the marketing rep what contact information she had on file for me and she replied that in the old system my profile is completely blank, which was leading her to think that perhaps the list she was given should have been vetted before she started contacting people. She rescinded her offer for free advertising after I told her that I am employed by a competitor.

My clinical employer has opted out of Meaningful Use, so this vendor blog article about why urgent cares should opt in caught my eye. For physicians and practice managers who may not know a lot about MIPS, they did a reasonable job summarizing how MACRA brought several CMS initiatives together and how practices can avoid negative payment adjustments or earn a bonus. They mention that practices with a high performance score can be “proud to share with the public.” I’m not sure how relevant this is to the average patient – despite a push for consumer-driven medicine and patient engagement, as an urgent care physician, most of our patients choose our services based on our location and hours of operation or by word of mouth. They’re not out investigating Composite Performance Scores before they come see us to get help with their poison ivy or flu symptoms.

The piece goes on to make submission seem straightforward, with no mention of the amount of data that has to be gathered or the work that has to be done beyond what is typically done in the urgent care setting. It also cites a top score as a way to “attract top talent on a healthcare landscape where every advantage matters.” In my world, we’re attracting top talent simply because we have opted out of the federal programs. Physicians are tired of dealing with initiative after initiative and just want to practice medicine. We’ve not only opted out of the madness, but provide scribes if providers want to use that documentation style. At least from the inside, it feels like we’re taking control of our situation and delivering good care at reasonable prices with a minimum of hassle. It remains to be seen how the penalties will impact us and whether our non-Medicare book of business will be impacted if competitors start advertising their MIPS composite scores.

As a physician who reads a great number of chest x-rays, I also enjoyed this article about automating x-ray interpretation. We’ve automated readings of other studies such as Pap tests, and given the number of chest films that are taken each year, it makes sense to see how we can do better. There is always a debate whether a patient has an early pneumonia or whether they just have increased bronchovascular markings. The Stanford University Machine Learning Group is tackling this, with the algorithm now outperforming radiologists in diagnosing pneumonia.

Although the data don’t mention family physicians, emergency physicians, internal medicine physicians, or pediatricians, I suspect it would outperform us as well. At our practice, each film is read by two providers to reduce the risk of interpretation errors. Having the second review be part of a proven algorithm would be a bonus. In the mean time, we’ll continue making the decisions based on our interpretation of the x-rays along with the clinical picture of the patient in front of us, which is often more important than the film itself.

I don’t envision a future with photo booths where a patient pops in for an x-ray and gets a printed script based on the algorithm, unless it can also look at nutrition and hydration status, co-morbid conditions, history of medical non-compliance, current climate of antibiotic resistance, travel history, occupation, social supports, financial status, insurance coverage, and more. Those are all the things physicians consider in making our decisions that outsiders often overlook. I’m not worried about being replaced just yet.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/27/17

Conventional wisdom dictates that healthcare IT projects shouldn’t schedule a go-live on a holiday weekend due to resource constraints and time off. I was called by another consulting company to see if we could provide some go-live support resources for a hospital that decided to break the mold. Although our focus is largely ambulatory healthcare IT, I work with people who have extensive experience with both inpatient and outpatient systems, so I decided to bite. Especially with it being a holiday situation, the pay being offered was definitely attention-grabbing.

My consultants have been prepping for this for several weeks, viewing recordings of the hospital’s training sessions so they could see exactly how the system was configured and how the users had been trained to use the system. This is important when you’re a third-party go-live resource. Often clients elect not to deploy part of a system or to modify the functionality, which can result in issues when you suggest that the end users access a feature they can’t actually use. Ensuring your go-live contractors understand how the system is actually going to be deployed is a key responsibility for client leaders who decide to outsource their Day 1 support. I’ve seen this overlooked in the past and have learned to insist on it when my team is involved.

The videos were thorough. Nursing staff received about 16 hours of training, including some overlap into the provider workflows so that they could assist with supporting community physicians who may not use the system as frequently as hospitalists and other full-time inpatient providers. Physicians were supposed to attend about eight hours of training, and although they were required to be at both half-day sessions, I received report that there wasn’t a lot of enforcement of participation or a required demonstration of mastery before they would be issued their production passwords.

We were warned to be able to support specific providers more heavily than others and were given their names and specialties and typical rounding times. I haven’t experienced that in the past – usually resources are assigned to a particular nursing unit or another location where provider documentation takes place and are expected to just help people on the fly. This was the first time I had a “hit list” of people who might have issues and I thought it was a great idea.

Since the original consultancy was responsible for the communication with the hospital, they arranged all the logistics for who would be stationed at various parts of the hospital and made sure they had a mix of contract resources at the larger care delivery areas. I’ve seen this split out before, where one subcontractor would cover this floor, another would cover the next, and so on. I thought their mixing of the resources across the various units was a great way to hedge their bets, especially since they knew there may be some resource challenges with it being a holiday weekend.

Still, everyone was a bit nervous going into things, since you never know what a Thanksgiving weekend might bring. Typically, physician offices are closed the Friday after, which shifts volumes to the emergency department. There may be a lull on Saturday and then it usually picks up again as people who were trying to wait until Monday decide they can’t wait anymore.

Of course, there’s also the Holiday Heart Syndrome, which can lead to cardiac irregularities when people overdo it during the Thanksgiving and Christmas eating seasons. Sometimes non-healthcare people are surprised when we talk about these kinds of volumes and trends in planning and people casually throw out their stories of being in the emergency department or working urgent care during major days off.

My best story was working on labor and delivery on Super Bowl Sunday as a resident. Within 45 minutes of the end of the game, we were swamped, with all 19 labor rooms full and overflow into the antepartum unit. Women had remained laboring at home so as to not disturb viewing of the game, then headed right to the hospital as the clock ticked down. Several babies were born within 30 minutes of arriving at the hospital, which is cutting it close if you were planning for epidural anesthesia or using the birthing pool. I had volunteered to work that day since I wasn’t a huge football fan and didn’t have other plans, but made a point to mark my calendar for the next two years so that I didn’t experience that level of back-to-back deliveries again.

Our go-live officially occurred on Friday morning while many people were out doing their Black Friday shopping or spending time with families. There were no elective surgeries scheduled and very few outpatient procedures, providing an overall reduced volume through the hospital. I suspect there had been more than a few “early” discharges for patients who didn’t want to be in the hospital for Thanksgiving, either opting for skilled nursing or home health as a way to leave the wards early. Patients rarely want to spend a holiday in the hospital, so I’m sure the insurance folks were happy. Based on some of the admissions I saw on Friday, there may have been a few people who went home too early, which of course isn’t good for those readmission metrics.

Friday was largely uneventful, with most of the staff being full-time hospital employees and seeming to have been fully present for their training. The community physicians started rounding again on Saturday, but were scattered throughout the morning and early afternoon, making support easy. From an at-the-elbow perspective, we were relatively redundant, but it was good to have multiple people ready to pitch in should the need arise. Assuming budget permits, I’d always rather it be that way then having physicians fighting for someone to help them. Sunday was much of the same, although some different hospitalists rolled in to start seeing patients since their work weeks run Sunday through Sunday. Many of the hospitalists have worked on multiple systems, so this was barely a blip for them.

I headed out Sunday night, leaving a couple of my consultants to help with targeted support for the community physicians on Monday. This is of course where the rubber meets the proverbial road, where providers who may not have been as invested in training as they could have been start arriving on the floors and taking care of patients. The hospital had some great cheat sheets deployed to the workstations both in paper and electronic form, not to mention the go-live contractors, who will be on site in full force Monday through Wednesday wearing their hot pink tee shirts so users can find them. They’ll start tapering off after that, with the hospital planning to support with only internal resources starting Week 3.

I haven’t personally staffed a hospital go-live in some time, so it was a nice experience, and doubly so being at a place where things were over-orchestrated to the point that they were uneventful. Not every go live is like that, for certain. We’ll see if my team has any good stories to share later in the week, but I would love to hear some go-live stories from the trenches.

Have a good story? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/20/17

I spent a rare couple of days traveling for non-work business, but through the magic that is the small world of healthcare IT, I ran into a friend I normally only see at HIMSS. It’s always fun to run into people out of context, when you’re trying to make sure they’re really who you think they are before you call out to them. Since I was wandering around the city while my friends were attending a patient safety conference, it was nice to see a friendly face.

I did end up in some healthcare IT conversations over dinner and drinks, however, and I heard some horror stories from a conference panel on HIPAA requirements and security risk analysis. One of my friends admitted that she had her work laptop stolen and didn’t report it to anyone despite it containing protected health information. That sort of thing is one of the perks (or hazards, depending on how you look at it) of owning your own practice and not fully understanding the huge number of laws that impact our practices. At least she realized after attending the conference that she should have taken additional action.

One of my other traveling companions works for a large integrated delivery network, where policy and procedure reign. She shared her thoughts around a session on patient safety and how it relates to impaired or distressed physicians. I agree with her suspicion that we’re going to see more of those types of situations as physician stress and burnout increase. We had a great discussion on addressing the needs of physicians with chronic health conditions that are impacting their ability to deliver care. She’s in a leadership role, and given the size of her organization, has dealt with a number of issues including early-onset dementia, a surgeon with new-onset seizures that began in the operating room, and uncontrolled diabetes leading to a physician collapsing on a patient. She’s approaching retirement and I think she might have a bright future as a storyline consultant for a medical TV show.

We were also entertained by another member of our physician “ladies weekend” party who was trying her hand at social media. Even though her practice has been around for nearly 20 years, they’ve never taken the plunge. She was trying to figure out how to post conference snippets on Facebook and Twitter without being overly obvious or violating any terms of the conference or the social media platforms. They’re concerned about having patients follow them on Facebook and post personal details, revealing that they’re patients. We discussed different ways of controlling posts to their page and how to respond when there are potentially inappropriate submissions. Their practice could be a case study in physician workforce management and advertising: an OB/GYN practice which has recently converted to GYN-only to meet the needs of their “mature” physician staff, but wants to try to grow the practice.

They’re also trying to limit the number of surgical procedures they do, but I don’t think that they realized how challenging it would be to try to build a patient panel to support Well Woman visits that only occur once a year. They are considering the incorporation of some non-core procedures that we see other physicians adding as their demographics shift: facial aesthetic services, leg vein treatments, weight management, and other typically cash-only services. It will be interesting to see how their strategy has evolved when I meet up with her again at a conference we’re scheduled to attend in April. Hopefully by then her social media habits will have matured enough that she’s not obsessing over every “like.”

I returned home to a day in the patient care trenches, which made it seem like I was never on vacation. Work has a way of sneaking up on you like that, and since I was training a new physician assistant as well as keeping my eye on a couple of new patient care techs, it was more stressful than usual. We’re gearing up for a busy pre-holiday week and are starting to see increased volumes from out-of-town visitors. Add in the extra patients from primary care offices that are closing or working shortened hours this week and it will only get busier. Since I don’t travel for Thanksgiving, I usually work multiple shifts around it to allow my partners who do travel to have some breathing room. I’m sure by next Sunday I’ll be dragging, although hopefully some leftover Turkey and dressing will keep me fueled. Our practice has tripled in size over the last two years and there don’t see any signs that things will slow down anytime soon.

I closed out the weekend with some online training for an analytics startup that asked me to do some work. They’re looking for independent review of their overall approach but also of their training curriculum and whether outsiders think it will be as easy to implement as they have convinced themselves that it will be. Although the training was solid, there are definitely some holes in their workflow since they’re making the assumption that everyone in the office will be using the solution at the point of care. The problem is that it’s not embedded in the EHR, so it’s yet another one of those “one more place to go for data” destinations that clinical users struggle to reach. For small practices that don’t have dedicated care coordinators or care managers, the idea of analytics is daunting enough on its own. Add in the assumption that physicians should be doing it while they’re seeing patients and I think it becomes a bit of a non-starter.

I’ll complete my write-up for them later this week and then will have a debrief with their marketing team and training team next week. I’d rather have a debrief with their strategy team and CMIO, but we’ll just have to see where my preliminary findings take us. The startup’s leadership seems pretty convinced they’ve nailed it and I’m not sure how open they are to receiving feedback that isn’t 100 percent in line with their expectations. I’ve been in the startup space before and I know I’d rather receive critical comments from internal and external testers rather than from clients whose expectations we missed.

Is your organization all-in with analytics or just dipping your toes in the water? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/16/17

Not healthcare IT, but providers will probably have to document conversations on this in the EHR. The US Environmental Protection Agency has approved the release of so-called “weaponized” mosquitoes in parts of the US. They’re officially classified as a “biopesticide” and their creator, MosquitoMate, will be licensed to sell them for five years. The lab-grown male mosquitoes are infected with a bacteria; females mating with them will produce eggs that don’t hatch. The goal is to reduce the spread of diseases such as yellow fever, dengue, and Zika. The modified mosquitos don’t bite and will be on sale to municipalities and individuals. The US isn’t the leader here, with lab-grown mosquitoes already in use in China and Brazil.

I struggle with articles that overly-simplify the challenges we face in healthcare and this one on HealthcareDIVE is a prime example. Trumpeting the headline of, “The healthcare of tomorrow will move away from hospitals,” it tries to boil down discussion from the US News & World Report Healthcare of Tomorrow conference into a few sound bites. First, it states that “locating services in a patient’s home or somewhere close by and easily accessible is more convenient for patients, but also produces more comprehensive and effective care.” This is a gross oversimplification and doesn’t take into account that some of the most convenient sites of care (retail clinics) are also the least comprehensive, as they are sometimes staffed by mid-level providers with limited scope of practice. I see dozens of patients each month who are referred to urgent care because their conditions are out of scope of the retail clinic, resulting in two visits and two charges for the patient.

This also doesn’t take into effect the proven concept that for some situations, regional or specialty centers provide better outcomes than local or community facilities. Complex procedures like cardiac surgery, neurosurgery, high-risk pregnancy, and other similar conditions fall into this bucket. This isn’t supported by their sound bite of, “If you have to go to the hospital, we have failed you.”

As a patient / consumer who has recently faced difficult decisions in this area, it’s not a simple choice. Should I keep going to the local physician-owned imaging center for my mammograms, where they are high quality but lower cost, or move to the hospital because it has a high-risk surveillance protocol and better track record for finding early breast cancer through combined mammography and MRI, but with a higher cost and a higher hassle-factor? I honestly went back and forth on this decision for a couple of months before I decided to go with the hospital option. Should the day come where something is found, however, I’ll be ditching that hospital’s cancer care team for the one at the academic medical center, which has an equivalent track record for finding cancer, but better outcomes in treatment. If these decisions are difficult for a physician, they’re doubly challenging for the average patient.

I agree with the statements that telemedicine needs to become more commonplace – and that means being reimbursed in the same way that we reimburse for face-to-face visits. Whether we’re living in a fee-for-service world or one of value-based care, somehow the physician, mid-level provider, or other caregiver’s time needs to be paid for. I agree that consumers are going to drive many healthcare shifts over the next few years – I look at the growth of my own practice (from five locations to 15+ in a little over two years) as an example that patients are voting with their feet and their co-pays for convenience along with the more full-service experience that we offer. Essentially, we function as a cross between a primary care office and an ED and provide all the services in between plus pharmacy for a fraction of the cost of the ED. We’re not cheaper than primary care and don’t quarterback a patient’s comprehensive care, but if you need to be rehydrated during your gastroenteritis, we’re the hip place to be.

Patients are willing to pay the larger urgent care co-pay in order to not have to wait to get in to see a primary physician (assuming they have a primary physician, which many do not due to the relative primary physician shortage in our area). It’s telling that most of our new staff physicians are former PCPs who have found the urgent care lifestyle more conducive to their humanity as compared to being a primary care doc. We’ve been accused of poaching primary care physicians and making the PCP shortage worse, but this is market economics at work. The idea that a physician is “called” to work long hours for low pay as a PCP has become antiquated as providers vote with their wallets and their free time to work 160 hours a month for the same pay as they were previously working 200 or 240 hours, with less stress.

When you look at it, urgent care provides a similar case mix to what many of us trained for during family medicine residency: acute care, chronic care, and procedures, the latter of which is missing in many primary care practices now that physicians are asked to do more high-level work and less of the procedural work that we found enjoyable regardless of the fact that it could be done by mid-level providers. Of course, we don’t have the continuity of care that originally sought as PCPs, but we have more continuity with our families and our personal lives. The playing field has changed as third-party forces have transformed healthcare from a calling to a job.

I do appreciate the comments from Jason Spangler, MD, MPH, a quality and medical policy director at Amgen. He calls for the industry to “pay and incentivize patients toward high-value care and disincentivize them against low-value care.” Modifying patient behavior is extremely challenging, as anyone who has ever tried to convince a patient to change their lifestyle vs. just taking a pill once a day for high blood pressure knows. I’m sure there was a broader and richer discussion at the conference, but the coverage provided is problematic. Those who try to boil these complexities down to sound bites aren’t doing much to help the situation.

My condolences to the family, friends, and close colleagues of Uwe Reinhardt, healthcare economist and Princeton University professor. He was a master at dissecting the US healthcare system and showing how it defies logic. I once had the chance to meet him as we were assigned to share a car to the airport following a conference where we spoke on separate healthcare panels. He could easily have used the time to check email or catch up on phone calls, but instead he wanted to learn more about me and my thoughts on the US healthcare system from the primary care and CMIO trenches. He was kind, thoughtful, and a good listener, which are qualities we don’t always see among some of the loudest voices in healthcare. If you’re not familiar with his writings, they’re definitely worth a read.

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Curbside Consult with Dr. Jayne 11/13/17

Since I work with so many different healthcare organizations, I have a variety of behind-the-scenes views into various non-clinical applications. When we think about healthcare IT, most of our brains automatically jump to systems like EHR, laboratory information systems, PACS, etc. But there’s a lot more to keeping healthcare organizations and IT vendors on their feet – systems like scheduling, payroll, client management, accounting, and more.

One of the things that is often surprising to me is the variability with which various systems have been implemented, often to the detriment of their users. I’ll be working with a group that complains bitterly about how they have to log their hours, only to run across a different group happily using the same system.

One of the major pitfalls I see when comparing disparate installations of the same system is the level of customization or configurability available during implementation. Just as we see with clinical systems, those making the decisions on business systems often jump right to customization before even going live. Rather than using the implementation of a new system as an opportunity to refine work streams and reassess processes, I see organizations simply move their old data over and create more modern versions of the same old messes. Although we often see this with patient accounting systems when clients want to move their old accounts receivable to the new system so that they can decommission the legacy system more quickly, I recently saw it with a general ledger conversion, where the health system wanted to bring more than 15 years of accounting records into the new system.

The engineers involved were struggling with data integrity concerns about moving data that had been converted previously, as the organization was on its fourth accounting system in 20 years. They also had concerns about system performance and the size of some of the data tables. I asked about the business case for bringing that data across rather than archiving it, since most businesses don’t keep records in their current system longer than required by the law or generally accepted accounting principles. The engineers didn’t believe that there was a compelling business case since the old system was going to be archived, but were forced to go along with the project as scoped. The project also has other issues, such as being more than a year behind schedule, but that is a topic for another day.

I also see process improvement opportunities with respect to time-keeping software. Many of the time clock solutions out there are straightforward, but when you get to the point of having engineers and analysts log time against multiple concurrent projects, I’ve seen some messy systems. The most efficient systems seem to be those that can cross reference standard work streams against multiple clients or projects. The worst are those that require a subset of work streams be created under each client or project, resulting in potential errors in item creation and challenges for people trying to find the item where they need to enter their time. I saw that recently when a work item was misnamed when creating it under a new project and no one could find where to log their time because they were searching for “Requirements Creation” rather than “Create Requirements.” At a minimum, organizations need documented procedures and job aids for creating these types of entries so they don’t cause chaos for downstream resources.

One of my favorite vendors to hear people talk about is SAP. First, people don’t realize that SAP has multiple products. They also don’t realize that each product can be implemented in different ways. Corporate policy can also influence how a product is used and what level of access different users have. These types of policy differences can result in a graceful process to follow when mistakes are made or one that is arduous. They can result in empowerment for end users or multiple layers of control. It’s not just SAP, though – I hear the same types of comments about Kronos, Oracle, and pretty much anything that comes from IBM. Like many of our clinical and billing systems, there are significant dependencies on how these systems are implemented and how they are managed.

When I work with healthcare organizations, most of my billing is done through work orders, against which I document the hours my team renders based on assigned projects. Some organizations want third parties to work directly in their systems, logging hours as we go just like their employees do. This is where it gets interesting since they usually require a Social Security Number to set up an employee and there’s not a compelling reason for a third-party employee to necessarily provide that information. Once we get through the setup phase, the real fun starts, as we try to figure out project hierarchies and how to work through what can be less-than-straightforward instructions. As much as we champion role-based training for clinical and practice management systems, I don’t see it as much on the business / financial / management side. I’ve had to sit through trainings on parts of project management and time entry that I will never use. Although they’re not a great use of their time, it is sometimes fun to see what goes on in different kinds of organizations.

The other challenge I see in the behind-the-scenes world is having multiple systems in which employees have to work. There may be a payroll system, a time and attendance system, a credential management system for clinical employees, an internal help desk ticketing system, an expense reimbursement system, and a travel management system. Other organizations also add project management systems, customer relationship management software, external help desk systems, secure messaging, collaboration platforms, and more. And of course, there are the requisite email and calendaring systems that most of us use, along with instant messenger and other communications tools.

Sometimes we don’t think a lot about these systems, but they should be on the list when we think about competing priorities that our healthcare partners may have when they’re trying to perform major EHR upgrades, implementing new features, or other projects. I wouldn’t want to do an EHR go-live at the same time as a new time and attendance system. And if I was doing a new practice management system, I’d want to make sure other accounting systems are stable.

At one health system where I worked, the IT organization supported over 900 systems. The average user had permissions for between 15 and 20 of these. I’m curious how many systems an end user has to access in other organizations.

Are you taking steps to simplify and consolidate these functions, or just soldiering through? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/9/17

I’ve been trying to digest the recently-released CMS final rules. Overall, much of the flexibility we expected for the Quality Payment Program is now final, including the ability for providers to use 2014 Edition or 2015 Edition Certified Electronic Health Record Technology (CEHRT) for the Advancing Care Information category. Although many organizations are breathing a sigh of relief over this, there is a bonus for using only 2015 CEHRT and those organizations that kept the pedal to the floor may get at least a little reward for their efforts.

Additional items in the Final Rule include relief for providers impacted by Hurricanes Harvey, Irma, and Maria by automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0 percent of the MIPS final score. Small practices can get five bonus points to the MIPS final score, as can those practices that treat complex patients.

Although CMS continues to crow about their success related to the “goals of regulatory relief, program simplification, and state and local flexibility in the creation of innovative approaches to healthcare delivery” I know there are a lot of us that think any rule that requires 1,600+ pages to explain cannot possibly be simple. I’d personally like to see the “QPP for Dummies” edition to make sure I fully understand everything that’s in there. Even the Executive Summary is 21 pages long.

Last Monday CMS administrator Seema Verma also announced the “Meaningful Measures” initiative which CMS claims will help streamline quality measures that providers are trying to meet. Although this sounds like a welcome change, this isn’t the first time we’re heard about proposed program simplification. Although some payers follow the lead of CMS on quality measures, others put their own little twists on the measures clinicians need to report, requiring them to create custom reporting that mimics CMS requirements in a “missed it by that much” manner. If payers can’t agree on the most meaningful measures for patient outcomes, that doesn’t give those of us in the trenches confidence.

For many of us, the constant changing of measures and requirements just seems to highlight the idea that we’re all part of some uncontrolled experiment with no defined endpoint. The sheer number of hours spent by organizations on regulatory compliance is staggering. At least a couple of times a year, I have conversations with medical students who are questioning their career choices and who are trying to figure out if they want to go to business school, law school, or residency. I know it’s anecdotal, but I feel like we’re having a lot more of these conversations than we did in the era before Meaningful Use.

I haven’t had admitting privileges at my hospital for a long time, but I’ve been able to keep an adjunct status that lets me participate in continuing education sessions, attend Grand Rounds, and hang out in the physician lounge, which gives me a place to meet with students and residents to talk about career planning or mentoring. It’s been worth the small fee I pay every year to have a central place to have those conversations, since my “office” is in my house and sometimes meeting at a restaurant or coffee shop can be noisy.

We have a new hospital administrator who spoke at a recent medical staff gathering. I was struck by a several things. First by his youthful exuberance but relative lack of experience and second by his amazingly full command of what I can only describe as an executive word salad. Seriously, if he told me how much we were going to synergize around results-oriented outcomes one more time, I was going to burst out laughing. I am going to have to break out the Buzzword Bingo cards if I ever go to an event where he will be speaking again. I miss the camaraderie of the hospital, and the hilarity of the whole thing made me glad I took the time to attend.

While I was chatting with some of my colleagues, I heard some complaining about changes to how the AMA is calculating the need for licensing for CPT codes. Rather than counting actual end users, AMA is moving to a “User Proxy Method” that approximates the number of CPT code users in an ambulatory billing or clinical system based on the number of full-time equivalent providers in the practice. These counts are multiplied by industry data. In the case of an ambulatory clinical system with or without a billing system, the multiplier is four. The discussion at the hospital included overall unhappiness with AMA’s monopoly on coding, with one provider questioning whether the RICO act should be used to counter its grip on providers. In researching the issue, I noticed AMA still uses the “EMR” verbiage, which highlights how behind the times they are.

When I returned home from the hospital, I was glad to find an email from the last of my friends in Puerto Rico that I have been waiting to hear from. He and his family are safe, but were without power for more than a month and are still having difficulty obtaining supplies. Although stores are restocking, his community has returned to a cash economy. It sounds like there continue to be many health system challenges that won’t be resolved anytime soon.

AMIA2017 has been in full swing this week, with National Library of Medicine Director Patti Brennan presenting at Monday’s Sunrise Session and National Coordinator Don Rucker presenting on Tuesday. I didn’t make it this year because of a conflict, but hopefully next year’s calendar will be more forgiving. Looking at a schedule of available conferences for the next year, I’m going to have to choose carefully, especially since I need to fit in a board review course to prepare for recertification. Since I haven’t practiced traditional primary care in a number of years, I’m dreading the exam but given our need to comply with Board Certification in order to be credentialed by payers, I don’t have much of a choice. Not to mention, we have to maintain a primary board certification to keep our clinical informatics certifications, so letting mine lapse would be a double-whammy.

Have any good board exam prep tips? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/6/17

I did some work earlier this year with a small hospital that was having trouble recruiting and retaining physicians. Smaller facilities can have challenges, depending on geography and community demographics. This particular organization is a little over an hour drive from a major metropolitan area that has plenty of universities, professional sports, and cultural attractions. Depending on your willingness to commute, it would be entirely possible to live in the city or its suburbs and drive to work. There is also plenty of desirable housing in the growing semi-rural community, so the hospital leadership has been somewhat stumped at why they are having so much difficulty with recruiting and retention. I was initially brought in to do an analysis of their physician compensation strategy.

Looking at the physician salary piece is fairly straightforward. There’s good data available from practice management organizations along with specialty societies and various independent analysts. They were paying a little less than I would have expected, with some student loan repayments being offered that are largely irrelevant to mid-career physicians. Their benefits were a little below average, with relocation allowances and healthcare benefits on the less-generous end of the spectrum. They did offer a couple of more unusual benefits such as pet insurance, and disability coverage was solid. In presenting my findings, I asked if they had done any exit interviews with departing physicians and was surprised to learn that they had not. I offered to broaden my work with them to dig into this and they agreed.

I’ve not done many exit interviews as such. In my past life, our human resources department handled them and simply presented data and summaries to the hiring manager when an employee departed. However, I’ve done many stakeholder analysis projects and decided to use that approach when reaching out to physicians and other providers who had departed over the last year.

For those readers who may not be familiar with a stakeholder analysis, it’s in the realm of qualitative research. Participants are interviewed using a standard set of questions, with their narrative responses recorded and analyzed. Since everyone is asked about the same issues in the same way, response trends can be used to identify areas where an organization may have some work to do. Although some consultants will have a second observer attend the interview and assist with analysis of the responses to reduce potential bias, I’m usually a one-consultant show, so I record the interviews with permission. The results are transcribed and then I can more easily perform the analysis and group parallel responses to create the final anonymized summary.

Several interviewees referenced concerns about the commute after deciding to live closer to the metropolitan area for access to what they felt were better schools. Others wanted to live closer to the city to be closer to religious institutions that weren’t present in the community around the hospital. There were some common themes around the hospital not seeming to value diversity and physicians having difficulty fitting in, with several respondents referring to an “old boys’ network.” As people are interviewed, they tend to be more reserved with their responses, then become a little more free as they begin to trust the interviewer. These interviews kept that pattern, with people becoming less guarded as we chatted. I was glad that I was recording the discussions because some of them were pretty entertaining.

One leader was specifically cited multiple times as being a challenge to work with, largely because of what interviewees described as an obsessive focus on sports. It seems most of his conversations contained sports analogies that may not have been fully understood by colleagues who were not of a semi-rural American background. Attempts to gain market share were discussed as playing offense and defense, with plenty of stories about his time coaching his children’s various sports teams. There were also some perceived sexist remarks, with stories about fathers helping coach the teams and mothers being there to bring the Popsicles.

Others described a culture where medical staff meetings felt like a Three Stooges movie, with slapstick antics and inside jokes. Another described departmental meetings which habitually started late, with the pre-meeting downtime being filled by stories of colleagues going together on hunting and fishing trips, which was not only boorish behavior towards those who weren’t part of the trips, but also offensive to those who had religious or personal beliefs around those pastimes. A few alluded to some potentially offensive remarks around ethnic or racial backgrounds, but weren’t comfortable providing specifics because of concerns they might be individually identified.

As the interviewer, you have to stay objective and not indicate that you’ve heard those comments before. It would have been great to be able to say, “No worries, this is about the tenth time I’ve heard this, so you’re not going to be identified,” but you can’t. Stakeholder analysis is challenging, because when you hear about a specific individual multiple times, it’s hard not to start developing a mental picture of that person that can impact future interactions. Sometimes people start to sound like someone you’d want to sit and have a drink with, where others begin to feel like someone you’d never want to be stuck next to at a meeting.

After the interviews were done and I sat reviewing the transcripts, I couldn’t help but reflecting on some of the common themes. Unfortunately, they weren’t unique to this hospital or part of the country, but are things I see more often than I’d like during my travels. I have a habit of capturing some of the more bizarre things I hear in meetings, using a specific phrase in my notes to make them searchable. I looked back at some calls I’ve been on over the last year and found many of the same concepts cited by my exit interview participants. In addition, there were analogies about gambling in general, betting on horse races, and the Vietnam War, which I’m sure weren’t well received by their respective audiences. (Pro tip: probably not a great idea to use gambling analogies when you’re speaking to a group at a faith-based health system that isn’t on board with it.) Other stories in my files included a rambling speech from an executive who took more than a month off to follow a European sports competition, which probably didn’t resonate well with the hourly employees he was speaking to who will never have that luxury.

As I prepared my report, I did some serious thinking about how much to summarize the results vs. how many specifics to include. It’s hard to make meaningful change when you don’t have specific examples to use when coaching people and over-generalizations aren’t helpful. But I had a genuine sense that the people who were the most inappropriate during some of these physician interactions weren’t intentionally trying to offend, but that they didn’t seem to know better ways to interact with their colleagues or that they were creating a culture where people felt unwelcome. As leaders in the organization, I knew they woul’d receive my report and would see themselves, which would be difficult. They would also face challenges in trying to understand how much the cultural factors cited in the stakeholder interviews could be modified given the current state of the organization and its leadership.

I delivered the executive summary of the report in person, then walked through it in detail for a core group of leaders. Fortunately, they received the report in the intended spirit, which was to help identify factors that could impact physician retention and recruiting. There was some good-natured ribbing during the discussion, as leaders identified themselves and their hobbies from the report. They seemed willing to want to understand how to better work with colleagues from different backgrounds along with strategies to reduce misunderstandings when using personal stories and analogies in conversations. I referred them to a colleague who is much more adept at that kind of work and hope that the individuals most cited in the interviews can learn more about themselves and how they interact with others. I also made some recommendations on salary and benefits that I hope make a difference.

One of the reasons I enjoy working in healthcare IT is the great diversity of people with whom I interact. We have an increasingly mobile workforce and it’s a tremendous opportunity to learn about cultural practices from across the country and around the world. It’s also a challenge to think about ways that we can be more inclusive in how we conduct ourselves and in working with colleagues from different backgrounds. It’s also an opportunity for organizations to empower their members to speak up when inappropriate remarks or behavior occur. This organization not only lost some great physicians, but the turnover they experienced had a negative financial impact as they re-recruited for the same positions multiple times.

During the executive briefing, one of the physician leaders asked me about guidelines to determine when someone is crossing the line. I told them my general rule of thinking whether they’d want to say the same thing in front of their supervisor, spouse / partner, or their mother. If it doesn’t pass those tests, it’s probably better left unsaid or for a non-business conversation. I also put in a plug for effective meetings, because when you have an agenda, start on time, and stick to published topics, you’re less likely to go astray.

I recently ran into the leadership and cultural competency consultant that I had recommended to them and was pleased to hear that they’ve been working together for some time. It sounds like they’re progressing and have not only made some strides with a more welcoming environment, but also have seen a decline in physician turnover. It’s hard to know whether those elements are related, but I was glad to hear that the organization is doing well.

What strategies does your organization use to embrace diversity? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/2/17

I’m getting a lot of reminders and updates on things that should be done by the end of the year. CMS sent out a reminder that there are 30 days left to submit an “informal review request” after physicians review their 2016 PQRS Feedback Reports and 2016 Annual Quality and Resource Use Reports. These became available on September 18, 2017 and show physicians whether they will receive the 2018 PQRS downward payment adjustment. You have to love such a fancy way of describing a penalty. I continue to be surprised by the number of physicians who still don’t know what a QRUR is or how to review it to see how they’re doing with what CMS sees as their quality metrics.

Although we’re still waiting for the 2018 Medicare Physician Fee Schedule Final Rule, it’s a safe bet that it will be finalized close to what was presented in the Proposed Rule. Physicians who review their reports and feel their payment adjustment status is inaccurate can request an informal review of the results through December 1. Even if you think your results are accurate, the QRUR provides some good information on how CMS thinks you are doing and can be used to help inform future plans for the transition to value based care.

The American Medical Informatics Association (AMIA) has launched a new journal, JAMIA OPEN, that is aimed at sharing research with the broader community. All articles will be open access and the online journal will include a focus on innovation and diversity across AMIA’s informatics areas. The format will also include abstracts written in patient-facing language so that non-informatics readers can understand how the research described might be relevant to patient care.

I don’t have time to attend most vendors’ earnings calls, but I enjoy reading the transcripts. I’m having difficulty reconciling some industry trends with the reality of healthcare in the US. Athena isn’t the only one in this situation, but there was a fair amount of discussion during the earnings call, so they’re top of mind.

The problem is this: the powers that be have decided that we need to move towards value-based care, yet organizations are still aligning themselves around traditionally fee-for-service models. Athena is still hanging its hat on the “visits per provider” metric and blaming decreased visits (partially due to recent hurricanes) on decreasing earnings. I get how the math works, but isn’t decreasing visits one of the key goals of managed care and/or value-based care? We want to keep patients healthier and out of the office, out of the hospital, or if they do have to come in, have them in less frequently.

Whether it’s a natural disaster or natural attrition of business due to healthier patients, having vendors continue to be dependent on encounter volume or charge volume seems like it’s going to be a long-term problem and not just a short-term one related to storms. Other economic factors such as lack of insurance or job loss also negatively impact these numbers, and depending on how things go in 2018, they may become larger factors for subgroups of Americans. People who don’t have insurance and don’t have jobs usually don’t have money and therefore don’t go to the doctor. Then when they do, it can often be a desperate situation ending in write-offs, bad debt, or agency-based collections.

Towards the end of the call, one of the analysts asked about utilization trends, specifically whether an increase in collections later in the year could be linked to high-deductible health plans. He asked whether utilization is increasing as people hit those deductibles and whether it will start to go back down after the beginning of the calendar year. I can’t speak for others, but as someone who has met her deductible for the first time in my life, I can tell you my healthcare utilization did change. What was different this year was having major surgery, which in my situation as a relatively healthy person, is the only way I could possibly have met my deductible. Once I knew I was over that hump, I made sure I completed some previously-recommended preventive services that would otherwise have had large patient-pay components and that I completed them during this calendar year. I’d have had the tests eventually, but meeting my deductible took away any financial excuse for not doing so. Had I not have had surgery, though, I might have been tempted to push those screenings into 2018.

Jonathan Bush responded to the question specifically citing visits per physician as “the biggest needle-mover.” This is where I have trouble wrapping my brain around a vendor who seems to be approaching a conflict of interest with what their physicians need to do to succeed under payment reform. If vendors are incented by patient volume, how dedicated will they be to building features that manage things like prospective payments or capitated-type payments? How interested will they be in helping practices manage problems around the true cost of care? I don’t have a lot of knowledge of how Athena does things specifically, but I know with some of the other vendors I work with, those types of features and that type of support still feel like an afterthought.

There was another question that dealt specifically with value based payments and whether ACOs are impacting volumes. Bush mentions that interoperability should reduce duplicate procedures and testing, but they can’t yet draw conclusions from the data they are seeing. Of course, all of this also begs the question of whether a revenue cycle or practice management system vendor is the right entity to help a practice through these difficult times or whether it’s a bit like the fox guarding the hen house. Maybe practices would be better off receiving information from independent advisors or from regional or specialty medical societies.

Where do you get your information about how to best manage the shift to value based care and how to cope with payment reform? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/30/17

When I first started consulting, I did it as a bit of a “side hustle” on top of my CMIO day job. My initial focus was helping small practices with system selection, since this was in the early days of EHR adoption and many didn’t have the resources, time, or understanding to know where to begin with the process. It was as much about providing a service to my peers and keeping them from being led astray by vendors who would promise them the moon but who were only able to deliver them a lump of gray dust.

I had a fair amount of experience in this area, having been through a process with my first EHR which barely worked and where every question I asked was treated as an “enhancement request.” Of course, I also had some pretty hefty student loans to pay off and wanted to make a larger dent in them than I was able to do with my salary, so I can’t say my motivation was entirely altruistic.

As Meaningful Use launched and the market exploded, my side hustle grew and I learned more about what made different kinds of practices tick, long with a great deal about what turned that ticking into a time bomb. I started to run into work where I would need to help recover what was often billed as a poor EHR installation but turned out to be organizational dysfunction, and started focusing my available continuing education time on change leadership and related disciplines. I moved into optimization work, and as most of you know, was able to eventually quit my day job and go into business for myself.

I’m seeing history repeat itself, though, as the number of requests for assistance with system selection is increasing. Of course, this time around they’re largely system replacements rather than new installations, but the themes I’m seeing are the same.

Even though some practices are reluctant to move forward based on uncertainty around CMS reporting requirements in the coming years, others see the relative relaxation in requirements as a reason to move ahead with a new EHR system for 2018. Although the industry is seeing migration of smaller practices onto hospitals’ community platforms, we’re seeing a good number of groups that want to remain independent but don’t think their current vendor is doing right by them. The largest uptick in interest that I’ve seen is in specialty practices who want to move off of a broader EHR platform onto something that is more specialty specific, which poses its own challenges since the market has been consolidating and quite a few niche vendors have either left the market or have decided not to pursue full certification.

This has been educational as clients bring some vendors forward that I haven’t heard of before let alone interacted with, so there is a general feeling of déjà vu. It’s been a nice challenge to research the different vendor candidates and get to know their products and review the information they provide to sort the wheat from the chaff. This time around there are many more vendors who are willing to give clients short-term access to web-based products so they can kick the tires themselves rather than relying on sales demonstrations or just talk. I’m seeing more willingness for vendors to provide complimentary analysis of financial and claims data and offer recommendations on how to optimize the revenue cycle in preparation for a turnover. Some are offering packages to help work down the accounts receivable in the legacy system as a part of their quote for a new system. I’m also seeing willingness to deliver clinical optimization services as part of the sales process, making sure the prospective clients have the best chance at a successful migration.

None of this comes cheap, though, so vendors are really putting it on the line this time around. Maybe I’m seeing some over-confidence or maybe they have just learned from experience that successful EHR adoption is more than implementation of a system and automation or revision of processes. They want to fully understand where their potential clients are coming from so they don’t get burned by unhappiness after a less-than-successful implementation or wind up with a client who leaves them in five years or so.

In some ways, this is wise, but I’ve seen it play out in different ways with clients depending on what is found in those complimentary analyses. Some shoppers may see it as a chance to work with a knowledgeable vendor who has a vested interest in their future success. Others, however, are seeing it as a chance to go back for a do-over with this current vendor, often asking for complimentary services similar to or in addition to what they have already received from a potential replacement vendor.

This is causing significant stress for vendors at risk for replacement, who are being asked to spend what can be a relatively large amount of resources to retain their clients. For those who aren’t good at managing these expectations, it can accelerate a client’s departure.

I ran into a conflict of interest situation recently, where I was working with a client on a system selection. They wanted to leave a vendor for whom I have previously done some contract consulting, so I was familiar with how the vendor operates. Knowing the strength of the system and the way the client was struggling alerted me to the fact that the client had some non-software operational issues that needed resolution. I pointed this out to the client, but they wanted to proceed anyway and engaged me to attend demos with them and provide objective analysis. One of their prospective vendors also provided some complimentary services, so they decided to ask their current vendor for the same services.

Not knowing the client was working with me on a replacement evaluation, their current vendor reached out to me to try to salvage them. I would have loved to have switched hats and transfer my efforts to fixing the client on their current system since I had pointed out the client-side issues to my client in the first place, but contractual obligations tend to get in the way in situations like this. The client may decide to stop their replacement evaluation and switch gears to a remediation project, in which case I’m going to probably be out of the picture because the client isn’t going to pay me to do what the vendor is offering for free and I’m not comfortable working with the vendor on this particular client since I have specific knowledge of the recommendations of their competitors. I’m fine with it either way. I just want the client to receive what they need to get things moving in the right direction in the most financially responsible way.

I’m afraid this type of engagement may become the new normal as the forces of market consolidation continue to work and as clients become more concerned about the future. It’s often tempting to spend resources on buying a new system rather than spending to fix what you have. Although some might think of the latter as throwing good money after bad, often it’s a more responsible choice if the underlying system is a solid one. We’ve all seen people who spend $40K on a new car because they don’t want the hassle of spending $700 a couple of times a year on an old one, even though $1,400 per year is a lot cheaper than $8,000 a year in car payments plus higher insurance. From an economics perspective, this may not be much different, but the psychology around it is much more challenging. It certainly brings up issues that are challenging and that I’m looking forward to helping clients address.

Are you seeing movement with system replacements? Email me.

Email Dr. Jayne.

EPtalk with Dr. Jayne 10/26/17

I had some additional adventures in patient-land this week when I went for a trip through the MRI scanner. Although it wasn’t a portal to adventure like some of the pediatric imaging suites I’ve seen, it did have its moments. The radiology department was running behind schedule due to short-staffing, which they promptly attributed to the hospital’s upcoming Epic go-live. Apparently, they need to get all the technicians through the training by the end of the month in order to meet the required training timelines. I was having a fairly specialized study that must not be done very often, and the only technician trained for the positioning needed was working in the emergency department, so I had to wait for her to arrive despite having been on the schedule for weeks. The study went off without a hitch, although you know you’re sleep-deprived when you sleep through your MRI despite all the banging noises. When it was time to assist me off the table, the tech let slip that she was glad the images turned out well because it’s the first time she’s performed this particular study. Not a confidence builder but I’m glad my results were unremarkable. I get to do it again in a year, so hopefully they’ll be through their Epic issues and have a little more experience with specialized MRIs under their belts.

The ONC Annual Meeting is coming up, from November 30 to December 1 in Washington, DC. This year’s theme is “Tackling Barriers to Interoperability and Usability.” After a keynote from the National Coordinator, attendees can choose from a variety of breakouts on topics such as the Trusted Exchange Framework, standards, data infrastructure for patient-centered outcomes research, and reducing provider burden. There will also be a panel discussion on improving health IT usability. The hotel block expires Sunday, so make your reservations now.

I had to take some annual training this week for one of my clients, including HIPAA, fraud and abuse, harassment, and a charming refresher on how to use fire extinguishers. There were a few other courses required of all hospital employees and contractors. Fortunately, I could do them online while watching my favorite new show on Netflix, The Doctor Blake Mysteries. The HIPAA course reminded me of a recent article about a Capitol Hill pharmacist who commented publicly about some of his prominent patients, although he later retracted this to say he was talking speculatively. In addition to serving Congressional staffers and lobbyists in the community, his pharmacy delivers medications to the Capitol’s Office of the Attending Physician. Even if he was joking as he says he was, it’s a bad idea for a healthcare professional to put himself in this type of position.

I had never heard of the Office of the Attending Physician before the article, which apparently serves as a mini-concierge practice staffed by Navy physicians, nurses, and ancillary personnel. Lawmakers pay around $600 annually for the physician services, although the prescriptions are billed to insurance like they would be for any other patient. The Office has an annual budget of $3.7 million, which is certainly more than many of the primary care physicians I know who are carrying thousands of patients in their panels. The article mentions that the Office doesn’t yet use e-prescribing, which most of the rest of us have been forced to adopt, but rather that the physicians call prescriptions to the pharmacy by phone, which slows his business.

The justification for the Office is to allow lawmakers to receive care without interrupting their busy schedules, but I think that maybe if our legislators had to juggle physician visits like the rest of us do, they might be more sympathetic to the plight of the average patient. If they had to wait for physicians who were running late due to multiple competing priorities, overloaded panels, and clunky EHRs, they might have a different feeling about mandating how physicians practice. And if they had to sit on hold while making an appointment, then wait a few weeks for the visit, put in a time-off request, take off work, hand-off their responsibilities to a co-worker, clock out, sit in traffic, and barely make it to the office on time for their appointments, they might have a better understanding of the healthcare system they’re trying to fix legislatively.

Speaking of who should tell physicians and other healthcare professionals how to practice, I enjoyed this piece by New York Times op-ed writer Sandeep Jauhar. I had previously enjoyed his book “Doctored” about physician disillusionment, and so was interested to hear his thoughts on whether physicians or business leaders should make decisions about care in our hospitals. He notes that 90 percent of the nation’s hospitals are run by leaders without medical training, along with the increasing focus on profitable service lines regardless of the general medical needs of a community’s patient population. I’ve seen that in my own city where hospitals compete brazenly for orthopedic and cardiac procedures while running other service lines with a skeleton crew.

Jauhar notes that physicians are partly to blame for their loss of authority at hospitals: “If we had taken better care of our institutions, perhaps there would not have been a need for others to manage them for us.” It’s something to think about as we consider the many forces impacting patient care, not only for physicians but for other clinicians – we have lawmakers, payers, regulators, attorneys, accountants, and technology vendors driving our interactions with patients and with our peers. It’s certainly not going to get any better unless we do a better job advocating for our patients, our colleagues, and ourselves.

Weird news of the week, just in time for Halloween: A patient is diagnosed with hematohidrosis, a condition in which she literally sweats blood. The write-up appeared in this week’s Canadian Medical Association Journal. With only 18 documented cases in the last five years, it’s not surprising that we haven’t heard more about it, but it’s a condition you certainly wouldn’t miss if you ever came across it.

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