EPtalk by Dr. Jayne 2/8/18

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/5/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/1/18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/29/18

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/25/18

The hot topic of conversation around the physician lounge this morning was the Apple announcement about integrating EHR records into its Health app beginning with the iOS 11.3 beta. My physician colleagues are almost universally iPhone users, with many having Apple watches. There are some big-name hospitals and health centers involved, including Johns Hopkins Medicine, Rush University Medical Center, and Cedars-Sinai. There are a number of tantalizing articles about the solution, promising that records from different organizations will be integrated into a single view. It sounds largely like C-CDA data, including allergies, medications, diagnoses / problems, immunizations, lab results, procedures, and vitals. I didn’t see any mention of visit notes or diagnostic testing reports.

Apple’s COO Jeff Williams said that, “By empowering customers to see their overall health, we hope to help customers better understand their health and help them lead healthier lives.” Speaking as a clinician, there’s a significant leap between viewing data elements and truly understanding how they relate to overall health. It will be interesting to see how Apple displays laboratory results, including flagging and trending – it’s hard to tell from the screenshots I’ve seen. Hopefully they’ll integrate educational resources either from the patient portals they’re pulling data from or from other reputable sources.

I agree that having health data on your iPhone might be a tool to make people aware of what’s in their medical charts, but many patients are going to need time with a clinician, health coach, or other health advocate to make sense of some of it. Clinicians beware: many more patients may be seeing their data, so it’s time to get those diagnoses and medication lists cleaned up.

Just when you think things can’t get any wilder with CMS, some portion of a rule or requirement jumps up to remind you there is always something more mind-numbingly tedious on the horizon for clinicians. This time it’s the CMS Patient Relationship Categories and Codes, created under the CMS Quality Payment Program. Although CMS frequently says it aims to “minimize the burden of participation” and to enhance “clinician experience through flexible and transparent program design and interactions with easy-to-use program tools,” they always seem to come up with something that adds clicks to our workflows with questionable return on investment.

Flying in under the MACRA radar was a subsection on “Collaborating with the Physician, Practitioner, and Other Stakeholder Communities to Improve Resource User Measurement,” which mandates the creation and use of new sets of codes to be attached to claims. There are care episode and patient condition groups and codes, along with patient relationship categories and codes designed to enable attribution of patients and episodes of care to clinicians acting in different roles. This all boils down to helping further assess the cost of care.

The MACRA legislation requires CMS to create a process with clinician and other stakeholders to review proposed codes. The draft list of patient relationship categories and codes was posted on the CMS website in April 2016 and opened to public comment. Clinicians were to be categorized based on their relationship to the patient. Initially there were five groups of clinicians in three relationship categories, broken down by whether they were acute or continuing care, whether they were primary or specialty care, or whether a consulting provider was involved.

Additional comments were solicited in December 2016 with an update to the categories:

i. Continuous/Broad relationship, namely primary care providers in continuity

ii. Continuous / Focused relationship, namely subspecialists caring for chronic conditions

iii. Episodic / Broad relationship, including physicians caring for a broad spectrum of conditions for a short period, such as hospitalists

iv. Episodic / Focused relationship, including specialists caring for time-limited conditions

v. Only as ordered by another clinician, including reading radiologists

The codes were to be operationalized using CPT modifiers, and discussions are ongoing as far as how clinicians should be preparing to use them on Medicare claims. Originally the codes were supposed to be mandated on claims after January 1, 2018, but I’ve heard very little about them until recently. The last update I could find from CMS was from November 2017 and it notes that use of the codes is voluntary, with CMS saying “We anticipate that there will be a learning curve with respect to the use of these modifiers, and we will work with clinicians to ensure their proper use.”

I’m not finding a lot of communication from CMS about the codes to help me with my learning curve, but there’s always a possibility I missed it among the dozens if not hundreds of requirements that physicians are trying to keep track of. I also haven’t received any communication from my EHR vendor as far as classes to learn the workflow to apply the codes and they’re usually very much on top of things like this. Even Google didn’t bring back many current results for something that supposedly went into use less than a month ago.

Regardless, I think many physicians have become so inundated with requirements, reporting, and regulations that they start to tune things out. I’ll have to start keeping an eye out for additional instructions. As an urgent care physician in a market that’s short on primary care physicians, I tend to perform services that fall into all of the categories. We’ll have to see when our EHR is ready to handle the new codes and what the real implementation timeline looks like.

I’m heading to the clinical trenches for the next three days, in a state with some of the highest influenza rates in the nation. Normally I truly look forward to my patient care days, but I’m dreading this schedule block a bit. I’ll be doing all the handwashing and cough-avoidance that I can and am considering spending the day with a mask on. It’s not an ideal way to see patients, but when 60 percent of the patients coming through the door are there because of flu-like symptoms, it might be worth the inconvenience. We’ve had several of our physicians and quite a few staff end up with the flu, and the recovery times have been long.

Here’s to staying healthy as long as you can, or at least until the influenza surge breaks. Got flu? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/22/18

I had several people calling me over the last couple of days, wanting to talk about the recent Allscripts ransomware issue. A couple wanted my advice on protecting themselves, even though they use different vendors and have different system configurations. I have some good friends who spend the majority of their time during security risk analysis and white-hat hacking, so was happy to hand them over to the experts. One was a physician liaison at my former hospital, who wondered if I would write a guest column for their newsletter to help community physicians be more aware of the risks of ransomware. Their deadline is a couple of weeks out, so I’m happy to help.

Another was from a friend who uses Allscripts and wasn’t sure if her practice was impacted or not, so I got to explain the difference between being self-hosted and vendor-hosted. It sounds like her system is self-hosted but connected to vendor-hosted subsystems that have been impacted. For the most part she was just glad that she could see her charts and also glad to have “someone who speaks IT and can translate” available. She had been getting emails from her practice that included language forwarded from Allscripts that didn’t meet the need for understanding.

I also received a call from a former colleague who now works for a vendor and who “just wanted to catch up.” The call quickly turned into the most glaring example of schadenfreude I’ve seen in a long time. He went on and on about how this is going to be the death knell for Allscripts and how he was going to hit his territory hard and try to make sales. I had to remind him that his company has had its own share of issues, not necessarily with ransomware, but with outages on its own hosting platform.

There is plenty of quicksand for any vendor to land in, and sometimes I think only dumb luck prevents vendors from falling into the pit. Not to mention, going into a practice that has been impacted by a major outage and trying to sell a replacement system might not be a good idea in the short term. The proverbial corpse isn’t even cold and practices are still down, so a little patience and respect might be in order.

I have always preferred vendors who sell their products based on their own merits rather than by tearing down their competitors. Trying to make a purchaser feel bad about their current vendor calls into question their past decision-making and isn’t a way to win friends, in my book. Outages aside, every system has flaws and there isn’t one perfect solution out there. For every rock-solid feature, it seems like there’s something clunky hiding in the background to haunt you after you’ve already signed the contract. EHRs aren’t different from any other technology. As features evolve, sometimes they hit the mark and sometimes they don’t. It’s like buying a car – there’s always something you miss from your old car, or something you didn’t find on the test drive that becomes a daily annoyance.

I feel bad for the hosted physicians who are having to deal with the consequences of the ransomware and are being told to plan to be down on Monday. Although Allscripts is working on a read-only solution, it’s not clear how they’re going to deploy it or what it will include. This should be a wake-up call to physicians and hospitals and a good prompt to review their downtime solutions and maybe even give them a test. At my practice, we have monthly reviews of the downtime process and site leads have to check weekly that their downtime supplies are ready to go, but despite the preparations it’s always at least a minimum level of mayhem when downtime hits. The reality is that although ransomware and hacking get the spotlight, the majority of downtime events have more conventional or mechanical causes.

I’ve personally been the victim of the guy with the backhoe that cuts the fiber, the guy who accidentally triggers the Halon fire suppression system, and the lady who crashed into the data center and knocked out the electrical transformer. There’s also the winter storm that took down power lines, the system that froze because the server was out of memory, and the person who triggered a giant report to run against the production server in the middle of the day. Any one of those issues can make a system unusable and lead to a downtime event.

In my career at Big Health System, we had a utility that created a “lite” version of charts each night, sending records for all the patients in my panel to a local desktop. The lite chart basically contained the medication list, allergies, diagnosis list, and six months’ worth of laboratory and radiology data. It didn’t include scanned documents, but was enough to field a patient’s phone call. The utility also sent a “full” version of the chart for each patient scheduled for an appointment in the next 72 hours, which included the lite chart plus six months’ of chart notes and scanned documents from the laboratory, radiology, and consults filing structure. Theoretically, that would be enough to get one through an office visit with enough essential information.

That solution was great for a network outage but not for a power outage, so we had to make sure we had a fully-charged laptop with either a wireless modem or the ability to tether to a cell phone in the event that we lost power. The belt-and-suspenders coverage provided by this combination served us well through a variety of challenging situations. Of course, we also had a full disaster recovery plan, with distant servers and near-real-time fail-over processes, but thankfully I only had to experience that situation a couple of times.

Not every practice is fortunate enough to have staff dedicated to ensuring a smooth downtime. Still, you’d think with all the natural disasters we’ve seen in the past two years, that people would be doing a better job of it. I look forward to the day when I no longer hear about a practice whose only downtime preparation includes some photocopied visit note forms and a hope that someone printed a copy of the patient schedule before they went home last night.

For vendors servicing smaller practices, offering services to help clients put together a solid downtime plan would be great. I’d be interested to hear what vendors offer support for that type of a solution, and what other organizations small practices look to for downtime advice.

In the short term, however, I’m wishing the best to my colleagues on Allscripts. I hope the outage is short lived and your sanity makes it through mostly intact.

Have you been impacted by ransomware? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/18/18

The US News & World Report “Best Health Care Jobs” list is out, with a confusing Top 10 that illustrates how the list has become irrelevant. Pediatrician and obstetrician / gynecologist are ranked separately from physician in the top 10, and looking into the top 25, we find that anesthesiologist, surgeon, and psychiatrist are also separated out. Perhaps they’re confusing “physician” with “primary care physician,” but that doesn’t make sense with the separation of pediatrician.

Regardless of how you slice and dice the MDs and DOs, the physician assistants and nurse practitioners beat us at #2 and #3, respectively. Topping the list was dentist.

Even if you go into the “Best Health Care Support Jobs” list you don’t find healthcare IT folk, which is sad since I think we have some of the best jobs in the business. We get to play a key role in supporting all the other healthcare jobs and figuring out ways to get them the information they need to do their jobs better. We also keep the time and attendance systems running to ensure people get scheduled, the payroll systems up to ensure they get paid, the learning management systems available to train, the drug cabinets dispensing, and the equipment tracking and bed board systems running, not to mention the countless other systems we support. Here’s to healthcare IT!

The hot topic around the physicians lounge this morning was the President’s recent physical. Everyone had an opinion despite not having examined the patient. There was quite a bit of debate about the inclusion of cognitive testing, which isn’t part of a traditional examination of the President. The Montreal Cognitive Assessment was administered, and as of Wednesday afternoon, the website was down with a message that it was “under maintenance.”

It would be simplistic to say that passing that test means someone has ideal mental health. It screens for mild cognitive dysfunction, looking at memory, attention, and other processes. It doesn’t screen for depression, anxiety, personality disorders, or a host of other conditions that fall under the spectrum of mental health. Focusing on this test as a sole marker of mental health does a tremendous disservice to the many patients who face mental health issues every day.

There was also quite a bit of discussion regarding Eric Topol, Sanjay Gupta, and their curbside reviews of the released Presidential cardiovascular data. There was much debate about the definition of “excellent” health as mentioned by the Navy physician. I don’t know anything about the physician who performed the examination and his usual patient population, but I know that many of us in the trenches (and anyone who has been sued) tend to avoid such superlative terms when speaking with or about patients. We’re more likely to say someone’s values are within established guidelines or are within the published normal range, or to say they have average risk based on their history and physical, than we are to say someone is in “excellent” health. I haven’t seen physicians be so passionate about a “checkup” in a long time, but I doubt it’s going to lead to a boom in primary care careers.

Props to ONC for its new handout (which it refers to as a graphic novel) outlining how sharing medical information can help care teams make better decisions, and how not sharing information can lead to negative outcomes. It uses the example of someone in substance abuse recovery who might end up being prescribed opioid pain medication, which is a real-world scenario that I see often in my line of work. As much as many of us complain about ONC, their efforts in this situation are appreciated.

AMIA has issued a Call for Participation for its 2018 Annual Symposium, to be held November 3-7, 2018 in San Francisco. This year’s overall theme is “Data, Technology, and Innovation for Better Health” and submissions close March 8. AMIA seems to love San Francisco, Washington, DC, and Chicago for conferences. For those of us on limited conference budgets, how about some variety venues such as Denver, San Diego, Dallas, or Atlanta? Most of those have pretty decent weather in November.

Weird news of the day: BMJ Case Reports documents a situation where a man who tried to hold in a sneeze ended up with a perforated throat. Since sneezes can propel droplets at over 100 miles per hour, I appreciate his willingness to keep it to himself. He probably would have been better off sneezing into a tissue or into his elbow if no other alternatives were available. Blocking a high-pressure sneeze can also result in damage to the ear drums and pulled muscles.

A reader reached out in response to my recent ponderings around Epic’s Share Everywhere. It went live recently for patients at UCSF. I asked whether there are any patient case stories yet, but haven’t had a chance to hear back. Several of the hospitals in my area use Epic, but I haven’t heard of any recent upgrades. I’m heading back to the clinical trenches this weekend and will remain hopeful that a patient will roll in, give me a token, and grant access to a wealth of medical records.

That’s more of a pipe dream, as is the hope that the regional influenza peak will start winding down. Our patient volumes continue to be more than double what they usually run, so staff is really getting worn down and we’re ready for some relief. There were thousands of new cases of flu across the state this week, which is roughly 20 percent of the cases reported this season, so I’m not thinking we’ve hit peak yet. Just short of 700 people in our state have died of influenza this season and several colleagues are reaching out to patients asking them to cancel office visits if they have flu-like symptoms.

Good luck to everyone as you try to stay healthy and avoid influenza – wash your hands, avoid crowds, and cover your cough, but don’t stifle your sneeze.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/15/18

Wintery weather has snarled my travel plans somewhat. I’ve been feeling a bit like the characters in “Planes, Trains, and Automobiles” having to cobble together various arrangements to get from point A to point B.

My laugh of the trip occurred after dealing with a canceled flight from Chicago’s Midway Airport. Fortunately, I was able to quickly book a rental car, then grabbed some caffeine at a local restaurant and headed on my way. Since I was in a hurry to get ahead of traffic, I didn’t look at my receipt in detail until I was several hours away, snug in my hotel and working on my expense report. Apparently Diet Coke is now a “sweetened beverage,” at least according to this charge under the Cook County Sweetened Beverage Tax. I did a quick Internet search to see if it applied to all soda or just drinks with sugar and found out that the tax has been repealed and actually expired December 1, 2017. I guess a software update is in order for this point of sale system.

I was immediately missing my other clients who are located in warmer climates, but enjoyed working with a new chief medical officer who wanted an independent opinion of his hospital’s long-range plan. It was a good change to be able to do some forward-looking work rather than the clean-up and troubleshooting involved in some of my engagements.

As more seasoned physicians retire, I’m seeing younger physicians move into leadership positions. These newly-minted leaders may have MBAs or MHAs, but not a lot of experience managing their peers, especially if those colleagues have been on staff for a long time. Larger organizations may have resources in place to mentor these physicians, but others hope they’ll just grow organically into what the hospital needs. I’ve been through enough formal leadership development exercises to know that the skills they will need aren’t going to just appear overnight.

Various organizations including EHR vendors offer “boot camp” programs for new medical leaders. The ones I know of are pretty solid programs, but some of them are expensive and might be only offered once a year. They are generally a couple of days of intense meetings and quite a bit of instruction.

For a new medical leader, it can be a bit like drinking from the proverbial fire hose. Then, when you return to your day job, it can be hard to try to apply some of the strategic concepts that you were presented with when you’re struggling with day-to-day issues. You might also be trying to learn the EHR systems while building a clinical practice. You may also have to figure out the best way to deal with colleagues who are looking to possibly manipulate new leadership into giving in to their demands. We’ve all heard stories of medical members that set upon a new chief of staff or chief medical officer and try to convince him or her that the EHR is the root of all evil and needs to be replaced. Some dive in and investigate before coming to their own conclusions, and others take reports of widespread dysfunction for fact, which can be disastrous if acted upon out of context.

There are many power dynamics at play within the average hospital’s medical staff organization. When new leaders are brought in from the outside, it can create uncertainty, distrust, and in some situations, it might even bring out some underlying paranoia. I’ve worked with clients like that, who have medical staff members who are convinced that new leadership has been brought in strictly for the purpose of shaking things up and that the new CMO or CMIO is going to try to fire everyone.

Although there are certainly situations where some serious housekeeping needs to take place, for the most part, hospital administrators aren’t looking to completely clean house. There may be a few disruptive physicians who need to be dealt with, but it’s not exactly easy to replace an entire medical staff, especially if the physicians are voluntarily on staff rather than employees. One wouldn’t want to lose the referral base that comes with community-based physicians, especially if the facility has a solid referral network that is tied to an accountable care or other risk-sharing platform.

At times I think about going back to the CMIO trenches, but then I’m reminded of how a new CMIO is sometimes treated. I’ve worked in an organization that had a previous CMIO who I replaced and that can be difficult if your predecessor was well liked or if there was very little boat-rocking. I’ve been around when the CMIO position is newly created and that can have challenges as well. Technology leaders can be nervous that the CMIO will meddle in their affairs and operational leaders can be suspicious as well. Other clinical leaders can be worried about losing control of their departments or service lines, especially if the new CMIO is overly enthusiastic.

In my first CMIO position, I was subjected to senior members of the medical staff who demanded referrals, and sometimes not very subtly. It was implied that I’d need to send business their way if I expected their support in medical staff matters.

I had a close friend who became the first CMIO at a large health system. Since he came from the ambulatory side, the hospital medical leaders didn’t trust him. Other ambulatory physicians didn’t trust the fact that he was a generalist. One particular senior cardiologist continuously harassed the new CMIO, telling everyone that he personally would have been better suited for the job even though he had no informatics experience and didn’t apply for the position. The organization’s leadership didn’t do much to help solve the problem, especially the CIO, who was more interested in how the organization appeared on “best places to work” lists than he was in how the clinical and financial systems were performing and whether the health system was receiving solid return on investment.

I’ve looked at some open CMIO positions and it’s hard to think about uprooting yourself and moving to an environment that might not be quite as advertised. I’ve been on site with clients who put on a great show for visitors, then as you become more familiar and they let their guard down, you learn things that want to make you run shrieking away. Several of the positions require candidates who have completed Epic rollouts from soup to nuts, which puts those of us who come from best-of-breed organizations at a slight disadvantage. I’m not thinking about making a change in the near future, but always like to keep my eye out for interesting opportunities.

Looking for a CMIO, particularly in a warm locale that doesn’t have a tax on Diet Coke? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/11/18

It’s been a while since I’ve shared from the reader mailbag. I have to say it’s been hard to keep up lately. I’ve been filling on an “interim” CMIO engagement that feels like it’s never going to end. The hospital hasn’t taken my advice on productive work and process improvement, so every day is an email battle. Couple that with an increase in spam and nonsense press releases landing in my Dr. Jayne account and it’s a recipe for late night eye-crossing.

From Retail Medicine: “Re: CVS-Aetna merger. I agree with your concerns. I envision their community approach to healthcare being short on care and long on profit. How do we work to protect patients who are not aware that they are not receiving the care that they need and deserve? It is clear that those setting the rules have little understanding or empathy of the situation.” The reader attached a copy of the letter they sent to the CEOs of both companies, which brings up many good points. A significant portion of visits to retail clinics may be unnecessary since they are for upper respiratory infections, sprains, and strains – all of which can be self-managed without clinical intervention using common sense remedies such as rest, fluids, and over-the-counter medications. We see this at our urgent care, where patients come in when they have had symptoms for only a few hours and haven’t tried anything to address the symptoms. Nurse triage lines could help, but many patients aren’t aware of the services their insurance plan offer. It remains to be seen whether higher co-pays for emergent and urgent visits will make a difference with these visits. Other points included the need for retail clinics to coordinate with primary care physicians through a comprehensive communication system.

From Vintage: “Re: smart glass in exam rooms. Sounds like big fins on autos in the early 1960s – eye-catching, but useless and phased out in a year or two. Surely the money paid for smart glass could have been allocated to investments with more direct impact on patient care or improvements to the working facilities of care givers. But it looks cool, I guess.” I suspect another way that cost savings could be achieved would be eliminating the large-screen monitors for so-called transparent charting. I’m sure there are plenty of physicians who don’t want their lack of typing skills or difficulty navigating the EHR to be obvious to patients. There are still too many physicians who fall into those subsets. I work regularly with physicians who have been using an EHR for years, but when you watch them, they navigate as if they have never seen the screens. I wonder if there is a biological condition that inhibits formation of muscle memory in a subset of end users? I’m always amazed when physicians who mastered complex medical disciplines struggle with straightforward actions like entering a chronic condition on a problem list.

From The Field: “Re: observations from implementing Epic. My clinical work is entirely divorced from my IT work – I show up, see patients, and head out, electing not to get involved in a multi-layered bureaucracy. No one thought to ask me to jump in on the rollout. As my clinical colleagues struggled with various issues and just blamed the EHR, I found myself slicing the baloney thinner. Some issues were with software. With a little research and overhearing some scuttlebutt, it became apparently that other issues were because certain modules of the software weren’t purchased. Still other issues involved configuration and some were user –dependent, where users upstream in the flow of clinical information weren’t using the EHR in ways that allowed downstream users to have a flow of data. A year and a half later, I realize that we are really still implementing the system, finally getting back around to fixing things. On another aspect, the support teams could be very enthusiastic but counterproductive. I began to dread calling in a bug because of the time it would take to process it while I was trying to see patients.” There are always rude surprises when end users discover they’re missing critical pieces needed for them to be successful. I see this when practices purchase a laboratory interface but fail to spring for the mapping needed to make ordering tests a seamless experience for clinicians. Or when content is missing for key specialties, or when non-visit but high-volume workflows such as care coordination or telephone medicine are weak. I admire a clinical informaticist who can manage scope well enough to avoid being sucked into a black hole that’s not in his or her sphere of ownership. The point about the help desk is well-taken – the best support systems I’ve seen involve having strong local super users who can quickly document the details of an issue and log it on the clinician’s behalf, allowing patient care to continue.

From Weirder than Weird: “Re: do-it-yourself circumcision kits. Did you see this article?” I intended to mention it, but it was lost in the holiday shuffle. There is a similar listing on the US Amazon site, although the item appears to be unavailable. That has left the door open for plenty of interesting questions, answers, and reviews. It made me curious what other medical or quasi-medical offerings were on Amazon. I was surprised to find biopsy forceps, uterine curettes, prostate biopsy transport vials, and ringing in at $1,400, a positioning kit for breast MRIs. While the “Young Scientist” brain dissection kit is unavailable, you can have a porcine heart or a fetal pig shipped for less than $45. From the comments on some of the listings, there are plenty of families gathering around the kitchen table to learn about anatomy. Apparently you really can get it all on Amazon.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/8/18

I read with interest the news item last week about the Vermont Health Information Exchange. While that state’s exchange is under the microscope for issues with spending and data quality, there are plenty of other HIEs out there that are struggling with being useful at the point of care. Since my work spans multiple states, I’m able to see what is available to clinicians and how well it integrates with clinical workflows. There are variables whether the exchange is truly an exchange – namely whether data can be pushed or pulled or whether it’s little more than a view-only repository.

In the Vermont situation, 91 percent of interviewed stakeholders think that the state needs an HIE, but only 19 percent of interviewees feel that it is meeting their needs. One of the major barriers cited is Vermont’s opt-in policy, which limits the number of patients whose data is present for sharing. At this point, only about 20 percent of patients have opted in.

I had my own adventure with opt-in in my early days as a CMIO, when we created a private HIE to share data among physicians affiliated with our hospital. Although there wasn’t a specific state law that forced us to be opt-in, there were case law citations that prevented us from assuming all patients gave us permission to share data. We were able to maneuver through it over time by having all participating practices add language to their new patient consent forms that permitted sharing through the HIE. The practices also had to go back and have new consents executed for existing patients, and that took time.

Our vendor was subsidizing the interfaces because we were a beta client for their new HIE platform. Our hospital was picking up the rest of the tab, so there was no cost to the community physicians. My staff and I did countless road shows trying to convince physicians that this was a good thing to be part of, but at the same time, our CIO spent a lot of time trying to kill it simply because it wasn’t his idea and it was being executed by clinical leadership rather than IT leadership.

We ended up being live for quite a few years until our state HIE began to take shape. In all, it was an exciting time, but very different from the environment we’re in now, where interoperability is at least a little bit easier.

Despite having been live for several years, my own state HIE still struggles. It doesn’t communicate with our state immunization registry, which reduces its utility for primary care and urgent care physicians. All the immunizations sent to the HIE are strictly added as read-only data element, and there is no mechanism for resolution of duplicates or for reconciling with the immunization registry. A physician looking to validate immunizations on the HIE also has to go to the registry, and since the registry actually functions as a source of truth, why not just go there in the first place?

Our HIE doesn’t store any diagnostic imaging, only PDF report documents. Sometimes these are useful when an existing finding is well described and can help serve as a comparison, but there are entirely too many radiology reports out there with “clinical correlation recommended,” which means the reading radiologist isn’t going to stick his or her neck out by providing a specific diagnosis. When we find unusual things on an x-ray or CT, we’re hard-pressed to understand whether they’ve changed from previous. Instead of being able to provide the patient with immediate reassurance, we’re left giving him or her a copy of our films on a CD for them to take to their primary physician or the pertinent specialist to get it sorted.

The consultants evaluating the Vermont HIE recommended that it provide quality reports to support data-driven care. Our HIE doesn’t do any kind of reporting either, which to me seems a waste of a good population management tool. We’re in the midst of the worse influenza season we’ve seen in the last decade and yet can’t leverage that data for real-time reporting or surveillance. We have to wait for data to be reported to the state health department, then for it to be parsed and sent back to us in static form.

The Vermont HIE review also revealed concerns about patient matching and the function of its master patient index. We struggle with that in my state as well. Our state HIE’s program for identifying potential duplicate patients and merging them feels like it’s virtually non-existent. Since the matching algorithm appears to use address as one of its criteria, when I search for patients I find records that are clearly the same patient but are treated as unique individuals because they have different addresses, even if the rest of the demographics are the same.

We don’t tolerate that level of records duplication in my current practice, and in my former life at Big Health System, we had aggressive policies in place to identify, validate, and merge duplicate patients in our system on a regular basis. There’s no reason the HIE can’t do the same, especially with subpopulations that are known to be transient, such as college students, migrants, and homeless persons.

Another general concern around HIEs that plays out across the country is the sustainability of their funding models. Many are heavily subsidized with state funds and others are cobbled together with a variety of funding sources.

I worked with a practice recently whose HIE is struggling with funding. Practices are either required to do a full integration with the HIE at a cost of more than $40K and then pay a couple hundred dollars per provider per year to stay connected, or if they don’t want to do a full integration, they can pay a steep annual fee for providers to have web portal access. My client’s practice has a residency program with many rotating providers along with a number of locum tenens providers who fill in at their rural clinics. The fee for portal access is strictly per provider, with no regard to resident, full-time, or part-time status. For residents who are only in clinic for a couple of half days a week during a four- to six-month rotation, it’s too costly. For part-time physicians and those who are functioning in a job share situation, it’s not cost effective. We attempted to negotiate a break with the HIE, but were unsuccessful.

In my own practice, where I’m surrounded by Epic hospitals, I’m waiting for the advertised Share Everywhere functionality to start making an appearance. Although it was to be included in their November release for MyChart, I haven’t been inundated with patients whipping out their phones to give me access codes so I can see their records and send a note pack to their Epic-based care team. I’d be interested to hear from anyone who has seen it in the wild or used it to access patient information.

How satisfied are you with your HIE options? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/4/18

The New Year has started out with a bang and a reminder that for some IT organizations, old habits die hard. I tried to log in to my flexible spending account website to submit a receipt for the contact lenses I put off purchasing until 2018, only to be locked out. I wasn’t able to do an online password reset, so had to call customer service. There I was told that my password (which I just set back in December) was expired and that it has to be changed “every 90 days because of HIPAA.” I guess they missed the memo that HIPAA doesn’t require a specific password expiration interval, and also the one where NIST and other organizations are advising against forcing regular password expiration without reason. HIPAA remains one of the most incorrectly cited regulations I can think of and there’s not much hope for improvement.

I also tangled with a pharmacy that insists on calling our office to request verbal authorization to change prescriptions from capsules to tablets and vice versa, even when our electronic signatures are placed squarely on the “substitution permitted” signature line as required by state regulations. This particular pharmacy is the only one who calls and I can’t imagine that their business is so slow that they don’t have anything else to do than to make unnecessary phone calls to physicians.

I’ve always been a bit annoyed at the fact that most EHRs display a dizzying array of formulations that prescribers have to sort through. For many medications, it doesn’t matter if the dosage form is a tablet or capsule, but we have to select one or the other nevertheless. Of course it matters if it’s a liquid or a chewable when you have a patient who doesn’t swallow pills, but otherwise it’s just one more thing we have to assess when we’re clicking through the day. I had to play bad cop and threatened to report them to the State Board of Pharmacy if they continue harassing us.

I’m looking forward to the day when I have robust clinical decision support in my EHR that takes the diagnosis I just loaded and the drug I’m selecting and only shows me the dosage forms and instructions that are pertinent for the clinical situation given the most current clinical recommendations and local antibiotic resistance. To do that in our current system, we manage order sets that each client has to build and maintain. I know there are more integrated solutions out there, but I don’t think they take the local resistance rates into account. At least not yet.

For the vendor with whom I was on the phone the other day troubleshooting an issue with MIPS calculations, I’m going to recommend a New Year’s Resolution: if you’re going to bother being on a call, make sure you’re paying attention. This call was the culmination of efforts to manage multiple support tickets around several interrelated issues. At first I was impressed by their SWAT approach to getting the right teams on the call to try to solve the issue. My confidence flagged the first time that someone had to be asked a question twice due to “being on mute,” which we all know is a (somewhat illogical) euphemism for “not paying attention.” This happened again not five minutes later, with the second support rep at least admitting that he “was multitasking.” I would question the judgment in play when you multitask while you have a disgruntled client on the phone along with five or six of your peers who all have other (if not better) things to do. I used to work with a guy at Big Health System who would routinely be “on two conference calls at once.” I could never figure out why anyone would think that was a good idea.

I had a bright spot in my week when I was orienting a new physician to our group. He wasn’t aware of Clinical Informatics as a subspecialty, but having been a computer science major, was very interested in hearing more about the path to board certification. He had been doing informatics work at his previous employer but didn’t see himself as much more than a super user. When we talked through some of his work, it was much broader than he thought. It’s always good to see the sparkle in someone’s eye when you discuss something they find exciting rather than thinking that conversations about EHR workflow are a chore. We’ll definitely include him in our clinical champion group and see how much he wants to participate now that he’s with us.

I read with interest the reader comment from Sick Doc about urgent care centers being closed on holidays. Now that my practice is approaching 20 locations, we did some modifications of our holiday hours this year. Normally we are open 365 days of the year, but staffing every holiday in a practice that size was taking its toll on staff morale. We remained open, but not at every location, consolidating operations within a 10-mile radius of identified “core” locations. Signage and directions were placed at closed locations with matching website modifications.

We piloted this approach with Thanksgiving and it was successful, so we continued it into the Christmas and New Year holidays. Overall patient volume was down but only slightly, and I think the decrease was within what you could reasonably attribute to people not wanting to miss out on family gatherings or to venture out into the bitterly cold weather we’ve been experiencing. We’re proud to offer care 16 hours a day, which is the most any urgent care in our area provides. Our staff definitely appreciated the greater odds of being able to spend time with family. They’re running pretty ragged with the spiking volumes due to influenza, which we’re countering by having lunch delivered for the staff every day, at least in the short term.

Urgent care is definitely a growing market segment, with an announcement today that Mercy is partnering with GoHealth Urgent Care for Midwest operations. GoHealth already partners with health systems in New York, Portland, Hartford, and San Francisco. I hadn’t heard of them prior to the announcement, but got a kick out of their website’s picture of innovative facilities “engineered for your comfort and privacy” that appears to show a fishbowl-like exam room with glass walls along with a glassed-in vitals station where everyone in the waiting room can watch you step on the scale and get your blood drawn in the phlebotomy chair.

The press release mentions that these are “smart glass” rooms, which I assume means they become opaque when people are in them. For a profitable urgent care, that should be most of the time, making the technology’s value somewhat questionable. The terrazzo floors look nice, though.

Basic visits at the Bay Area clinic start at $250 (cash price paid in full at the time of service) and are $150 in Portland, $120 in Hartford, and $125 in the Big Apple. I wonder what Mercy’s existing urgent care physicians think about the announcement and whether their clinics will remain open?

According to the release, charting will be transparent on wide screen monitors in each room using Mercy’s Epic EHR. GoHealth didn’t have great reviews on Glassdoor, so I’ll be watching this one closely.

What do you think about smart glass exam rooms? Leave a comment or email me.

Email Dr. Jayne.

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.