EPtalk by Dr. Jayne 11/16/17

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/13/17

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/9/17

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

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

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

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

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

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

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

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

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

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

Have any good board exam prep tips? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/6/17

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/2/17

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/30/17

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

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

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

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

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

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

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

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

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

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

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

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

Are you seeing movement with system replacements? Email me.

Email Dr. Jayne.

EPtalk with Dr. Jayne 10/26/17

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/23/17

I’m a big fan of former Surgeon General Vivek Murthy, MD and of his willingness to explore popular culture and current trends to further public health. (If you haven’t seen him talk with Elmo about vaccinations, it’s worth a watch.) His recent contribution to the Harvard Business Review addresses the “loneliness epidemic” that is a growing health issue for many people. He notes that although we are technically more connected than ever before, greater numbers of Americans report feeling lonely.

This isn’t the first time someone has written about the concept of loneliness. The Atlantic broached the idea that social media was making us lonely back in 2012. Even five years ago, it described us as “living in an isolation that would have been unimaginable to our ancestors, and yet we have never been more accessible.” I got a kick out of rereading the article, which described a world prior to the Facebook IPO. It addressed ideas that behaviors such as passive consumption of social updates and individuals broadcasting updates to the world links directly to feelings of disconnectedness. Reading the carefully curated updates of others has also been linked to depressed mood.

Of course, Facebook and other social media platforms aren’t always passive. I ran into a situation today with one of my hobbies, where I ran into an issue that could only be described as a calamity. A quick post to a hobby group had an answer for me in exactly 53 minutes, from someone I have met a couple of times and trust but don’t feel I know well enough to pick up the phone and call. We had some back-and-forth about the issue and my project, and I felt like I now know her well enough that next time I might just pick up the phone. After a couple of other people weighed in on my issue, I walked away with a greater feeling of connectedness rather than loneliness. This underscores the need to not paint technology as the culprit with too broad a brush.

Murthy takes these concepts and builds on them in a public health context. He notes the impact of loneliness on members of all age groups and socioeconomic backgrounds, citing it as one reason people become involved with violence, drugs, and gangs. He highlights a direct connection of loneliness with mortality, citing a study comparing it to cigarettes and obesity as a cause of shortened lifespan. It has also apparently been linked to higher risk for heart disease, dementia, depression, and anxiety. I have to admit, I haven’t seen any public health programs in my community that are specifically deigned to combat social isolation. Loneliness is also linked to burnout, which is something we’re seeing increasingly in healthcare. From a workplace perspective, Murthy notes that it “reduces task performance, limits creativity, and impairs other aspects of executive function such as reasoning and decision making.” He goes on to note that employers play a role in driving change by “strengthening connections among employees, partners, and clients but also by serving as an innovation hub that can inspire other organizations to address loneliness.”

I haven’t run across any employers yet who are specifically addressing the idea of loneliness, but I’m seeing organizations try to develop greater relationships between employees. They may be going beyond traditional team-building activities to spinning up employee support groups, such as those for new hires, working parents, telecommuters, veterans, and more. Given the number of hours that we see people spending in the workplace, it makes sense that it might be supplanting community organizations as a hub of social engagement. He notes that particular types of employment including telecommuting and contracting engagements lower the opportunities for direct interactions, but that “even working at an office doesn’t guarantee meaningful connections.”

Murthy steers the essay back to his public health roots, noting that loneliness causes stress, which can elevate the hormone cortisol, along with inflammation that can damage blood vessels. Stress can also impair brain function including emotional regulation and decision making. Social connections can lead to workers who are less likely to be sick and who can produce more quality work. He goes on to detail specific actions that can aid social connections in the workplace:

• Evaluate the current state of connections in the workplace.
• Build understanding of high-quality relationships.
• Make strengthening social connections a strategic priority.
• Encourage coworkers to reach out and help others.
• Create opportunities to learn about the personal lives of your colleagues.

He expands on those actions by talking about concepts that we don’t consistently see in many workplaces, such as a culture of kindness and identifying the building of high-quality relationships as a priority. I’ve been privileged to work for people who embrace these ideas, encouraging colleagues to get to know each other beyond our roles as workers and more as people. At one office we were encouraged to personalize our workspaces, where another restricted display of non-approved decorations. It isn’t hard to guess which one led to greater personal conversations and understanding, and helped build some of the relationships that keep me sane on a regular basis. In other workplaces I’ve seen employees intentionally pitted against each other, or treated so unequally that most people would have significant challenges trying to build relationships in those environments. I try to include a review of workplace culture as an element in many of my engagements, and it’s good to see a respected source like Vivek Murthy give credence to the need to address what people often consider the “soft” disciplines.

Murthy closes citing a concern that “if we cannot rebuild strong, authentic social connections, we will continue to splinter apart.” We’re certainly seeing plenty of splinting in our world today, and in many workplaces. I hope his efforts to bring a discussion of loneliness to the fore garner some real attention. I’d be interested to hear whether any of the clinical informaticists out there are pursuing work in this area, or whether loneliness and social connections are being addressed in your workplace.

Have strategies to bring people together? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/19/17

With the growth of my business, I’ve been trying to recruit some additional consultants to the fold. We’re busy enough now to support employees along with our contractor consultants, which is a good problem to have although I don’t like the additional administrative work that comes with it. Fortunately, my partner takes care of a lot of it, but I still get pulled into a fair amount.

We are using a variety of sources to find people and have found a couple of additional contractors that I would love to hire full time. Unfortunately, they have other ongoing work that they don’t want to give up, so I’m happy for them to work with us in a relative state of 1099 bliss.

Finding contract consultants seems to be fairly easy. We see quite a few who have strong backgrounds with major firms who either want to slow down the pace or who are semi-retired. We have one consultant who was a hard-charging leader at one of the big firms who took time off for family and wants to put a toe back in the water. There’s a lot of variety. The only downside we’ve seen to working with these folks is coordinating availability around other projects. Some of them are great to work with on physician engagements because they are willing to do calls and web conferences in the evenings after physicians are done seeing patients (and after the consultants are done working with other clients during the day). Although we have to pay contractors more than we might pay an employee, even with benefits at play, we’ve been fortunate to have some high-quality players working with us.

Finding consultants as employees is a little different. Although we’ve gotten lucky with a couple of hires, there are a lot of people out there who fancy themselves as consultants but who really don’t have any experience as actual consultants. I blame this on the proliferation of the word “consultant” into job titles far and wide. At a local department store, the sales team members are “retail consultants.” At some EHR vendors, trainers are now referred to as “implementation consultants” even though they are simply delivering prescribed checklist-based training with no consultative aspect to it at all. There’s a thought that because people are great trainers, or great support analysts, or call center reps, that they’ll naturally be good consultants. I’ve found that I can train people on different EHR platforms or different revenue cycle systems far easier than I can train them to be consultants.

Being a consultant is more than being a deep subject matter expert or having process improvement skills. You have to have a large toolbox and know when to use which techniques to help move your client forward. You have to be part expert, part salesperson, part therapist, and part janitor at times. Often, we’re thrown into messy situations with lots of dysfunction, and have to push past the obvious list of projects we’re supposed to tackle to address the root issues that will prevent any of them from being successful. We have to help clients understand who on their teams is working for them and who is actually working against them and what changes they need to be successful. We have to convince people to do things they adamantly do not want to do, or to get their buy-in that at least if they won’t do what we ask them to do, that they won’t sabotage us as we try to move others through a process.

I’ve been weeding through countless resumes of people with “consultant” in their employment history who don’t seem to have practical skills for actual consulting. I’m also finding that people have trouble reading and processing a job description and mapping their qualifications to the potential role. For example, our posted job description is fairly specific about wanting to see actual consulting experience, along with at least two years working for a mid-size to large healthcare organization. I’m looking at a resume right now for someone who has only worked in ambulatory physician offices and never at a group larger than five providers. He’s also looking like a bit of a job-hopper, having moved about every 18 months over the last six years. Once can attribute a short tenure somewhere to “bad fit” or “took something because I had to,” but not when you see it repeated over and over. There’s usually something else going on there.

One of the positions we’re recruiting for is strictly clinical and we need applications to have an actual clinical credential of some kind. They can be a medical assistant, nurse, pharmacist, paramedic, etc. and we’re flexible about it, but they do have to have a credential or equivalent work experience if they worked in a situation where a credential was not involved (sometimes we see this with our military applicants). We continue to have applications by people who have been EHR analysts or EHR trainers whose only clinical experience is working with clinicians. Needless to say, I’m not impressed by their ability to read and comprehend if they apply without a credential and without some kind of other documentation of experience that would explain why they are applying without a credential. It seems like they aren’t reading for detail and that’s definitely not someone I’d want to try to build into a consultant.

I continue to be surprised by the number of just mechanically bad resumes I see. Mismatched fonts that make them look like a ransom note, failed formatting, typos, absent or overdone spacing, and more. (pro tip: emojis do not belong in a professional resume). I also see some pretty over-the-top cover letters. One applicant talked about his “excitement to take the reins of your organization and steer its future in the right direction.” He seemed to have missed the part where I was recruiting for a field consultant, not a CEO. Another resume listed a degree that I didn’t recognize and couldn’t find on Google, which is a direct trip to the recycle bin. If you have an unusual or international credential, a brief explanation would be appreciated (although I’m still suspicious that I couldn’t find it on Google).

Another applicant is a desktop support rep and has been deploying laptops to end-users for a large corporation. No mention of EHR or clinical skills and can only travel half-time despite the position being posted for at least 75 percent travel. One applicant said she could travel 10 percent. Another has been in sales for the last five years, mostly with behind-the-scenes hospital systems like autoclaves and laundry machinery. Before that, she was a real estate broker. I understand that people may be in difficult circumstances and are applying for anything that might remotely fit, but a lot of time is wasted by applications that appear to be spammed out without respect to the actual job description.

My favorite application is one from a gentleman who boasted of “creative use of accounting systems to identify opportunities to address reporting issues.” As a business owner, I usually don’t want to see the words “creative” and “accounting” in the same sentence. I’m sure he was trying to convey that they used the accounting systems in a novel way or used accounting to address a clinical problem, but we’ll have to wait and see. I scheduled a phone interview with him just out of curiosity. Other than the potential verbiage concern, he meets all the other posted criteria and has been consulting for a couple of years. Sometimes you just have a to take a chance on someone.

Have any good tales from the hiring manager trenches? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/16/17

I work with a fair number of dysfunctional organizations and hear regularly from readers that they can see pieces of their own organizations in my writings. I hope not too many of you see yourselves or your employers in this week’s installment, which deals with the subject of accountability.

Generally defined as responsibility, in some organizations, it has become little more than a corporate buzzword. Some groups like to throw accountability around without much mention of its companion, governance. Especially when you’re dealing with projects that are a combination of clinical/technical or operational/technical elements, governance is key.

I actually like what Wikipedia has to say about it, that “accountability is the acknowledgement and assumption of responsibility for actions, products, decisions, and policies including the administration, governance, and implementation within the scope of the role or employment position and encompassing the obligation to report, explain, and be answerable for resulting consequences.”

The line about being within the scope of the role is particularly key, as I see many examples where organizations expect employees to be accountable for things beyond their control. Asking a manager to be accountable for the output of their team is fairly common, as long as it’s clearly part of the job responsibilities and the manager is given the tools needed for the team to be successful. All too often I see organizations asking leaders to be responsible for work product that is outside the expertise of their teams or to try to produce results with wishful thinking as their principal tool.

When my clients start throwing around accusations of lack of accountability or engaging in finger-pointing, I like to introduce them to tools that their leadership teams can use to better understand how accountability and responsibility really work. My favorite is the RACI matrix, although I’ve worked with different variations such as RACIQ and RASCI.

For those of you who may not have worked with a RACI matrix, it’s basically a chart of who does what in a business process. It helps clarify roles and responsibilities and can prevent the kind of “not me” conversations we see when things are not progressing according to plan. RACI illustrates that as much as we like to think about the proverbial buck-stopping with a singular individual, department, or team, the one-man-show rarely works in modern business.

RACI breaks down overall responsibility/accountability into the following subgroups:

• Responsible. The people or teams who actually perform the work.
• Accountable. The individual who answers for the completion of the work, which may be delegated to others or to a team. They have to approve the work done by the responsible group. To be successful, accountability needs to be owned by a single person, although I see entirely too many examples of failed attempts at shared accountability.
• Consulted. The people who are subject matter experts or otherwise have an opinion about the work being done. Conventionally this can include legal, compliance, or other professionals who don’t have to actually do the work but whose policies may dictate how it’s done.
• Informed. The people who need to understand the progress of the project or process. Often this may be notification that a project is complete.

We’ve all been part of projects where we find out too late that there was someone who should have been in the Consulted group, but we didn’t bring them into the process until things were too late. This results in rework, frustration, and low morale when projects have to be redone or revised.

Unless the use of a tool like RACI is baked into a company’s culture, teams may not spend enough time during planning phases to identify what inputs are needed or what communication needs to occur. The idea here is that time should be spent in deliberate thought around making sure project stakeholders are identified. When you first start doing it, it seems time-consuming and artificial to classify tasks and deliverables but after you’ve done it a few times it starts to feel natural and flows more quickly. It’s a way to prevent surprises that becomes worth the effort.

It’s also a way to help counter the siloed work that sometimes happens in larger organizations. When you have a process that forces you to actively think about who should be informed, it helps the clinical people remember to talk to the technical and operational people and so forth. It reduces the chance of a project leader being asked, “Why didn’t I know about this?” or, “How long has this been going on?” The key, however, is to have the process discipline to make sure that you’re thinking about the various parts of a project and not skipping quickly through the matrix, or just doing enough of the matrix to be able to say that you’ve done it. Leaving blanks in the chart isn’t desirable, but can be done to allow a project to move forward with near-term follow up to resolve the empty field.

One of the keys to RACI is that it can identify the way responsibility and accountability shift throughout the lifecycle of a project. At one stage, a group may simply be informed or consulted, where in a subsequent stage, they may be responsible. Accountability may move from a design manager to a build manager to a marketing manager to a sales manager as a project moves to market. Simply having the matrix as part of organizational processes can bring people together around common definitions. I’ve worked with groups who have varying definitions of accountability, which can lead to confusion and disappointment. Bringing everyone onto the same page is always a strong move towards ensuring project success, and if you’re going to use a responsibility matrix, it’s a must.

I’ve been working recently with a consultant who hails from Australia. I love learning different idioms and phrases he uses to describe situations that are common no matter where you work. In talking about ways to help organizations through their dysfunction, he introduced me to a new one that fits right in with what RACI is trying to accomplish. I think I’m going to steal his description for the next time I have to teach it to a client. Because who doesn’t like a tool that can help keep you from acting like a jellyfish at a disco?

What’s your favorite idiom? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/12/17

My travel schedule has been very busy with organizations that are taking advantage of the relative relaxation of requirements in some of the regulatory programs. They’re using the time to tackle workflow issues and work towards standardized best practices in preparation for the next round of regulatory hurdles. A fair number of my clients are non-profit organizations, but there are significant variations in their ability to fund these initiatives depending on how non-profit they are and how they run. We all know of non-profit organizations that have millions (if not billions) in the bank and those that run on a shoestring. At least half of my non-profit clients fall into the latter category, including community health organizations and other programs which are largely grant-funded.

Working with these organizations is a challenge and I was pulled into one of those situations last week. The practice is experiencing severe performance impairment in not only its EHR and practice management system, but in other applications. They brought their IT services in-house a couple of years ago to save money and have been trying to diagnose the issues without success.

I had recommended an IT vendor to do an assessment and it took several months to get them to agree to the cost. When he finally had the opportunity to look at the system, there are multiple potential root causes. The first is that their servers are well beyond their service life and everything is running on versions of software that are no longer supported. They haven’t taken maintenance releases or patches in more than a year on some of the applications and system resource use is off the charts. If their IT systems were a patient, I’d have to diagnose multi-system organ failure.

Now that we had data defining the problem, it was time to sit down and talk about a timeline for solutions. We discussed the fact that any attempts to enhance the EHR or the other applications would likely not have demonstrable results due to the overall performance issues. Not to mention that their situation leaves them vulnerable to total system failure, hackers, and more. Their cash-strapped state is why they gave up their white-glove IT support in the past and they’ve been holding things together with the proverbial bubble gum and duct tape since then. When you’re working with an organization that has prohibited overtime and reduced clinical shift coverage due to lack of funding, asking them to spend tens of thousands of dollars on servers and software is a non-starter. We discussed moving their system to a hosted environment to reduce some of the issues, but they don’t think they even have the cash flow to handle the monthly charges.

It’s difficult knowing that their users are experiencing the pain of using a system that often just doesn’t run properly, but that there isn’t a ready answer. Their patients are experiencing less-than-optimal care because the practice can’t implement some of the newer bells and whistles of the system because it will barely handle the basics. I spent several hours with the CEO and CFO, with the ultimate outcome being that they simply can’t afford upgrades and will have to just “make do.” They’re a safety net care provider, so it’s not like they can raise their fees or start offering lucrative cosmetic procedures to boost the bottom line. We’re now looking into additional grant programs and funding sources, but there isn’t going to be a quick fix if we can find one at all. I hate to see an organization like this flounder, but unless someone wins the lottery and throws some cash their way, they’re a bit stuck.

In addition to their IT woes, I was also asked to assist with some staffing issues. They’ve having trouble with physician retention and have had to start filling in with some locum tenens providers, which usually isn’t great for continuity or morale. To make matters worse, on one of the days I was there, the locum physician had the license plates stolen from her rental car. Apparently, the practice has provided special anti-theft screws to employees to secure their plates, but didn’t think about the locum. It made me think twice since I was in a rental car as well, although I didn’t think my plates from across the country would be as much of a temptation since they’re memorable and obvious, which might be a theft deterrent.

The practice is also struggling with hiring new staff, with some applicants being afraid to work at one of the organization’s locations. They don’t have the payroll to add security guards, and apparently there have been some incidents with angry drug-seekers threatening staff. This has introduced friction because the organization decided that requiring at least one male to be present on every shift was the solution and the men don’t want to work there, either. Although I can help with things like standardizing workflows to make the day flow better and people to be more efficient, I doubt the employee satisfaction that brings will do much to fix some of the deeper problems.

For people who work in other parts of the healthcare IT industry who might not always see this side of the equation, I offer it as food for thought. Whether you’re in development, marketing, public relations, finance, investing, etc. you may not always be exposed to the different situations that practices are living up to. It’s important to remember that ultimately the patients are the customers, and the teams that have to use our systems and solutions to care for them. A practice that is worried about keeping the lights on or worried about keeping its employees safe may not care very much whether your corporate logo is in one font or another or whether you’re using the most agile development methods. If they’re less than interested in what you’re trying to get them to buy, it may be because they’re farther down on the hierarchy of need than you can imagine.

This week, I’m working with a practice that is the polar opposite, one in an affluent suburb that is looking to maximize patient engagement and specialized offerings while delivering enough wow factor to lure patients from the competition. It makes me feel like I’ve gone through the looking glass into another world after last week.

Have any tips for helping practices on a shoestring budget? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/9/17

I spent another weekend seeing patients, the by-product of a practice that is expanding physically faster than it can expand its staffing. In an environment where various organizations are grappling for market share, there’s good business justification to grow quickly, but it can create pressure on the people, processes, and technology needed to support the growth.

I mentioned last week that we had a mini-release from our EHR vendor that added some clunks to the documentation workflow. The clunks are still there, with no end in sight as far as streamlining around them. They were added to facilitate document upload to a health information exchange, but we’re not connected to one. Based on some of the patients who arrived at my location, I could really have used the HIE.

The day started pretty slow, allowing me to catch up on some journal reading and continuing education. I read an interesting article on physician burnout from the state medical society in one of the states where I’m licensed but don’t practice. In addition to physician burnout, it talked about how physicians receive healthcare in general, which is to say poorly at times. There are many physicians who feel like seeking care is a burden, either to their schedules (having to cancel office days or move patients for a sick visit) or to their colleagues, who have enough on their plates.

This leads to physicians often treating themselves, which is generally a bad idea. It’s hard to be objective about your own symptoms and examining yourself isn’t the most productive diagnostic activity. Nevertheless, it happens, with studies estimating the prevalence of self-treatment from 52 to 90 percent. Physical illness can impact how we render care, as can psychological problems like burnout. The article mentions that in the particular state, licensure applications require physicians to self-report any conditions that limit or impair judgment or affects the ability to practice medicine in a safe and competent manner.

I’d argue that burnout can affect the ability to practice medicine in a competent manner – loss of empathy, loss of patience, tunnel-vision, and more – but physicians aren’t likely to self-report because that triggers the need for a sheaf of documentation and an investigation from the licensing board. The article goes on to mention a 2009 study that found that 69 percent of state medical licensing applications ask questions that would be considered “likely impermissible” or “impermissible” based on the Americans with Disability Act and relevant case law. Other countries have fewer barriers to physician care, with Norway leading the pack with a group of physicians trained by the Norwegian Medical Association to specifically care for other physicians.

It was in the context of having read this article and been thinking about physician stress and burnout that I cared for a couple of challenging patients. The first had some drug-seeking behavior that was validated by a query to my state’s Prescription Drug Monitoring Program. It’s not integrated with my EHR, but rather is a separate website, but I was happy to do those extra clicks to confirm what I suspected. Score one for technology assisting the physician, although the technology doesn’t make the conversation with the patient any easier, especially when you’re denying them the care they’re seeking. Fortunately, this was a patient who accepted her situation rather than one who became angry when I refused to prescribe oxycodone, because as an urgent care, we’re not well equipped to handle angry or potentially violent patients.

That happy technology-enabled bubble burst a few patients later, however, when I was confronted with a medically complex patient with difficult social circumstances. She had issues following a transplant for over a year, largely related to changes in her insurance and inability to get new coverage. Transplant patients need coordinated care that has many inputs, including the surgical team, organ-specific team, pharmacists, social workers, and more. Being disconnected from your team and having to rely on episodic care can result in organ rejection and serious complications. She had bounced around due to the insurance issues and then was further impacted by a recent hurricane, which displaced her to another state.

At least in her previous city, urgent care or walk-in clinic providers might be willing and able to call the transplant team for advice, regardless of the insurance coverage situation. However, providers in another state aren’t going to necessarily have that willingness to try to make that connection, especially if they’re in a stressed healthcare system. The patient realized that and had been trying to connect with a transplant group in her new state, but began to have signs of organ failure before establishing that connection.

Due to some family issues, she traveled to yet another part of the country, and several weeks and a 30-pound weight loss later, she wound up in my urgent care an hour after we closed, halfway across the country from either of her previous residences, feeling terrible and looking very ill. As soon as I heard the basics of the story from my triage nurse, I was wishing that clicky HIE popup was actually connected to something. I can log in separately to a regional HIE, but it’s a fairly immature repository that rarely contains anything useful for my local patients, so I wasn’t hopeful about finding anything on this interstate traveler. Regional HIEs often have web access for people like me, but I doubt they’d be too keen on a request from out of state, and even if they were, it’s not like that request is going to get validated and turned around at 11:00 on a Sunday evening.

After seeing the patient and dividing her concerns into short-term and longer-term categories, I started to work on a plan. One concern for transplant patients is the sensitivity of their medication regimens and their relatively immune-compromised status. In general, you can’t rely on the “bread and butter” medications we use every day because they can have serious consequences. I maximized my use of drug interaction checking but was still unsure about my plan, and had to turn to a quick literature search to see if I could get the answer. The search was fairly silent about what I was considering in my plan of care, and without documentation of safety, I couldn’t use it.

As a community physician, I don’t have any transplant colleagues I can just call up and ask questions. The hospital I’m most closely affiliated with doesn’t have transplant services, so that was a dead end as well. Since this was after closing time, we were paying overtime to our staff, and as an hourly employed non-partner physician, I couldn’t authorize more overtime to have them start to call around to the local academic centers and hope we could track down a transplant fellow on call as it approached midnight.

I was left with providing simple and supportive advice to the patient for her short-term problem, with the hopes that she could reach her original transplant team in the morning and that they would be able to offer definitive advice despite the lapse since her last visit with them. I can’t begin to describe the feelings of helplessness that these situations evoke for caregivers. We are wired to help people and our training supports that. But when we’re placed in situations like this, it’s hard to not internalize that sense of failure or the feeling that you should have been able to do more. Especially when there are multiple and ongoing situations like this, they contribute to physician burnout and further stress our healthcare system.

In thinking back through it with my CMIO hat, would a true national HIE have helped? Maybe a little. If I could have looked through past records and seen how her previous physicians handled similar symptoms, that might have given me a clue. If I could have accessed past medication lists (older than the year I could get from our Pharmacy Benefit Manager link) that might have helped. Direct messaging to providers wouldn’t have helped given the time of day or the acuteness of the situation, but at least I would have felt more like I was doing something. Direct messaging might have been tricky though, because she didn’t know the individual names of her physicians, but rather listed the transplant program as her primary care provider.

Health information technology has so much promise, but most of us are working with only bits and pieces of it and it’s not in an integrated fashion. The care we’re giving isn’t worse than it was in the paper world, but how we feel about it has changed. We feel like we should be able to do more with the technology or that we could have done better if we were fully connected along with the rest of a patient’s caregivers. There’s a certain psychic load to knowing what could be and comparing it to where we are.

I don’t know what the answers are, but hope that the people who are making healthcare policy and deciding how and if we are going to fund different healthcare initiatives think about situations like this. It’s not only how it impacts the patient, but also how it impacts the caregivers and their ability to stay resilient. In my area, losing a physician from active practice can result in between $200K and $300K in replacement and ramp-up costs, not to mention the lost patient accessibility during the transition time.

We’ve got to find a better way to ensure the available technology makes it to caregivers across the country, not just those in academic medical centers or large cities. We have to figure out how to help those who are in backwards states that don’t adequately fund PDMP or HIE efforts. We have to figure out how to get past hospitals and health systems that are actively engaging in information blocking and refuse to share patient information with the greater clinical community.

Do you see a solution in your crystal ball? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/5/17

This week is National Health IT week, with events being held across the country. The “points of engagement” for this year’s events include: supporting healthcare transformation; expanding access to high-quality care; increasing economic opportunity; and making communities healthier. I’m particularly fond of the point regarding healthcare transformation, as so much of my work revolves around helping healthcare organizations make sense of the changing delivery environment and payment models. Many organizations are transforming for the right reasons, such as patient and community health, and those efforts make me feel energized and that I’m doing valuable work.

However, I still see far too many organizations that are on the “stick” end of transformation, only changing because they feel they are being forced to. Many of these groups are fighting themselves as they move through the change, with the C-suite saying change is here while allowing some of their more vocal (and often more profitable) physicians and subspecialties to basically opt out. I watched one group mandate that primary care physicians enter all data through discrete template fields, while allowing their orthopedic surgeons to dictate because they were afraid the surgeons would leave the group. This kind of behavior doesn’t do much to engender collegiality or build professional rapport. The most successful groups I work with are transforming because they believe in their ability to deliver care more efficiently and effectively, but trying to spread that enthusiasm continues to be a challenge.

It feels like there is considerably less buzz around Health IT Week than there was even just a few years ago, let alone what it was like in the heyday of excitement around Meaningful Use. Even Google seemed a bit lackadaisical, with my “national health IT week 2017” search bringing up an article about the 2016 events as the fourth item in the search. Let’s face it, healthcare IT isn’t as sexy as it once was and there aren’t as many so-called rock stars out there doing the moving and shaking, but it’s something in which every single one of us is a stakeholder. Having gone through yet another round of medical adventures this week, I’m grateful to have care with physicians that continue to use technology to its fullest and who enable me to be a more educated and engaged patient.

Despite the relative lack of buzz, healthcare IT continues to be of interest to young physicians and those still in training who have decided that clinical medicine may not be right for them. Maybe it’s the rigors of the schedule, the stress of feeling responsible for so many outcomes, or lack of resilience to deal with the chaos that can be modern medical practice that are raising interest. I’ve been mentoring a young resident who is considering whether he should pursue a clinical informatics fellowship or give practice a try. It’s hard to watch a once-idealistic trainee talk about his level of burnout before he’s even made it out of training. Primary care salaries continue to lag behind other subspecialties and doing something other than going straight into the trenches has a certain appeal. He’d like to stay in our metropolitan area for family reasons, so I’m encouraging him to try some moonlighting shifts in the urgent care setting to see if that’s a better fit.

One of the reasons he’s so burned out is that his residency program hasn’t truly embraced the model of team-based care. The faculty physicians are still in the mold of doing things how they were trained, which means a lot of work rolls downhill to the trainees. They have to do all their own patient callbacks and aren’t allowed to leverage staff to manage routine patient requests or to do care management activities – everything must be done by the resident physicians. I don’t dispute that this gives them a lot of knowledge about managing patients, but it doesn’t teach them how to work effectively with other members of the care team or how to lead the care team. The residents don’t get assistance with chart prep or morning huddles, leaving them to try to address gaps in care as part of the routine office visit. Worst of all, when patient-facing work is delayed by other clinical rotation activities, the patients aren’t getting good care. I’m trying to help him arrange some elective work in a setting where he can see clinical transformation in play, along with a rotation with a clinical informaticist in the academic setting. He needs to see first-hand that healthcare IT isn’t all that glamorous either, and depending on where you wind up, you may not escape patient care.

I’m still waiting to see if all this talk about the shift to value-based care will increase primary care salaries, but I’m not holding my breath. I do have a number in mind for which I would hang up my frequent flyer card and go back to primary care, but it would also require some addressing of the details of physician autonomy and practice structure. The wait for a new patient appointment with a primary care physician in my community is upwards of two months if you have commercial insurance, three months for Medicare, and four to six months for Medicaid. When people complain about the potential for rationing in healthcare, they don’t understand that in all practicality, it’s already here. These issues are daunting to new physicians (and old alike) and aren’t doing much to increase enthusiasm among physicians in crisis.

I’m always on the lookout for new vendors and found one this week in the form of CampDoc. The product is positioned as an electronic health record system for camps and they’ve been doing some epidemiologic research looking at the camp population. In addition to injuries, heat-related illness, insect bites, and allergic reactions, camp physicians also have to contend with head lice, infectious diseases, and disaster preparedness. They’ve partnered with the University of Michigan to broaden their research, which has been presented at the American Academy of Pediatrics, the Society of Academic Emergency Medicine, and other groups. Upcoming studies will focus on head injuries and concussions during summer camp activities. Interested parties can visit their website or reach out to CampDoc for more information.

For all you IT road warriors out there, join me in saluting Southwest on their retirement of the Boeing 737-300 series planes. The last of the fleet without Wi-Fi or exit windows that open like a DeLorean vs. having to be thrown out, they officially ended service September 30. I was pleased to see that several will be turned into firefighting tankers and others are in the process of being brokered. I’ve spent many hours in its confines, usually on time. I’m looking forward to its replacement, the 737 MAX 8 ,which has enough range for destinations in South America and the South Pacific. If SWA ever heads to OGG or HNL, I’ll be cashing in my points faster than you can say humuhumunukunukuapua’a.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/2/17

I saw patients this weekend and was dismayed to find a mini-release from my EHR vendor that disrupted my muscle memory. Apparently they’ve decided to create a workflow to allow documents to be uploaded to a health information exchange. However, instead of putting that feature in place to automatically send when I sign my charts, they’ve broken the signing process.

Previously, upon hitting the “signature” icon, I received a nice little pop-up where the cursor defaulted into the field where I could enter my PIN, then the pop-up closed after PIN entry. Now I get the pop-up, to which has been added a pre-populated “send to HIE” field with the cursor defaulting nowhere. Since we are not connected with a health information exchange, I have to unclick the HIE field, put my cursor in the PIN field, then key my number to sign the chart. Although technically it’s two clicks, it’s a whole lot of annoyance. I was surprised by how long it took to attempt to correct the muscle memory issues as I continued to try to go directly to PIN entry for signature. Even after 50-plus patients, I still wasn’t handling the transition smoothly all the time.

I’m often the proverbial canary in the coal mine since I work mostly weekends and our vendor likes to roll updates on Saturday nights. I talked to our EHR champion and she wasn’t aware of any way to turn off the auto-populated checkbox or to get the cursor to default to the PIN field.

By way of calculation, we can take my 50 patients, multiply it out to the 750+ patients seen daily in our practice, then times all the practices serviced by our vendor. It’s a significant amount of waste. It’s definitely enough to make one wonder whether the EHR vendor does any focus group work or user acceptance testing at all when they ship these changes to the masses. Since we’re on a Web-based product, the updates are automatic, meaning it’s impossible to pick and choose. If there were any actual improvements in the release, I’m not sure what they were since I wasn’t able to tease them out during 12 hours of patient care.

It was a rough shift overall, especially since I was working at one of our expansion locations that is still under construction. We purchased an independent urgent care facility whose owner wanted to retire, where they were seeing roughly 8-10 patients per day. Our owners figured that the low volume would allow us to do some renovation and expansion while staying open. The ongoing shortage of primary care physicians in our area has fueled a boom in our business, which we sometimes aren’t staffed to handle. Couple that with an office being in disarray due to construction and you have a recipe for a chaotic workplace.

I arrived today to find two of three bathrooms out of commission for construction, which made it tricky to handle patient needs at times. One exam room was doubling as a staff break room, with a refrigerator crammed in the corner and the microwave propped on the exam table. The dedicated laboratory area had been relocated onto one of the nursing station counters, throwing a wrench into some of the workspace efficiency.

Sometimes you forget how well your practice runs until something pushes it off kilter. Although we’ll benefit from swapping the business office and oversized lab for four new exam rooms and a right-sized lab, growing pains aren’t much fun. I was having flashbacks to the last emergency department I staffed, which completely renovated the department over an 18-month period while we continued to see steady volumes of patients and also deployed a new EHR. It was fairly traumatic for the staff, as we struggled to enter orders when we couldn’t even find supplies and were pressed into smaller quarters during the build-out. The construction chaos was bad enough, but adding in the frustration of the extra clicks in the EHR didn’t help.

The shortage of primary physicians is also causing more patients to come to the urgent care who don’t have urgent care problems. I’m glad that we’re less expensive than the emergency department and fill a vital after-hours need, but we’re not equipped to handle complex medical situations or social issues.

About 15 minutes prior to closing, a patient arrived who was seriously ill. She was in the middle oncology treatment and was afraid she had pneumonia. We made a quick decision that she needed to be transferred to the hospital, but we had the complicating factor of the minor children who were with her. We were reluctant to call for an ambulance transfer without someone to care for the children, knowing they couldn’t ride with her, but her condition was worsening. We also can’t have children in the office without a parent or guardian, especially after closing.

As we worked with her to quickly try to find someone to pick up the children, the rest of the story unfolded, revealing an even more tragic explanation for why she was caring for her grandchildren. At least if we could get her to the hospital, social workers could assist. We finally found a solution when one of our patient care techs called the ambulance district and convinced a dispatch supervisor to head over with the ambulance so he could transport the children to the hospital.

These are the situations that can’t be captured well with discrete data, and when you’re trying to problem-solve well outside the box and get the patient ready for transfer, every click counts. We have to complete our H&P documentation so it is printable for transfer and finally I gave up and just free-texted most of it. By the time our patient was stabilized and loaded, the staff was mentally and physically exhausted.

It’s important for team members who work on the IT or billing side of the house to understand the kind of situations we’re facing in patient care. I’m pretty sure I didn’t code the visit as accurately as I could have or gather as many quality measure data points as I should, which would count against a lot of physicians. I won’t take too much heat for it, but it will definitely skew my treatment cycle time metrics. As I reflected on the day overall, I started to question myself on continuing to practice clinically. Although it’s important to see patients to keep me grounded, it’s significantly more stressful than just being on the IT or consulting side and I completely understand why we can’t keep physicians in primary care practices in my community.

Hopefully my next shift will be more in the box than out, but you never know any more in healthcare.

If you’re a CMIO and don’t see patients, how do you stay grounded? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/28/17

Hot on the heels of Anthem and Express Scripts as they work to curb the opioid epidemic, CVS Health announces restrictions on coverage for certain opioid doses and durations. The Caremark unit of CVS is one of the largest pharmacy benefit managers, covering nearly 90 million patients. Starting in February, patients requiring short-term opioid therapy will be limited to seven days of medication.

I was surprised to learn that some patients with short-term pain needs were receiving 20-30 day supplies of medication since I don’t see a lot of that prescribing behavior in my community. Patients requiring long-term treatment will be limited to a dose of 90 morphine milligram equivalents. Patients must also demonstrate that they’ve been treated with immediate-release medications before they will be allowed to fill prescriptions for extended-release medications. Physicians will be able to appeal the restrictions through a prior authorization process, and employers and insurers can opt out of the restrictions. They’re basing the restrictions on recommendations from the CDC, issued last year. CVS is also adding medication disposal units in 750 of its pharmacies.

The healthcare IT season is starting to heat up, with the Epic user group underway and the Cerner conference approaching. From a vendor standpoint, the buzz ebbs and flows until it reaches its apex at HIMSS, but I’m starting to see some activity among health systems and larger medical practices. Maybe it’s the potential relaxation of some of the regulatory burdens that people were anticipating, or perhaps there are other forces at play, but groups seem to be talking about making technology and systems investments when they had previously been keeping their purses closed.

I’ve been asked to give input on a couple of RFP documents, which could result in some large purchases that I didn’t see happening in the next couple of years. It could also be that organizations want to use the relative regulatory lull to get ready for any future crushes. I’ve worked with a couple of groups that have done rip-and-replace system transitions across reporting periods and shifting regulatory requirements, so I agree it’s smart to move things forward now if you think you’re ready to make a change.

I’m not mourning the demise of the 2014 NCQA Patient Centered Medical Home Standards, which are nearing their end. Practices who had already purchased the 2014 survey tool can use it through September 30, but after that, organizations have to transition to the 2017 standards. This has been a confusing time for many of my clients and I’m certainly looking forward to being able to support groups on a single set of standards. Patient-Centered Medical Home efforts continue to get quite a bit of attention, even for practices that aren’t trying to maximize their payments under MIPS.

I’ve been trying in vain to contact a colleague in Puerto Rico, not only so I can know that he’s OK, but also to ask if there is anything I can do to help other than sending money. The reports I’ve seen are personally heartbreaking and professionally unfathomable. A week after Hurricane Maria’s landfall, most of the island is still without power, including more than 50 of the island’s hospitals. A little more than half of the residents have access to drinkable water.

The hospitals that are still open are running on generators and attempts to connect them to the power grid have resulted in a few hours of success followed by a return to the generators. Patients are seeking emergency care in larger numbers than facilities are prepared to handle — partly due to water, power, and supply shortages — but also due to the fact that many facilities are also damaged and unable to operate at all. Those facilities that are able to run are not at full staffing levels and surgical case volumes are limited.

Some descriptions liken it to a war zone, with healthcare providers making due with whatever then can find. It sounds like pharmacy stocks are holding out, although there are glitches with electronic payment systems and technology infrastructure. Patients are being evacuated to Louisiana and South Carolina, with the Navy’s hospital ship USNS Comfort expected to arrive next week.

The Comfort is no stranger to natural disasters, having been on station in Haiti following the 2010 earthquake and in the Gulf of Mexico following Hurricane Katrina in 2005. It can staff up to 1,000 hospital beds and has 12 operating rooms. Still, patients with critical needs, such as open heart surgery, are being encouraged to travel to the continental US for surgery, although travel off the island remains an issue.

The Department of Health and Human Services has relaxed rules on physician licensure, allowing physicians to practice in the emergency area under an unrestricted license from another state rather than requiring them to be licensed where services are rendered. HIPAA penalties are also being waived with regard to distribution of privacy practices documents and sharing medical information with family members. It could be six months before power is fully restored and the needs will be great to combat public health crises related to the storms and flooding.

The One America Appeal, originally launched by the five living former US Presidents to support recovery from Hurricane Harvey, has been expanded to include areas devastated by Irma and Maria. Donations will go to a fund managed by the George H. W. Bush Presidential Library foundation, which will distribute them to existing disaster relief funds supporting affected areas. The Foundation will ensure that 100 percent of donations will go to hurricane recovery, and donors can specify which recovery effort they want to support, if desired. I’m hoping I hear from my friend soon and that he and his family are safe.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/25/17

One of the more useful clerkships I completed during Medical School was one in Occupational Health. It provided me the opportunity to visit a variety of different workplaces and to learn about the health-related challenges faced by different types of workers. I worked with employees at a zinc refinery, a radiation-contaminated EPA Superfund site, at our affiliated health system’s laundry facility, a soap manufacturing plant, and several other locations. One of the workplace types we didn’t visit was the typical office setting. Although we learned about the repetitive motion injuries common in decorative butter-ball rollers, we didn’t learn much about health conditions caused or aggravated by computer use.

Since then, we’ve heard more about carpal tunnel syndrome and repetitive motion injuries. In addition to hand-related conditions, those of us who spend the majority of our days in front of a computer can encounter complications of decreased mobility along with symptoms such as numbness and tingling of arms and legs. Headaches, neck pain, and back pain are also common. Although many of those symptoms can be combated by ergonomic interventions, many companies lack the knowledge or resources to pursue special positioning devices, supplemental hardware, or new work areas. I have several colleagues with standing desks and those can make a difference with the mobility issues, but sometimes introduce additional problems when individuals embark on an activity plan that is different than what they have done previously.

The American Optometric Association also notes issues with what they call “computer vision syndrome,” which is a cluster of visual problems resulting from prolonged use of computers, tablets, cell phones, or e-reader devices. Symptoms can include blurry or double vision, eye burning, itching, and red eyes. It extends a little farther than the “eye strain” of old, and is also more prevalent due to the large number of workers exposed to computer work throughout the day. Some estimates cite a figure of up to 70 million workers who are at risk. The journal Medical Practice and Reviews recently published a paper on the condition, explaining some of the physiology behind the symptoms. Prior to reading it, I hadn’t really thought about the fact that computer work is known to reduce the frequency of blinking, leading to dry eyes and irritation. Although the paper specifically looked at the condition in Africa, it cites computer vision syndrome (CVS) as “an emerging global epidemic, which if not clearly understood and appropriate interventions designed, may have negative impact on productivity and economic development.”

Risk factors for CVS include working with a monitor that is too close (20 to 28 inches is ideal) or monitor height that is too high. Placing the monitor in a lower line of vision causes the eyelids to be open a smaller distance, which reduces the frequency of dry eye symptoms because less of the surface of the eye is exposed to the air. Having a slightly lower monitor is also supposed to promote neck relaxation. Anti-glare filters are also recommended when glare is an issue. Since computer use is a major risk factor on its own, the authors note that due to the increased use of computers among students and children, symptoms are also present in that population.

Many of us in healthcare are highly focused on conditions that inject the most cost (and most comorbidity) into the healthcare system, such as diabetes, heart disease, obesity, and chronic pulmonary diseases. I was surprised to read that the estimated expenditure on eye diseases in the US is $16 billion each year, more than twice spent on breast cancer when you look at another disease to place it in proportion. In addition to the ergonomic recommendations, experts also recommend simple preventive steps, such as taking a break every 20 minutes to stare at an object at least 20 feet away. This recommendation poses a challenge for those of us doing close-up work in an exam room, which is rarely larger than 10×10 feet in many offices. It’s not clear whether switching back and forth between the screen and the patient adds to or helps eye symptoms. Workers with dry eye symptoms can also use moisturizing eye drops.

Eye symptoms and musculoskeletal issues aren’t the only things we have to worry about in the modern workplace, especially those of us that bring work home with us or work on highly flexible schedules. It’s been suggested over the last several years that exposure to artificial light at night may be linked to depression. One study in the journal Molecular Psychiatry showed that hamsters exposed to dim light at night over a four-week period had changes in brain chemistry that were linked to depression. The good news is that the effects could be reversed by returning the hamsters to a normal light-dark cycle for a couple of weeks. The fact that the study was done with hamsters made me think about the fact that many of us feel like we’re on a hamster wheel on a daily basis, so perhaps the results are more relevant than we might think.

CDC, through its National Institute for Occupational Safety and Health, lists additional challenges in the office environment – temperature, humidity, light, noise, task design, and psychological factors such as personal interactions, work pace, and job control. In the world of healthcare IT, I definitely hear about the latter three. CDC also mentions that “job stress that results when the requirements of the job do not match the capabilities or resources of the worker may also result in illness.” In the world of ever leaner workplaces and job consolidation, there is no shortage of that type of stress.

I’d be interested to hear from readers in various sectors about how their employers are or are not addressing occupational health issues. Does your employer encourage you to check your bags so you don’t have to hoist them in the overhead bin? Are you allowed to relax while traveling or are you expected to work with your laptop balanced on your knees because it won’t fit between the tray table and the seat in front of you? Do home-based employees get a budget for ergonomic workstations or at least comfy chairs? Is it better in academia versus industry? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/21/17

I took time out from consulting this week to attend the first-ever Smartsheet user conference, held in Seattle. I’ve been a user of Smartsheet for some time, primarily because it makes it easy to share project plans and documents with clients in a way that I can control without having to deal with versioning issues. I like the ways people can collaborate and it just feels easier to me to use than other Web-based collaboration tools. When I heard a few months ago that they decided to host a client conference, I jumped at the chance to see what it looks like when a company decides to make that happen. I’ve heard plenty of tales from the EHR world about clients who attended the first user group for a given vendor, many of which take the “bunch of guys and a couple of cases of beer” story form.

I suspected Smartsheet had progressed well beyond that narrative based on the agenda, which included a wide variety of sessions and social events. The conference kicked off on Monday with a meet-and-greet at The Parlor in Bellevue, just a hop, skip, and a jump from the conference hotel. Pool tables and ping-pong competed for attention with Monday Night Football, along with a variety of snacks and drinks. For those of us who are perpetually jet lagged, it was a nice way to start a conference. The conference went into full swing on Tuesday with over 1,000 people in the audience for the keynote session. They brought in local DJ Darek Mazzone to introduce the crowd to the Seattle music scene and it definitely set the tone for the morning. Prior to the conference, I didn’t know anything about the company’s leadership, but found them engaging and passionate about the work they’re doing. Based on the staging and lighting budget, it was clear they had spared no expense in aiming for a first-class entry into the user conference space.

The company used the event to launch several new features, some of which were literally rolled out immediately prior to the conference kickoff. I hadn’t been aware of their mobile app before they discussed it at the keynote (not sure how I missed that little tidbit) but quickly downloaded and started testing it. After the pumped-up buzz of the keynote, everyone headed out to breakout sessions. The halls were crowded, which was a testament to the sold-out status of the conference, which seemed a little large for its surroundings. The first few breaks between sessions were crowded with videographers trying to capture footage of the crowd along with client interviews. I took advantage of one of the breaks to talk to one of the mobile developers, who was very interested in hearing what users think of his product and who didn’t give me any sass about the fact that I didn’t even know it existed until a few hours prior.

Breaks were also prime time to continue on the “swag journey,” which drew participants to various booths highlighting different product features. The swag was outstanding, with a high-quality messenger bag for everyone (although I was surprised that it didn’t have a Smartsheet logo). I bypassed some of it but did snag the conference survival kit with its band-aids and mints along with a tech case with some headphones that my teenage house-sitter will like. I took a pass on the fidget cube and tattoo stickers. The swag hunt punch-cards led to some jokes among attendees who had difficulty figuring out which booth had which swag (or whether a booth had swag at all) until they learned to “follow the hole punch crumbs.” We’ll see if that gets changed out for next year.

One conference element that I hope does get changed out is their preregistration and attendance scheme. Attendees had to preregister for sessions and then have their badges scanned for admittance to a session. If you were one of the unlucky attendees like me who didn’t receive the preregistration email, you had no idea you had to preregister for sessions, and were consigned to a second-class “standby” lane just outside the meeting room. Others who did preregister weren’t showing a green light when scanned, and were sent to the end of the standby line. The way it was handled at some sessions was less than customer-friendly, and I hoped that after a couple of rounds of this silliness the conference organizers would have tried something different. It continued throughout however, with room monitors ranging from just letting people in regardless of whether they scanned green or not, to being belligerent with attendees. I resigned myself to the standby line but was able to get into every session I wanted to attend. The bottom line though, is that for a company that talks a lot of about reducing wasted time and streamlining work, they added some major inconvenience (and dissatisfaction) for their attendees. Pro tip: Have people pre-register to get a feel for the room size you need for each session, then bump that by X percent and just let everyone in without a bunch of silly lines.

Some sessions featured a sketch artist creating story boards during the sessions, which was fascinating to watch if you were lucky enough to get a seat in the front. My favorite session was one on collaborative work, led by Margo Visitacion of Forrester Research. She addressed a lot of issues that I cover in some of my change leadership courses, including helping people understand the new ways that work is done today and how knowledge workers operate compared to traditional work methods. My second favorite session featured Amy Sovereign from the City of Detroit discussing how their Program Management Office uses Smartsheet in their Lean Six Sigma efforts. The presentation format was more of a fireside chat, but with vibrant photos of the city projected on the big screen as they talked. They’ve done some interesting things with the technology including end-of-shift debriefing surveys when they deployed body cameras to the police department. She got several chuckles from the audience, talking about people who are “allergic to Lean Six Sigma” and how much people love their paper. I also enjoyed her comments about making sure that you have buy-in before deploying new solutions, because you “don’t want to put technology in a catapult.” It’s vivid images like those that can captivate an audience.

I was less-than-captivated by another session where the male panelist was introduced with all of his credentials and accomplishments, and the female panelist was introduced as “the lovely Miss Jane Doe.” I’ve never heard a man in a professional setting introduced as “the handsome Mr. John Doe” so I’m not sure why that is acceptable, and I wasn’t the only person it grated on. This phenomenon has actually been studied before, and I would encourage presenters and moderators to take a gander at the paper before preparing your next set of introductions. The session was also marred by horrible feedback between the speakers and the microphones and a constant humming, so I didn’t get much out of it. Speaking of ruining the audience experience, I’m not sure why people still think it’s OK to answer phone calls in the middle of the session and talk all the way down the aisle and out the door. Nor do I understand why someone would do a conference call in the hallway on speakerphone and not with headphones, but I saw that at least twice.

The lunch breaks were designed to be networking sessions, and on Tuesday I wound up at a project management-themed table with people from all kinds of companies. I don’t want to unmask my secret identity by saying who I sat with, but people I met at various points were from Target, Centene, Oregon Health & Science University, Comcast, MGM Hotels and Resorts, health systems, hospitals, EHR vendors, Microsoft, DocuScan, local school districts, municipalities, Salesforce, and more. It was a great conversation and very gratifying to hear about the way some of these groups were solving the same problems I run into with my clients. Of course, explaining my vague-sounding consulting firm always garnered some interesting looks.

Tuesday’s client event was at the Chihuly Garden, and on the hour-long bus ride (love that rainy rush hour Seattle traffic!) I met some fun people who had some great advice for doing different things with Smartsheet. The event featured not only the glass, but food and drink from various local vendors along with seafood, pasta, and an all-potato buffet with parmesan French fries, tater tots, kettle chips, potato skins, and a baked potato bar. The dessert tables had been picked clean by the time I figured out they were in a separate little greenhouse area, so I missed out on the eclairs. The featured cocktail included moonshine from 2Bar Spirits, but I steered clear.

Wednesday’s keynote included a panel of Smartsheet leaders taking audience questions, followed by Captain Chesley “Sully” Sullenberger, who I found riveting and one of the best of the many professional keynote speakers I’ve seen over the years. If you’re looking to be inspired to greater things such as duty, honor, dedication, and service, he’s your man. He had some great insights into how people and technology interact, along with the true nature of innovation – changing before you’re forced to. I do have to say though that watching the recap of Flight 1549’s journey at the beginning of the speech was haunting. I’ve made plenty of life or death decisions in very short timeframes with patients on the table in front of me, but I can’t imagine being in his seat with 155 passengers on board and figuring out a solution that saved everyone. He recounted how hearing the flight attendants shouting “Brace, Brace, Brace” to the passengers functioned in a sort of cheerleading capacity to help him through the situation. He highlighted the performance of his team during the incident and how everything in their careers before that helped prepare them for the situation. One of his statements really resonated with me as he discussed how 208 seconds has come to define his entire career as a pilot. I thought about that several times the rest of the day – if we had three minutes that would define our careers, what would that look like?

Overall, I was happy with my choice to attend, although the registration fee plus a couple of nights of Seattle-area hotel rates put a dent in my budget. Smartsheet did a great job with their inaugural client conference and I’m looking forward to seeing things grow. They’ve certainly come a long way from their startup in a little yellow house in Kirkland, WA.

Email Dr. Jayne.