Curbside Consult with Dr. Jayne 1/2/17

It’s the time of year when many of us are making resolutions around how we want to change things in the coming year. I was struck by a recent Washington Post piece about “busyness” being a new status symbol. It mentions that marketers have picked up on the concept as a hook to push items that promote multi-tasking or help people continue to manage time constraints. One Columbia University profession who researched the issue found that people with leisure time were not perceived as having as high a social status as those who worked more.

I see this playing out in a couple of different ways in my consulting work. One is the way mentioned in the article, where people embellish their busyness as a way of trying to look like they’re working harder or more than their colleagues. I recently had to do a workplace intervention with a client whose employee would repeatedly take vacation time, then work on his vacation, and expect it to be credited back to him. (It still surprises me that they needed a consultant to help with that conversation, let alone a physician consultant, but it does pay the bills.)

The employee had a somewhat misplaced sense of loyalty to his customers, defining his worth by his ability to be at their beck and call. He also exhibited a lack of trust in his peers and also his supervisor, refusing to list anyone on his out-of-office message and therefore forcing himself to be permanently on call. He also had no sense of work-life balance and didn’t understand that the company values people taking time off to recharge and refresh.

As someone who has done a fair amount of employee counseling, I have to say it was a pretty bizarre conversation with this guy. He was certainly at the extreme, but I see all kinds of examples of people on this spectrum. Many people have convinced themselves that they’re the only person who can possibly handle a client. As a student of human (and client) behavior, I would argue that if you have clients that fall into that bucket, there is a certain amount of co-dependency going on and a team approach is going to be helpful for everyone and likely better for the client long term. Others tend to fall more into martyrdom mode, keeping toxic projects, clients, or co-workers on their own radar so that they don’t impact others. Although this kind of busyness seems altruistic, it can be harmful in the end.

Another way I see this playing out is when people really are hyper-busy, mostly due to poor management. I have one client who constantly cranks out executive status reports listing how far off the mark their projects are, but there is never any mitigation. When 60 percent of your teams are not meeting production goals due to resource constraints, it might be a good idea to address those constraints.

I see some groups throwing more bodies at the problem without understanding that sheer numbers might not be the answer. I see other groups who won’t add more personnel because of a perception that it would take too long to ramp up workers who can take on the totality of the stalled tasks. So they choose to do nothing, instead never catching up or sometimes falling farther behind. The morale in the trenches on these teams is abysmal because they’re being constantly told they’re not meeting expectations, but they are largely powerless to create change given their current corporate culture.

With as lean as healthcare organizations are trying to be in the face of constant downward payment pressure and regulatory burdens, I continue to be surprised at the lack of accountability of management in many organizations. If a manager can’t articulate his or her resource constraint along with a request for mitigation, then they don’t need to be managing. As companies reduce head count, I see people given management responsibilities who have no business being there and no support to try to learn how to manage.

Just because you’re the best on a team doesn’t mean you’re cut out to be a manager. And often people thrust into those positions try to continue doing their previous jobs because they’re not comfortable managing, which puts things even farther in the ditch. It’s not the employee’s fault, though – the people above them put them in that position, and that’s where the accountability needs to live.

I see people routinely working 50- and 60-hour weeks because they have to in order to keep up with the demands placed upon them. Given the job market for many workers, employees are not empowered to say no to ongoing demands. I have a good friend who works for a global company and works in multiple time zones, which translates to a 15-hour work day much of the time. His company has had multiple layoffs in the last few years and he’s a single parent to kids approaching college age, so his willingness to say no is directly proportional to his perceived ability to find an equivalent position should he be let go. Especially in healthcare and with companies supporting healthcare, this should not be acceptable.

I also see people working those types of hours because they’re cobbling together multiple part-time jobs to make ends meet. Maybe they’ve had a medical bankruptcy, are dealing with family members impacted by drugs or incarceration, or have other significant challenges. Maybe they lost their job and are trying to stay out of debt while getting their kids through school. There should be no negative thoughts on that level of busyness and the rest of us that aren’t in that situation should consider ways in which we can steer our society to reduce the need for it.

I’ve written before about the work habits in different countries and some of our uniquely American work habits. Interestingly, the Columbia University professor did a similar study looking at the perception of busyness by Italian subjects. They ranked being busy at work as having less status than being able to have leisure time.

Having lived in the stress of a high-productivity physician culture and then in the corporate culture and now in the self-employed culture, I’d definitely rank the ability to have more leisure time as one of the key reasons I left traditional practice. They money I made as an employed physician wasn’t worth the fact that I had no life and was constantly on call. Not everyone has the opportunity or ability to make drastic changes, however, especially at mid-life. But we can support each other in making small changes that enrich our workplace and help each other out.

For those of us that are working crazy hours because we can (not because we have to), let’s not fall into the trap of equating busyness with self-worth. Let’s look at how we can address workplace culture, strengthen management, and raise accountability to improve our working environments. For those who have figured out this workplace equation, let’s see how we can improve our communities and our country to meet the need of our fellow humans. Here’s to a 2017 where we’re not busy just to be busy.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/29/16

I’m happy to report that organizations seem to be getting the message that it’s a bad idea to wait until the end of the year to prepare for quality reporting. I’ve already had nearly a dozen clients sign contracts for assistance with quality reporting and similar initiatives in 2017. That’s a big change from last year, when many of my clients didn’t start getting serious about it until after the end of the first quarter.

One of the barriers in 2016 was lack of vendor readiness. It’s hard to get excited about working on metrics when your vendor hasn’t released their reports yet. Even though the changes are usually small and it’s possible to use the previous year’s reports as a proxy, there seems to be a psychological barrier to doing so. Regardless, most of my clients are on systems whose vendors are already prepared for 2017 reporting, so I’m grateful.

For those clients eager to wrap up 2016, CMS released its attestation worksheets for eligible professionals and eligible hospitals. The attestation system opens January 3 and will be accessible through February 28. If you haven’t started gathering your data, it’s time to start, and the worksheets allow organizations to make sure they have dotted the I’s and crossed the T’s before accessing the online registration system. It’s also a good time to test your logins as well as make sure your registration information is correct.

Even if you don’t plan to complete your attestation until the end of February, fixing issues early is definitely the way to go, although the system will be down this weekend for updates prior to the opening of the attestation period.

Still, many organizations aren’t ready to go quietly into 2017, with the American Hospital Association calling for President-elect Trump to put an end to what is still being referred to as Meaningful Use 3. The organization cites concerns over hospitals spending significant amounts of money to upgrade their systems to the point of compliance. They also requested support in avoiding anti-kickback provisions in the event that providers compensate each other as part of value-based care initiatives. Any modifications to the anti-kickback rules would require Congressional intervention.

The hospital trade association is also seeking a streamlined process for reviewing hospital mergers. The current process has different review criteria for the Federal Trade Commission and the Department of Justice to challenge mergers or acquisitions and there is hope that Trump’s past business deals will set the stage for a relaxed climate in the future.

A friend who works in the process improvement space sent me this LinkedIn article by David Feinberg, president and CEO of Geisinger Health System. It discusses his goal to eliminate waiting rooms in the next two years. It’s a fluffy piece with a lot of discussion of patient-centric care, which aids in getting people on the bandwagon. But as a practicing ED physician, I think it misstates some issues or misses them entirely.

“A waiting room means we’re provider-centered – it means the doctor is the most important person and everyone is on their time. We build up inventory for that doctor – that is, the patients sitting in the waiting room.” Sometimes having a waiting room means that many patients showed up at the same time, or that patients are too sick to be quickly dispositioned. Maybe there just aren’t enough rooms for the patient demand. But the mere status of having a waiting room doesn’t mean we’re not patient-centric.

My current practice situation is the most patient-focused organization I’ve ever been in. Nearly 95 percent of our patients are treated and released in less than an hour, including pharmacy services. Nearly 98 percent of our patients are roomed immediately on arrival. But yes, we have a waiting room, and sometimes it is full. Recent weather events prevented patient travel during a 12-hour ice storm, which led to tremendous volume once the roads became passable. You can’t necessarily design processes around mother nature, but we had some in place. We flexed staffing and worked as quickly as possible with scribes and other supports.

“For starters, treatment will start the moment patients enter the emergency room because remember, it’s an emergency.” This statement is a great emotional appeal, but it’s not the reality of what many of us are seeing in emergency facilities around the country. I would wager that nearly 80 percent of the patients I see do not represent a true medical emergency.

I understand that the nature of an emergency is somewhat in the eye of the beholder, but having the sniffles for one day is not an emergency. Nor is being sunburned while drunk in Cabo San Lucas and then coming to the ED two days later when you arrive back in the States. Also, “I can’t be sick for the holidays because I have 20 people coming over” is not an emergency, either. But it’s the reality for many of us in the trenches. And if you have five people that arrive at the same time, I’m going to treat the one with chest pain or a stroke before I treat the person who cut their finger two days ago and is just now coming for stitches because their mother told them they had to. Yes, my comments are emotional appeals also, but hopefully the point is made.

He goes on to say “our industry is ripe to be disrupted,” which jumps on the overused disruption bandwagon.

Let’s talk about what else the patient care industry needs. First, we need to sink resources into greater patient education and health literacy so patients know what is and is not an emergency. I spent some time in the UK, and they’re really great at this, running ad campaigns to educate patients. They have multiple versions of the same theme and make it clear that people who don’t need to be in Emergency are causing delays for those who do need to be there. We don’t see that in the US because we’ve swung the patient-centric bar too far in some cases as we continue to pursue patient satisfaction scores, sometimes at the expense of quality.

We need more primary care physicians who are compensated at a level where they want to stay in practice and not retire or go part-time or switch to urgent care. We need to incent them to provide after-hours care and keep their patients out of the ED. We need to help them put systems in place that protect them from burnout. We need to reduce the burden of legal-driven care interventions so that physicians can trust in multidisciplinary teams without the constant threat of lawsuits. We need to incent them to deliver low-intervention care when it’s warranted, and help them educate patients away from the “you have to do everything” mentality.

We also need streamlined data exchange so that the ED isn’t in the dark because a rival health system is engaging in information blocking. You know who is responsible for ALL the information blocking in my area? The hospitals and health systems themselves. Not the EHR vendors. Every system in town has great exchange capabilities, but the hospitals put up faux HIPAA blockades around my ability to find out whether the patient has just had labs drawn.

They’re also engaging in care blocking, as I recently learned when they refused to accept the printed labs and CT scan on a CD that I sent with my patient during his transfer, instead requiring everything to be repeated in-house for liability reasons. That is insane and needs governmental regulation more than EHR vendors do. The same hospital also removed a patient’s IV and stuck her again after transfer because they “couldn’t trust the sterility of the original vascular access.” Again, it’s insane to cause a patient discomfort and remove a perfectly viable IV because you’re afraid of the lawyers.

We definitely need change, but it’s more than hiring more doctors or building more exam rooms. We need cultural change that addresses not only patient attitudes, but the reality of resource constraints in the US healthcare system. But “don’t go to the hospital because you are afraid of being sick, but are not in fact sick” is not a sexy, attention-grabbing campaign.

It will be interesting to see where Geisinger is in two years and whether they meet their goals.

What are your organization’s goals for 2017? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/22/16

There has been a lot of information coming out of CMS over the last couple of weeks, and I’m sure some organizations are missing it in the holiday rush. I know I missed some of the announcements when they came out last week. Sometimes I’m not sure whether subscribing to multiple news feeds and aggregators helps me or adds to the issue.

Some of the hottest debate is around changes to the CMS bundled payment programs, including two new mandatory programs for heart attack care and bypass surgery. The other changes are to the hip and knee replacement program. The new programs will qualify as Advanced Alternative Payment Models for the purposes of MACRA. Within the Acute Myocardial Infarction Model and the Coronary Artery Bypass Graft Model, flat fee payments will occur instead of line-item payments for procedure-related services.

These models will launch on July 1, 2017 and run through December 31, 2021. Hospitals from 98 metropolitan areas were selected for participation, which again is mandatory. Any savings during the first two performance years can be kept by the facilities, but starting in the third year, hospitals will be required to repay a portion of the extra costs with a gradual increase in that repayment portion. Bonuses for demonstration of defined quality metrics will be available, starting at 5 percent in the first three years and moving up to 20 percent in the fifth year.

There is also an incentive for providers to refer heart attack patients for rehabilitation under the Cardiac Rehabilitation Incentive Payment Model. Hospitals will receive $25 per service provided to patients post-MI or bypass for up to 11 services per patient. After that, the payment goes up to $175 per service. Cardiac rehabilitation has proven value in the clinical realm, so it’s nice to see CMS putting money in play to incent desired behaviors.

Bundled payments under the Comprehensive Care for Joint Replacement Model are also expanding, adding hip and femur fracture care. The Surgical Hip and Femur Fracture Treatment Model will also count as an Advanced APM under MACRA. CMS webinars are forthcoming and will detail the new payment programs and the hoops that providers must jump through to qualify for bonuses. As is usual for new CMS programs, there will be a flurry of fact sheets and open forums where providers and organizations can ask their questions. Response to the announcement has been mixed, with the American Medical Association in support and the American Hospital Association against, largely due to the fact that participation is mandatory.

Hospitals in the impacted regions have a little over six months to prepare, which isn’t a lot of time when you’re talking about the need to analyze current state and apply interventions to support a new paradigm. Those of us in the consulting space would encourage everyone to start thinking about this, even if you’re not in one of the mandated performance areas, to start making changes as well. It’s highly likely that these programs will expanded and the sooner you prepare, the easier the transition will be.

CMS also announced two new Accountable Care Organizations, one of which is tantalizingly named “Track 1+.” It has less downside risk than the existing tracks in the Medicare Shared Savings Program and is designed to bring smaller practices into the risk-assumption fold. It is set to launch in 2018 and the hope is to bring up to 70,000 providers on board. Smaller or rural hospitals could have less risk than their larger counterparts, which could be attractive to those organizations who are on the fence about being an ACO. Interested groups can submit an intent to apply as soon as May 2017. Whether they’re admitted to the track or not, there is good reason to start preparing now.

The second one, the Medicare-Medicaid ACO Model is designed to address the needs of dual-eligible beneficiaries who are covered under both programs. Although these patients could previously participate in Medicare ACOs, there was no financial accountability for the Medicaid spending for these patients. The new ACO allows for management of both sets of costs. States can submit letters of intent to work with CMS to design the state-specific requirements. Up to six states will be selected with priority given to states with lower Medicare ACO participation. Once states are identified, applications will be released to ACOs and providers.

Regardless of the proliferation of new models, some analysts have suggested that they may not be fully rolled out or may be significantly changed after new leadership hits HHS after the inauguration. That’s exactly the same kind of thinking we’ve seen intermittently over the last decade, where providers wait to take action because they think there’s a chance of change. For some, that has caused a lot of angst when they realized that their watch-and-wait attitude only served to cause a flurry of activity later. I sympathize with their hope that a new administration will come in and wipe the slate clean, but given the continued escalation in healthcare costs and the political pressure to drive them down, it’s not entirely realistic. I still would love to see regulation in the health insurance space but that’s not entirely realistic either.

As of early 2016, nearly 30 percent of Medicare payments were tied to quality and value and the next milestone is to try to tie 50 percent of payments to those parameters by 2018. We’re going to continue to see a proliferation of new programs that can be confusing and maddening. I hope those in the trenches are considering New Years’ Resolutions that promote serenity and relaxation, because it’s going to continue to be a slog.

Have you started thinking about your resolutions yet? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/19/16

Winter roared across much of the US this week, reminding many people that no matter how good we think our technology might be, mother nature sometimes has the last laugh. Our region’s weather went way beyond what forecasters expected, bringing the transportation infrastructure of several metropolitan areas to a complete stop. Conditions went from bad to worse right before the evening rush hour, stranding people in their cars for hours. It was bad enough throughout the weekend that fire trucks were skidding off the road and airplanes were sliding off the runways.

Unfortunately, that kind of weather doesn’t stop those of us in healthcare who are responsible for manning the patient care trenches and for supporting the systems that make our work easier. Sometimes that means getting up an hour earlier than usual to make sure that the car is defrosted and there is plenty of extra time to get to the hospital or office. Other times it means staying late to make sure everyone is taken care of, regardless of what might be going on in our own lives.

I was seeing patients this weekend and we had several rushes, seeing nearly 50 patients in the first few hours we were open. One of my staff was uncharacteristically attached to her cell phone, as she worried about her son heading home on the icy roads from his first semester at college.

In patient care, though, we’re expected to be “on” all the time. We don’t necessarily get a break to check in with our kids or family and make sure they’re OK, especially when we have dozens of needy patients in front of us. And in this era of consumer-driven healthcare, there doesn’t seem to be much room for the caregivers to be human.

Normally our center delivers high-quality care in an efficient manner, but this weekend we were just swamped, as were the rest of the centers in our group. Normally we have some providers who float between the locations, but there was no room for that as patients tried to be seen between the freezing rain and the impending snow. Patients were calling from location to location checking out the wait times. My scribe and I scurried from room to room as fast as we could, with him literally finishing one patient’s visit documentation as I started our introductions in the next exam room. Despite our efforts, there was still an hour wait at one point, with a couple of patients leaving without being seen.

Regardless of the wait, we’re still significantly faster than the emergency department. This was confirmed by the patients who arrived in our waiting room after giving up elsewhere first. At least at our practice, patients generally wait in their own private space, with cable TV and comfortable chairs.

As a physician, I feel awful when patients leave without being seen, whatever the reason. It means that we missed an opportunity to treat an illness or maybe to just provide reassurance. Sometimes those missed opportunities can have life or death consequences, and that possibility is always on our mind even if most of what we’re seeing is colds or sniffles. I’m glad my patient who had an acute appendicitis decided to brave the weather and come in and to take me up on the CT scan I offered to confirm it. For a while, he had debated not seeking care, which could have been disastrous.

Due to the ice, we saw a fair number of people who slipped and fell, sometimes hitting their heads. Especially with elderly patients or those on blood thinners, we have to be vigilant about evaluating them since the margin for head injuries can be small. I know the weather created chaos in many people’s schedules, but I don’t think I’ve seen as many patients trying to talk me out of an appropriate workup as I saw this weekend. On the other hand, there were quite a few patients trying to talk me into treatments they didn’t need, such as antibiotics for their viral illnesses or the illnesses they are afraid of catching.

No amount of embedded clinical decision support in my EHR is going to help me through those conversations. I can give the patient an antibiotic and lower my clinical quality metrics, but raise my patient satisfactions scores. Or I can hold the line against antibiotic resistance and risk bad reviews. Despite a patient mix that was similar to my last few shifts, my patient satisfaction scores were lower than usual. Comparing them to the patient wait times, though, showed a trend – regardless of the care, patients who waited longer gave lower scores.

When I first got into informatics, I worked on projects that involved preventable harms and straightforward, evidence-based medicine. The data often helped identify situations where a change in behavior could improve patient outcomes and where the interventions needed were clear. Those were my bread and butter, and I have to admit I feel completely unprepared to deal with the kind of data that is now in front of me. It’s not just the data in our system that I have to address with our providers, but the public-facing reviews. When potential patients see the low scores and negative reviews for today on Yelp, they’re not going to know that it was in the context of a major ice storm and below-zero temperatures.

Patient engagement is supposed to be a good thing, but sometimes it’s a double-edged sword. There’s enough to learn in medical school and residency already, and adding the need to learn how to manage social media and online patient reviews is something that feels foreign to many clinicians. Add the stresses of managing EHRs that can be less than cooperative, the usual staffing and office dramas, insurance headaches, and more, and you have a recipe for burnout.

I’ve been keeping my eyes peeled for continuing education courses or informatics presentations that discuss dealing with this situation. I know that good rapport with the patient along with empathy, discussing the situation, etc. can help avoid low patient satisfaction scores when we err on the side of clinical quality. But in the pressure cooker of most care delivery organizations, those discussions can be hard to execute.

I’m hoping some of my CMIO and CMO readers will have some suggestions because I’m somewhat at a loss here. I know I’ve written about this before, but it is definitely weighing heavier on me after this weekend. Although being at the forefront of a new specialty’s growth can be exciting, it’s sometimes maddening especially when you’re not connected to an academic center. As clinicians, we’re focused on getting to the root cause and trying to fix things. When we don’t have the answers, we tend to dig in and keep investigating until we find them, or at least something we can test drive.

How do you react to low or decreasing patient satisfaction scores, especially around events out of your control? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/15/16

Lots of vendors are sending holiday greetings. Although I appreciate the sentiment, there’s a lot of noise this time of year and I think a lot of the messages get overlooked. I’d like to recommend that vendors consider sending friendly greetings throughout the year. Perhaps cardiovascular solution vendors might consider National Tap Dance Day on May 25. Geriatrics vendors may want to consider As Young as You Feel Day on March 22, where storage vendors may want to consider World Backup Day on March 31.

I was glad to have a couple of extra days off the road this week since several of my clients are still struggling with how they’re going to wrap up their reporting for Meaningful Use attestation and other quality programs. I know organizations are busy and healthcare is a crazy changing place, but there’s no reason for leaving things until the last minute. I have two clients who have yet to select their clinical quality measures for the year. They can’t seem to understand that if their numbers haven’t improved throughout the course of the year, there is no magical force that is going to get them to the desired threshold with only 10 patient care days left.

I mentioned this phenomenon before. A reader shared his experience with using LogicStream to measure adoption of workflow best practices down to the clinician level. Designed to reduce unnecessary variation in care, it sounds like a great way to track compliance with specific clinical protocols and alerts. However, there are a lot of physicians out there who still struggle with the idea of “variation in care,” especially in the ambulatory space.

Let’s face it, we have a lot more compelling studies from the inpatient arena, and given volumes at many acute facilities it’s much easier to see when a specific clinical pathway is superior than it is at the average physician office. I have a lot of physicians that fight me about the EHR workflow being “contrary to how I practice medicine” and it’s always a battle to try to explain that the way they are practicing might just not be best practice. Most of the top-tier EHRs are designed with best practice and evidence-based workflows. I know I’ve mentioned in the past the physicians who argue about reconfiguring preventive care guidelines to match their own personal practice that isn’t supported by the US Preventive Services Task Force, the American Cancer Society, or anyone else who actually has data.

I feel for the organizations that have to try to rein these physicians in. On the other hand, the organizations are to blame because they allow this to go on. I’m not going to say it’s easy to get rogue physicians under control, but it can be done. Sometimes they will respond to targeted interventions and sometimes it takes a change in their contract to elicit the desired behavior. But if you can’t get a physician in line even with a contractual agreement, I would argue that it’s better for the practice to consider making them available to the workforce. In the new world of transparency around quality, the viability of keeping someone around because they’re productive or popular is less every day, especially if they’re doing something squirrely related to established protocols for patient care.

Another project taking a lot of my time this week is a strategic planning engagement for a midsized, hospital-owned provider group. For the past couple of years, they have been running on fear and adrenaline, acquiring as many small practices as they could in hopes of solidifying their referral base. Now they have a provider organization that looks like the Wild West. The only referral metrics they’ve been tracking are hospital admissions and surgical cases, leaving physician-to-physician referrals completely unaddressed. I’m not even sure the physicians know who their peers are since the acquisition strategy didn’t include much internal marketing to other members of the group. Some members have been migrated to the enterprise ambulatory EHR and some were allowed to stay on their own office systems, so interoperability isn’t what it needs to be, either.

Because they were so focused on building their provider base, they lost focus on other key projects such as staying current with EHR upgrades and making progress towards patient-centered medical home recognition. The coding and compliance staff was focused on onboarding the new providers and stopped their regular audits of existing physicians. Rather than having quarterly audits like they’re used to, some physicians haven’t had a coding audit for more than a year. If someone’s gone off the beaten path with their coding, that’s not the kind of thing you want a delay in uncovering.

I had several calls with them this week, trying to prepare an agenda for a strategic planning retreat in January. They’re struggling with their end-of-year ACO and PQRS reporting, however, and all they wanted to talk about was the perceived issues they’ve having with their vendor. I say “perceived” because I have other clients working with the same vendor who are doing just fine. They say they can’t give the quality reports to their providers because they’re not granular enough and the providers don’t understand them. I’ve seen the reports, and they’re extremely clear – they have the name and number of the measure and a brief synopsis. The providers can drill down into the individual patients to see why someone is passing or failing. It turns out the organization has been printing them out, so of course they’re not as impactful as delivering them electronically so they can be used interactively.

The reason for the printed reports is so the office managers can use highlighter on them and sit down and discuss them with the providers. I’m not sure why the red-yellow-green display in the EHR report package isn’t good enough or why they can’t sit down in front of a screen instead of a piece of paper. This is a classic case of “blame the vendor” for an operational problem. I said as much, trying to steer them back to the agenda at hand, but they continued to try to return again and again to their “pressing issues.” I’ve been working for months to help them understand that they have to get out of the weeds and start looking at the bigger picture and not continue to be ensnared in “pressing issues” because it’s simply a classic case of avoidance behavior.

They need to decide who they want to be when they grow up. Do they want to be a big fish and keep growing? Or are they happy where they are and ready to make the most of their provider membership? Are they ready to start working on quality in earnest and remediating any poor performers? Until they set some direction, they’re going to continue to struggle.

I’ve got another call with them tomorrow to try to continue to nail down the agenda, but it’s slow going. They “forgot” to invite the CFO to today’s call and I wasn’t willing to move forward without the right players on the call. I’m planning to bring a second facilitator with me to the onsite planning meeting because I can see already that it’s going to take a village to keep them corralled. Sometimes these clients make me want to give up, but once in a while, one starts to really get with the program and those bright spots keep me going.

Does your organization have a strategic plan for 2017? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/12/16

As we approach the end of the year, things continue to be a flurry with clients who didn’t plan well screaming for services. I’ve reached the limit of what I can deliver with my small team since this is the last week my partner and I are spending on site with customers. We’re willing to let some business go because we’re not willing to run ourselves ragged trying to be everything to everyone. That’s the perk of owning your own business, although it’s sometimes challenging when you have to agree to disagree with clients.

For those clients that we would like to be able to serve but just can’t, we have larger consulting firms that we can refer them to when it’s crunch time. You would expect that some of them might elect to stay with the group that met their needs when we couldn’t, but a good number of them come back to us because they appreciate the fact that we knew our limits and steered them into capable hands.

One of the prospective clients that I steered to a colleague was one who wanted to hire an external help desk because they felt that their vendor’s help desk wasn’t meeting their needs. They feel the vendor’s Tier 1 support is passive-aggressive, doing things like intentionally calling the office after hours so that they can say they called back and didn’t reach anyone. The vendor offers a discount on maintenance if clients provide their own Tier 1 support, so they did the math and decided to outsource to a third party if the price was right. My colleague happens to be a former reseller for the vendor in question and was happy to take their business, so it was a win for everyone.

Since this is my last week on the road, I plugged in a post-upgrade go-live for myself so I could work Monday through Thursday and start my holiday travel a bit earlier than last year. It meant that I had to fly on the weekend, which is always interesting given the change in mix from business travelers to family travelers. I was pleased to see Chicago’s Midway Airport decked out for the holidays, with lots of twinkle lights and giant ornaments. There were “take a sweet treat” stands with bowls of Skittles. As I made my way down the B gates, there was even a man on stilts dressed as a toy soldier handing out boxes of candy. It was unexpected and made me smile so, kudos to the folks that put it together.

The mood didn’t last long once I reached my destination and had frantic voice mails from my customer that their upgrade wasn’t going as planned. I had encouraged them to start the upgrade on Friday night so that if they had issues, they would have time to resolve them. Instead, they insisted on starting it Saturday afternoon, citing staffing issues. This is the challenge of scheduling major projects around the holidays, because people want time off and to be with their families and weekends are challenging if they’re not scheduled well in advance or if your teams don’t have a lot of backup. They had done a dry run of the upgrade and theoretically should have had enough time, but ran into some issues.

Whenever I give training on an upgrade, I reinforce (and reinforce, and reinforce) how important it is to follow the upgrade playbook line by line. There is zero room for the kind of errors that result when steps are performed out of sequence or missed. Certain applications are finicky, and their pre-upgrade scripts are looking for specific criteria to be met in the client environment before they proceed. Depending on where a missed step occurs, it can cost hours to get the timeline back on track. Although I provided some high-level project management for the client, they were running the upgrade process themselves and I wasn’t supervising them as closely as I do when I am personally responsible for the upgrade event.

There is a step in their upgrade plan that requires them to disable their disaster recovery solution a certain way, and an enterprising DBA decided to do it a different way than what was documented. The result was the failure of the upgrade package, which wasn’t finding the conditions it needed. Instead of rechecking the plan and following it, the DBA restarted the upgrade two additional times expecting a different outcome. By the time I landed they were significantly off the timeline, and it took a couple of calls to figure out what had gone wrong and how to fix it.

The relative comedy of errors pushed on through most of Sunday evening, when they still hadn’t brought the upgraded system back up because data integrity checks were failing. We spend several hours on the phone with the vendor’s team trying to figure out what went wrong and weren’t able to isolate a cause. At that point, we had some decisions to make. We could either keep working on it and prepare to open the offices on Monday using downtime procedures, or we could restore the system from a backup and move forward. As we were weighing the choices, there was a question of whether users had been accessing the system during the backup that took some investigation and stalled things further.

We needed to make a decision as we approached midnight, and ultimately my client opted to restore from the backup and try the upgrade again at a later date. I was crossing my fingers that their backup process was solid since we all know clients who never test their backups or go to restore from one and find out it’s corrupted, or even worse, blank. Fate was smiling on us because the backup restored not only without a hitch but in less time than anticipated, which allowed us to get the users back on the system without too much of a delay.

Of course the end users were disappointed at their inability to use the new features, and the organization has to reschedule. We spent several hours today in a post mortem discussion of the event and what went wrong, and they appear to have learned some important lessons about following the playbook exactly and in asking for help when you run into a problem rather than just repeating the same steps over and over.

There wasn’t much go-live for me to support, so I am headed back to the airport. Although they failed, they made a smart decision and can try it again either after the first of the year. These are the hard lessons that most organizations learn at one time or another, and now they can join the club with the rest of us who have been there and done that.

What’s your worst upgrade story? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/1/16

Breaking Up is Hard to Do, or Caveat Emptor

I’ve been doing change management work for longer than I care to admit, so I’ve seen firsthand that change is never easy. It’s human nature to be risk-averse to some degree, and many people have deep-seated feelings that change is risky. I’ve enjoyed my work helping physicians and their staff members through the challenges of implementing EHRs and expanding their use of technology, moving them from the “no way” group to the “I can’t manage without it.”

I’ve watched some physician friends move through that transition and it’s been gratifying even though I haven’t been involved in their projects. As an EHR proponent, I’ve been on the receiving end of a lot of complaints about technology, and seeing people reach the point where it enables their work instead of causing heartburn keeps me going. Relying on EHRs has its own challenges, though, particularly when a practice breaks up.

One of my closest friends has spent the better part of the last three years going through such a breakup. Her group of three surgical subspecialists had been stable and productive for years when one of the partners became disabled and could no longer perform surgeries. They held it together while they recruited a replacement physician, taking on extra work to cover the portion of the overhead no longer funded by the departing partner. Unfortunately, the new physician didn’t work out and debts mounted. The remaining partner simply decided to stop working, forcing my friend to terminate the partnership rather than take on debt trying to keep the doors open.

The stress has been significant, but she was starting to see light at the end of the tunnel as she agreed to join another group in town. Since they were on the same EHR vendor, her hosting team promised her an easy conversion. She ran the pricing past me and I thought it looked low. Digging into the agreement, I noticed that it was only a demographic conversion and no clinical data was to be converted. Instead, the clinical data was going to be converted to PDF and added to the imaging portion of her new practice’s EHR. We talked through the ramifications of that, and whether she would rather have the data converted or abstracted. Due to the episodic nature of most of her patient relationships, she was willing to risk it.

I expected her to call after a week or two in the new practice, asking for an abstraction vendor. It wasn’t two hours into her new practice before she was inundating me with text messages and emails. The conversion wasn’t the problem – the EHR was the problem, along with the practice staff.

In a small practice, there may be only one or two super users. In this case, both of them had quit since the last time a new physician joined the practice. No one in the office knew how to add her to the provider master file, so they simply added her as a user since that’s all they knew how to do. As a physician, she didn’t know that was an issue until she started trying to issue prescriptions and apply her electronic signature to office notes. No one in the office knew how to contact the help desk, so she called me, knowing that I’ve worked with her vendor before.

I gave her the help desk number and some pointers on what to ask for and hoped for the best. I felt so bad for her. The average physician looking for a new practice situation is more focused on questions about the call schedule and how expenses are shared than he or she might be on asking about the number and availability of super users or system admins. Especially if we’ve come from a highly functional EHR support framework, it might never cross our minds. We take it for granted that things just work, not remembering all the hard work and setup that it took to get the system to the place where we could see patients.

We may also take it for granted that every installation of a given vendor’s system is the same. Although there may be core modules that are the same, practices and hospitals often customize and configure many portions of their system, unknown to the average end user. Additionally, not every installation is on the same version of a given piece of software. In my friend’s situation, her new practice was on an older version of the system. The visit documentation templates were nearly unrecognizable to her, as they pre-dated her previous system by several major releases. I’m sure asking for their release version and the number of their most recent content patch wasn’t part of her interview questions, either.

Fortunately, I was able to call in a couple of favors and get her some immediate help, although we haven’t been able to get her set up with electronic prescribing or updated letterhead for her patient plan documents. She’s not yet present in the patient portal and can’t order labs, but at least she can print prescriptions, document her visits, and bill out her charges.

Although the old adage about “buyer beware” certainly applies, these are uncharted waters for most physicians. Most physicians that are making moves are consolidating into larger groups or are being acquired by hospitals and health systems. It’s not as common for them to move from one small practice to another, but even in that situation, groups may be on a hospital’s community EHR offering or on a fully hosted solution. It’s rare to see a small practice trying to maintain their own client-server system and I think many physicians would fail to deduce that arrangement if they were in her shoes.

Back in the day when EHRs were just coming on the scene, I started my “on the side” consulting business by helping small practices with system selection and implementation. I’m thinking I may need to consider a new business line helping physicians on the move who need help teasing out potential EHR pitfalls during the practice selection process. It would definitely be a niche offering given the number of new grads joining hospital-owned practices, but for those physicians faced with a situation like hers, it would be worth it. Once the match was made, it would lend itself nicely to conversion and/or abstraction services.

My friend has given me permission to use her experiences to create checklists and questionnaires to help prevent other physicians from going through similar circumstances. I’m sorry she had to go through it, but I’m going to be ready for the next physician who needs help evaluating a practice opportunity.

How do you onboard new physicians? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/28/16

It was a busy holiday weekend for me, with several days of patient care. I saw several extended families with a “stomach bug” that was more likely to be food-borne illness. It’s never fun to suggest that Aunt Tillie’s cooking make everyone sick, but it does happen. At one point, we had so many patients receiving IV fluids that we had to call for more supplies to be sent from another location.

Although I think I won the prize for fluid administration, several other locations broke records for the number of patients seen in a single day. Not every patient was in need of such urgent attention, though. Dozens had conditions that could have waited or didn’t need to be seen at all. I’ll have fun analyzing the statistics once we complete our month-end close, but the potential root causes are interesting.

Over the last several years, we’ve seen greater patient empowerment, which is generally a good thing, especially when you’re talking about shared decision-making and improved health through greater patient involvement. But it’s less of a good thing when patient empowerment loses the “patient” piece and becomes more of an exercise in instant gratification.

To be clear, I’m not talking about patients with urgent medical needs, such as shortness of breath, chest pain, lacerations needing stitches, strep throat, etc. I’m talking about the folks who have had a cough for one day, who haven’t tried any over-the-counter remedies, and who expect the physician to work magic and get mad when we don’t have much to offer.

We had one patient come in as we were closing on Friday who stated that she was “miserable” with her symptoms, yet she came in at closing time because she was too busy with her Black Friday shopping to be seen earlier. Even her $50 co-pay wasn’t a deterrent. She could have called the after-hours line at her primary care office and received the same advice that I gave her, which was to treat the symptoms using over- the-counter remedies since it was most likely a viral infection. She ended up being upset with my treatment plan and demanded an antibiotic, which I refused to give her. I’m sure she’s going to call our administrators and complain.

I used to become more aggravated at situations like that, but they’ve unfortunately become par for the course. When my administrators look at the overtime that was paid out handling her care, I’m sure they’ll be a bit less sympathetic to her complaints.

I also had several patients who were there because they were worried about symptoms they did not yet have. One was a college student planning worried about getting sick before finals, because she had been having a runny nose for a few hours. Her mother was more concerned about “what could possibly be causing those dark circles under her eyes?” than listening to my discussion of needing plenty of rest, plenty of fluids, and some over-the-counter medication from Target. I recommended that she obtain a flu vaccine when she gets back to school on Monday (we have already exhausted our supply) and she stated that she refuses to go to the student health service because they didn’t have “real doctors” there. Her mother heartily agreed. I knew at that point there was no reasoning with them.

Some of these situations are the unforeseen consequences of shifting healthcare policy. My practice is big on price transparency. That’s part of our marketing since we’re significantly more affordable than the local hospital emergency departments. We’re not cheap, though – self-pay physician visits are right around $100 with testing and treatment on top of that.

Patients paying out of pocket tend to have better judgment when deciding to come in, and most of them have conditions that legitimately need a prescription treatment or other intervention. The majority of patients who don’t really need to be there have insurance and are somewhat insulated from the real cost of care. Even those with high-deductible plans tend to come to care a little more frequently than I’d expect, knowing that the charges will be billed through to insurance first so there isn’t a direct correlation between care and payment.

My dad recently found some old physician office fee tickets from the 1970s that made for interesting reading. I remember going to those physician offices. They didn’t have big billing staffs or revenue cycle management agreements or contracts experts or any of that overhead. They had a physician, a nurse or assistant, and a receptionist who also collected the payments at the time of service. Even adjusting for the wages of the day, the charges were reasonable.

I look at my practice (which is right at MGMA benchmarks) and see how many people are supporting me from a revenue cycle standpoint compared to how many are actually helping me deliver patient care and it’s disheartening. We have so many layers between the patient and the payment that are contributing to costs, and yet no one seems intent on reforming the insurance industry or their extreme profits. Back when I ran my own practice, I once calculated that the costs of managing the payer-related workflows in my practice (charge entry, payment posting, working denials, collections, office management functions related to those workflows, etc.) were nearly 30 percent of my overhead.

People are working hard in the realm of healthcare technology to streamline those processes and make them efficient as possible. The practice management system I use now leaves the one I had in 2005 in the dust and it’s significantly easier to use as well. We’re automating ways to get the most out of the healthcare system, but the underlying problems aren’t getting much better. In some ways they’re becoming more complex, as we now have to manage prospective payments, capitated payments, fee-for-service, increased patient-pay amounts, and other arrangements.

I recently watched a practice spend nearly $100,000 in staff and consulting hours on a project to address write-offs and refunds largely related to inefficiencies in payer processes. I guarantee that practice had more patient-centric priorities they could have spent that money on, but they were hemorrhaging money with their previous process and needed to fix things so they could move forward.

Even with our major shifts in healthcare policy, it often doesn’t deal with some areas of urgent need. I saw one patient who was actively delusional, yet had nothing to offer her because she wasn’t a danger to herself or others. Mental health services are so strapped in our community that unless you meet the latter criteria, it may take months to see someone. I spent nearly an hour trying to come up with a plan for her, which ended up being pretty pathetic compared to the care she really needed. But at least I was able to refer her electronically and with an associated C-CDA so when she does finally have an appointment, the receiving care team will have my data.

My next few patient care shifts are in non-holiday, non-weekend time blocks, so maybe I’ll see more typical urgent care cases that will help reset my psychology around the work I do and how it plays into the grand scheme of things from a healthcare reform standpoint. In the mean time, I’ve got some last minute HIPAA-related security risk assessments to work through for consulting clients that like to wait until the last minute to get things done. After that, I’ll start helping clients get ready for end-of-year data gathering and preparing their attestations for various payer programs as 2016 winds to a close. The end of the year used to be a slow time, but no more.

What’s your busiest time of the year? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/21/16

One of the challenges of running a business is managing your brand. While branding is associated historically with artisans burning their marks onto products and with ranchers applying brands to livestock, modern brand management can be a tricky thing. While we often associate brand management with consumer goods, an increasing number of healthcare organizations aggressively manage their brand identities.

Where many faith-based organizations traditionally named themselves after saints, the last decade has seen those identities give way to more broadly-appealing concept-based names: Memorial, Dignity, Unity, Mercy, Ascension, and more. Corporate initials have become prefixed to the names of even more facilities, a change that is deliberate and belies a deeper strategy. Health systems have gone beyond the traditional mission and vision statements to create marketing taglines that are specifically designed to evoke a certain feeling about the facility and its services. As “patients” have become “consumers,” we’ve seen more and more health organizations that are looking at market share, competitive intelligence, and brand differentiation.

Hospitals often have aggressive marketing campaigns around their emergency department wait times, the luxury of their labor and delivery suites, the availability of hotel-like accommodations, and more. The competition for market share has long trickled down to individual physician practices, where being affiliated with a given health system can generate more business or greater prestige. Although these may have been loose affiliations in the past, they’re becoming more solid as groups of providers shift into Accountable Care Organizations and other risk-sharing arrangements. Organizations that understand their brand and how they are perceived by the community can make stronger plays in the market than those who can’t.

As I work in physician offices across the country, the differences in brand awareness are striking. Many physicians don’t understand how important having a corporate identity can be, or conversely what a disaster it can be if you don’t have one. Does the staff wear uniforms that match and have a practice logo? If there isn’t a uniform, is there a dress code? Or do staff just wear whatever scrubs are at the top of the clean laundry? It amazes me when practice leadership hasn’t given this any thought. Having a uniform appearance (which doesn’t necessarily mean there must be uniforms) can convey to the patient that their experience is going to be organized and predictable.

Even though my practice has a strict dress code, we sometimes struggle with this. Different team leaders have different levels of tolerance for deviation from the dress code, which can result in consequences when the CEO, COO, or a medical director arrives unannounced. The fact that there are penalties associated with failure to adhere to the standard makes a difference, though, and it quickly becomes clear that if leadership isn’t going to tolerate straying from the dress code, they’re not likely to tolerate deviation from our customer service or patient care standards, either.

I see physicians who struggle with their own idea of a dress code – white coats that are filthy at the cuffs and elbows, rumpled clothes, dirty scrubs, and shoe covers with holes worn through them. They may be brilliant in their field, but they’re missing the fact that their personal brand screams “messy” and “disorganized” rather than “capable” and “professional.” This concept of personal branding becomes even more concerning when it extends to a physician’s social media presence. Where some are skilled at keeping personal and professional personas separated, others offer up a confusing mix of messages that may be concerning to patients or potential patients.

Even those physicians who may do a good job managing their own personal branding and social media presence often struggle with managing how their employees present themselves. Do employees use the practice platform to promote their own interests? Does the practice have any say in how physicians and employees present themselves on platforms such as Doximity and LinkedIn? I’m seeing more organizations that are interested in trying to get a handle on these external platforms, making sure their employees help support the professional perception of the organization. Some may require employees that blog to add a statement that the opinions featured in the blog are not those of the employer. Others don’t seem to notice that their employees have social media profiles. Case in point: the marketing director of a local Catholic healthcare organization was wearing a shirt that said “sex, drugs, and rock & roll” in his LinkedIn picture while prominently featuring his employer’s logo on his profile. I’ve also seen plenty of non-clinical people wearing scrubs in their photos, which always baffles me.

Hospitals and healthcare delivery organizations aren’t the only ones in our world that are spending significant resources managing their brands externally. Many healthcare IT companies are actively managing their brands, even though those that may not admit to having a marketing department. Although some efforts can be counterproductive (remember the Siemens Healthineers debacle?), others have had significant success. HIMSS is the big game of healthcare IT marketing and it’s clear to see who brought their A game to the exhibit hall.

In dealing with many vendors in the course of my consulting work, however, I wish more of them would pay attention to internal branding and ensuring employees other than the marketing team can deliver a consistent message. I work with one vendor that often communications information directly to their client base without communicating the same information to their employees, which as you can imagine results in a lot of misunderstandings, particularly when the communications include release dates or break/fix information. Even though they’re a relative start-up, there’s no excuse for not having a communication plan that allows your internal team to be educated before you start sharing information with your customers.

There’s also no excuse for not having consistent, professional website bios for your senior leadership, but I can’t say I didn’t warn them. When nine of 10 execs have professional headshots and the other has a selfie from his most recent fishing trip, that’s probably not the image you want to convey, unless you are a vendor that runs a fleet of charter fishing boats.

What’s your brand? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/17/16

I heard from a couple of clients that CMS has started to notify practices of their selection for the Comprehensive Primary Care Plus initiative. Although the web site says that they updated the Region and Payer lists on November 15, I was unable to find the updated lists on the site. I’m assuming they’ll be putting out a press release shortly, but it would be nice to get the information from the source before clients start calling. The program starts January 1 and there is much work to be done for those selected.

Some of my clients who applied don’t have experience with prospective payments and may need retraining on their practice management and accounting systems to ensure they know what do to with the money and how to manage it. Fortunately my partner has a lot of experience in this regard, but it’s a learning opportunity for me as well. In urgent care, the only prospective payments I deal with are our occupational health contracts and that’s a different kind of accounting altogether.

I’m receiving a lot of requests for support from organizations that are relatively new to value-based care. One in particular has received reports from their ACO and the numbers don’t line up with what they are seeing in data from their EHR vendor. Reconciling competing reports isn’t one of my favorite pursuits, but I’m fortunate to work with a great data analyst who is going to start digging in. I’m suspecting that the ACO data might have issues since there are measures that have the same population and one is showing a zero denominator where the others clearly have denominators. One would think the ACO would have reviewed that and completed some data integrity checking before sending their participating practices into a scramble.

I think we’re going to start to see some buyer’s remorse as practices realize what ACO membership really means for them. I’ve seen quite a few independent practices that felt pressured to join organizations or risk being left out of referral networks. Some independent practices don’t have the most business-savvy people making decisions and may gave gotten more than they bargained for with regard to their responsibilities as part of the ACO. In this particular situation, the ACO agreement didn’t address the idea of what happens when there are data reconciliation issues. Even when we complete the analysis, my client might still be penalized based on the faulty data. These types of issues are going to continue to surface as more organizations move into the value-based care space but might not have the expertise to fully manage what they are trying to do.

I spent several hours this week completing mandatory Maintenance of Certification activities for my primary board certification. It was a depressing activity since many of the questions covered minutiae that is hardly germane to the realities of practicing medicine. The format was an online “knowledge assessment” with provided citations for the information behind each question and answer. Notice I said “citations” and not “links” because finding the references was a manual process, and for some, a Google search failed to locate the materials. Other materials were fee-based and many were more than a decade old. I began to distrust whether I was spending my time wisely trying to find the right answer to pass the assessment vs. knowing that I was reviewing current information.

One of the questions were around the 2008 Physical Activity Guidelines for Americans, put out by the US Department of Health and Human Services. I’m not sure I need to know whether the Guideline officially recommends the frequency for alternating various types of activities in order to be a good physician. What I do know is that most of my patients need to eat less and move more. Splitting hairs with them on whether they prefer moderate-intensity exercise at a weekly minimum of X minutes vs. vigorous activity of Y minutes doesn’t play out in the six-minute office visit. If they’re overweight or have diabetes, hypertension, or metabolic syndrome, I need to focus on telling them that if they’re exercising they’re moving in the right direction and that they should consider doing more.

Maintenance of Certification is particularly difficult for those of us that work in non-traditional capacities or limited practice situations. For example, the modules where I am supposed to do practice improvement activities don’t necessarily apply to me because I don’t follow patients in continuity. Rather than giving me opportunities to do something relevant to my work, I have to do the same activities that traditional physicians do but with simulated data, and the learning value is pretty low. It’s particularly low because I’ve already done the exact activity before, in my last recertification cycle, because there are so few options for non-traditional physicians.

We are forced to maintain our primary board certifications for a couple of reasons. First, to be credentialed by payers, you generally have to be certified. Second, even to practice clinical informatics, we have to maintain a primary board certification. It’s a catch-22 for many of us who might consider dropping clinical practice altogether but want to stay certified in clinical informatics.

Speaking of that certification, the American Board of Medical Specialties approved a five-year extension on the so-called “practice pathway” to clinical informatics certification. Physicians who are currently practicing clinical informatics but who have not completed a fellowship can apply for certification through the 2022 examination cycle. I am grateful to AMIA for keeping everyone informed. The announcement cited continued workforce demand and opportunities for physicians seeking a full-time informatics career as contributing factors. Now we need a pathway for those of us who don’t want to maintain a primary certification to go “all in” for clinical informatics.

I’m way behind on my email due to some back-to-back travel and trying to get my board certification activities done. I was interested to see a request by the Food and Drug Administration for submissions on “Emerging Issues and Cross-Cutting Scientific Advances.” The FDA regulation process takes years, creating a need to assess how to regulate advances that are just now being thought of. The blog piece mentions ideas like intraoperative hibernation and brain-computer interfaces as examples. Submissions to the Emerging Sciences Idea Portal will be public, so I’ll have to make a reminder to follow up.

I’m taking a long weekend to recover from the chaos of the last several weeks. It put a dent in my frequent flyer and hotel points, but it’s exciting to have a trip planned that I’m actually looking forward to.

What’s your favorite long weekend getaway? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/14/16

Since I’m working both as a consultant and as an employed physician/CMIO, I have the opportunity to interact with quite a few different hospitals, health systems, physician organizations, and vendors. Maybe it’s the Supermoon effect, but it feels like some of the organizations and teams I’ve been working with have lost their rudder. It’s resulting in unpredictable situations that create challenges all the way around.

With one organization, I feel like I’ve been immersed in a spy novel. They’ve been planning to switch EHR vendors for quite some time and are well down the contract negotiation pathway with another vendor. Still, they keep stringing the legacy vendor along, demanding that executives be flown to the client site to address the issues and the relationship so that they can demand discounts and credits for perceived software inadequacies. I say perceived, because I’ve been working with them for well over a year and know firsthand that they haven’t implemented the legacy system correctly and refuse to take my advice or the advice of the other two consulting firms they have on site.

I wish there was some kind of whistleblower hotline to let the legacy vendor know they’re being played, as well as to warn the incoming vendor of the kind of people they’re dealing with. Maybe there is already some level of understanding of the situation, but in working with the earnest and dedicated sales and client management teams, the individual folks working hard to save the client don’t seem to have been clued in and are taking it personally when they figure out the client is lying to them. Client leadership is open about how much they can get out of the legacy vendor on their way out the door and it’s sickening. I’m grateful my contract with them expires at the end of the year because I won’t be offering them a renewal.

Another organization recently engaged me to do some coding education with its providers. In the decreasing world of fee-for-service, they’re eager to get every last dollar out of their problem-oriented encounters. The first thing I did was to look at the coding distribution across their providers, which was fairly close to what I expected. There were two physicians who were significant outliers, but the rest fell nicely along a curve that didn’t vary much by patient mix or payer mix. I figured my task was to first work with the high-end outliers, to find out whether they were over coding and putting the organization at risk. When groups get caught in that situation, the penalty is calculated by extrapolating the overage as if all visits had been handled that way. It’s to an organization’s benefit to rein that in so they don’t have a huge penalty in an audit.

In fact, the group wanted me to address those they perceived as under coding and get them up to the level of their outlier peers. I’m sorry, but if you’re a walk-in primary care clinic that isn’t even addressing complex chronic conditions or significant comorbidities, it’s hard to get a viral upper respiratory infection up to a 99214 E&M code without at least documenting the chronic conditions and how the infection might impact them. Just because you add a prescription medication to the plan or perform a 40-point physical examination doesn’t mean it was medically necessary or that the higher level of coding was justified. I was happy to provide the nuts and bolts coding education. but if they want to encourage up-billing. they’re going to have to use their own physician executives to explain how they want that done.

Another group who engaged me to do a workforce evaluation is being crippled by ineffective management and poor human resources policies. Workers routinely fudge their time cards to make sure they reach 40 hours a week, even though they’re exempt employees who aren’t necessarily required to document 40 hours a week. Unfortunately, they’re damaging their team’s reputation and creating risk for their company. Some of the workers are adding the time to administrative buckets, which negatively impacts the team’s productivity. The worst offenders are padding time on client-facing projects, in effect stealing from their clients six minutes at a time as they increment the billings almost imperceptibly to make up for their own shortages. I recommended that the 40 hours requirement be removed and time be monitored over the next few months to see if there are weeks that people are working more and weeks that people are working less, and to see if they were averaging 40 hours a week as expected. HR cited company policy for the 40 hours requirement, and failed to address the outright dishonesty by their client-facing employees.

I was raised in a world where people should be prepared to face the consequences of their actions, but in these situations, it’s clear that there have been no consequences to date and that those involved don’t even worry about the potential consequences. My business career has been under leadership that expected people to deliver what they said they would deliver, but to do it ethically and in a way that keeps the client at the front of their thoughts and actions. I’ve worked for leaders that were tough but fair, and were honest about the decisions they were making and the potential impact on downstream employees and clients. It’s what I’ve tried to be in my work, but sometimes I feel like the idea of “greed is good” has come back into vogue.

I don’t want to think that so many organizations are spiraling into the muck, and just as I was starting to feel that way, I had a company impress me with its integrity. I helped them with an extremely sensitive project and they made sure that as it unfolded I was in no way compromising my principles or proceeding in a way that didn’t make me comfortable or interfered with my other clients or responsibilities. They didn’t assume that just because I was a consultant and being paid a good amount of money that I was on board for anything they requested. I’ve never worked with a group that was quite that deliberate in how they handled their business relationships, but it was certainly refreshing. It was the kind of engagement that makes a consultant hope that if they eventually want a full-time resource, they’ll keep you on their short list.

I like working with people who say what they mean, mean what they say, and do what they say they are going to do. Are you fortunate enough to have that in your workplace culture? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/10/16

Most of the physicians I have interacted with over the last two days have commented about potential healthcare impacts from Tuesday’s election. Although the potential repeal of the Affordable Care Act was at the top of multiple conversations, there were many local and state questions with a health-related focus.

Colorado voters failed to pass Amendment 69, which would have allowed for a single-payer healthcare program to replace the state’s insurance exchanges and also private plans. Voters there approved Proposition 106, which would allow physicians to prescribe lethal drugs to terminally ill adults who are certified by at least two physicians as having less than a six-month life expectancy. Colorado voters also said no to increased tobacco taxes, with similar rejections in North Dakota and Missouri. The latter had two tobacco tax issues on the ballot, which likely caused confusion.

Regarding other smoking options, medical marijuana was legalized in Arkansas, Florida, and North Dakota, while Montana amended its existing regulations. Recreational marijuana use was approved in California, Maine, Nevada, and Massachusetts. Those eager to partake will have to wait a bit longer while states finalize the details around the actual sales and dispensary processes.

California voters approved a tax of one cent per ounce on sugar-laden drinks in Oakland, San Francisco, and Albany, while voters in Boulder, Colorado approved a two cent tax. California voters also elected to continue fee assessments on private hospitals, with the proceeds being used to fund Medicaid.

The most interesting ballot questions I saw were in Florida, with two non-binding referendums on the release of genetically modified mosquitoes to reduce disease. It’s an interesting idea as a public heath intervention and passed in Monroe County, but not in Key Haven. I’m a big fan of Jurassic Park and I can’t help but wonder if voters thought about what happened with those genetically modified dinosaurs when they made their decisions.

California was certainly a leader in the number of health-related questions, although voters failed to pass Proposition 61, which would have blocked pharmaceutical companies from charging state payers more than they charge the Department of Veterans Affairs. Not surprisingly, big pharma spent more than $100 million to oppose the measure.

Although the president-elect promised to repeal the Affordable Care Act as part of his platform, Republicans failed to earn a filibuster-proof majority in the Senate. The ACA was a long time in the making and had support from both sides of the aisle, so efforts to reverse are sure to be interesting. Filibusters are always attention-grabbing as well as a way to hear some interesting literature and potentially pick up some new recipes.

There is a chance that a budget reconciliation maneuver might be used, which only requires a simple majority, but this requires a review of the parliamentary process around budgeting to ensure that the process is compliant. This process was used earlier this year, but the bill ultimately suffered a Presidential veto.

Changing the ACA might be more difficult than people think, as more than 20 million people would stand to lose insurance coverage. Additionally, many Americans have been pleased with the portions of the law that protect patients with pre-existing conditions and extend the length of time that dependents can remain under their parents’ coverage. This enthusiasm has been tempered, however, by concerns over high coverage costs and rising premiums.

Trump has also mentioned allowing the import of prescription drugs from outside the US, as well as allowing Medicare to negotiate drug pricing directly with pharmaceutical manufacturers. Similar efforts have been blocked by the GOP in the past, so it will be interesting to see what’s different this time. It’s likely that a Republican-controlled legislature will take up the issue of funding for Planned Parenthood and perhaps other regulations related to reproductive healthcare.

The issue of filling the existing vacant Supreme Court spot was also the topic of several discussions. I’m sure the nomination process will be interesting once our new president takes office. We’re certainly in for an interesting ride over the next several months.

What chatter are you hearing about the future of healthcare after the election? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/7/16

One of the key tenets of the shift towards value-based care is the idea that physicians are increasingly graded on patient outcomes. Not surprisingly, this grates on many physicians.

There are complex issues involved when trying to get a patient to change behavior, even when it’s a relatively straightforward recommendation such as taking a medication. Conventional wisdom and multiple studies have demonstrated that close to half of all prescriptions aren’t taken as directed and many are never even filled. There are many factors involved: cost, convenience, commitment, side effects, etc. Additional factors related to specific patient populations may also include transportation, safety, health literacy, cultural barriers to care, and more.

When a significant lifestyle change is recommended, the factors involved become exponentially more complex. We live in a society that focuses on instant gratification. Health-related lifestyle changes typically challenge that paradigm and require ongoing hard work that results in slow change that can sometimes feel imperceptible. People want quick wins. Any clinician who has tried to discuss the pros and cons of moderation in diet and increased exercise vs. various celebrity-endorsed weight loss programs knows what I’m talking about. Patients see the claims of a dropping significant weight in a short time period and find the contrast of a slow, sustainable loss of a pound a week to be off-putting.

Other lifestyle changes are impacted by socioeconomic factors, including food insecurity, variable availability of healthy grocery options in the urban core, joblessness, homelessness, abuse, and more. Although physicians can refer patients to community supports and programs (assuming that the programs exist in your area and can maintain their funding in the face of increased need), there are limits to what we can do. That is where the idea of being graded on patient wellness starts to feel unwelcome.

Once you’ve considered the logistical issues involved in a change in patient health status, you have to contemplate the ethical ones. Autonomy and personal freedom are major issues in America today. Governments from the national level to the local level are trying to address issues such as the consumption of high-calorie drinks and the inclusion of unhealthy ingredients in foods. I still miss the trans-fat in my Oreo cookies, but I understand why it’s no longer there. But when you try to convince a patient to make a change, things can often get challenging.

Physicians are at the front line of trying to drive outcomes, but often our advice is often challenged. When I recommend diet and exercise for weight loss, patients want a pill. When I recommend a pill for high blood pressure because diet and exercise failed, I’m accused of being in the pockets of the drug companies. Even though 95 percent of the prescriptions I write are for generic drugs and many of those are on the $4 list at the local supermarket, it’s assumed that we’re getting kickbacks and are part of the healthcare cost problem.

Physicians have long been in a position of paternalism, although that is changing with the focus on patient-centered care. Still, there are patients who want to choose their treatments based on what I would do for myself or a family members. They don’t want to be part of their own decision-making, they just want to be told what to do.

But the next room you enter might have a patient and their entire extended family, all of whom have been all over the Internet researching treatment options, and want to discuss each one of them independently. It certainly makes one feel scattered when trying to see patients as well as a bit fragmented when you have to shift back and forth between two completely different frames of mind. Not to mention that it’s difficult to get payers to compensate physicians for the time spent in those conversations, and patients aren’t eager to pay for it out of pocket.

Then, there’s the principle of beneficence. By pushing patients to comply, are we still doing right by the patient? Where is the boundary between trying to engage your patient to take charge of their health and being pushy? At what point do you agree to disagree on the colonoscopy order the patient is never going to complete? I’m on the hook for the patient’s performance regardless of whether they go or not and regardless of how many times I’ve tried to get them to go or how persuasive my arguments might be.

Under the new healthcare payment schemes, our incomes are directly tied to our ability to motivate our patients to do what we recommend. A recent study may shed some light on which approaches are more productive in moving patients towards change. It confirmed the results of a previous study that identified potentially effective strategies for supporting patient self-management:

• Emphasizing patient ownership
• Partnering with patients
• Identifying small steps toward change
• Scheduling frequent follow-ups
• Showing care and concern

Researchers created a scale to measure where primary care clinicians stand and found that performance on the scale was associated with patient efforts. I found it interesting that they only looked at primary care physicians. Although everyone assumes we’re “most responsible” when trying to attribute certain elements of care, it really does take the proverbial village to care for patients. The study found that primary care providers who spent more than 60 percent of their time “counseling, educating, and coaching” their patients scored higher than those who spent less time in those activities. For most of us, being able to spend that portion of the visit motivating our patients would be a luxury.

I also found it interesting that some of the strategies they cite are challenging under new reimbursement schemes. Frequent follow-ups aren’t going to happen for patients on high-deductible health plans. The usual response to that concern is telemedicine, but most payers still don’t cover it. That translates to unreimbursed physician work, which is less likely to happen than actually reimbursed work.

Even something that seems relatively simple such as showing care and concern is increasingly difficult under payment reforms and technology incentive programs. Many physicians are stressed to the breaking point. Scarcity of primary care physicians in traditional continuity practice makes for long waits and short visits. When you have to spend time trying to hit as many metrics as possible in as little time as possible, it doesn’t make it very easy to get to know your patient. Adding the stress of technology issues doesn’t help.

Another factor that doesn’t help is the assumption that patient engagement is a software problem. The reality is that patient portals and online interactive education are just part of the toolkit, but it takes time to help physicians learn how to best use those tools, how to best encourage their patients to use them, and how to put processes and policies in place in their offices so that their use doesn’t increase the burden of physician work.

I’ve done formal training in motivational interviewing and healthcare coaching and know that physicians struggle with finding the time away from their practices to get that kind of training. Some of my rural colleagues have difficulty getting coverage for even a few days out of office. Regardless, having those as options for practice improvement activities under some of the regulatory requirements might have been additional motivation to move clinicians in that direction.

What are your plans for greater patient engagement? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/3/16

Although many are focused on the Presidential election, it’s important to remember that Congress is responsible for appropriations. Many professional and advocacy organizations are busy at work, encouraging both parties to keep the government funded. The American Academy of Family Physicians continues to ask Congress to continue funding for the Agency for Healthcare Research and Quality (AHRQ) and other programs tied to primary care and public health. One would think that those kinds of efforts would be relative no-brainers for our leaders, but if there’s anything that we’ve learned during this election cycle, it’s that brains are sometimes in short supply.

A recent Advisory Board daily briefing noted that “Most docs are Dems” according to data from Yale University research. Surgeons, anesthesiologists, and urologists are more likely to be registered Republicans, where pediatricians and psychiatrists were more likely to be Democrats. Contributing factors may include salary, age/sex demographics, and specialty culture.

In the “no surprise” department, a recent piece in the September issue of Health Affairs identified a decrease in the number of small practices, defined as those with nine or fewer physicians. Small practices dropped from 40 percent in 2013 to 35 percent in 2015, while the number of large practices (over 100 physicians) increased by a 5 percent margin. Increasing regulatory and administrative burdens will continue to drive physicians to larger groups or employed practice situations.

The meeting season is in high swing, with MGMA just having wrapped up and various vendor user groups including NextGen and Cerner about to take place. The AMIA Annual Symposium starts on the 12th in Chicago. I’m sad that I’m missing AMIA this year due to other responsibilities, but I have a couple of friends going who promised to fill me in. If you’re attending any of the user groups or AMIA, feel free to share your pictures of good times, great shoes, and groovy entertainment.

I’m often overwhelmed by my Twitter feed, but when I see something that is mentioned by both Atul Gawande and Farzad Mostashari, I take note. Both mentioned this Washington Post piece addressing the practice of enrolling non-terminal patients in hospice care. The Office of the Inspector General found that many patients signing up for palliative care weren’t told that it meant giving up curative treatments. Hospice care has grown to a $15 billion industry and patients that require fewer services are more profitable due to the flat fee structure. Hospice care can provide real relief for patients and their families during very difficult times and it’s appalling that shady characters would choose to profit from it.

Speaking of people operating on the fringes, I’m sometimes amazed at the things people say in the course of trying to make a deal. I may be young and my consulting company may be small, but that doesn’t mean I’m clueless. A prospective client that I’ve been meeting with has repeatedly asked me to do some things with my proposal that I’ll call “irregular” for lack of a better description. I’m no stranger to dealing with convoluted corporate accounts payable processes, but if you ask me to do things that require legal fees to determine whether they’re legitimate, we’re unlikely to do business together.

I came across an interesting statistic today that 20 cents of every dollar in consumer spending goes to FDA-regulated products, including many foods, drugs, medical devices, cosmetics, dietary supplements, and tobacco. Being in healthcare IT, we often think about the FDA in regard to device regulation, but may forget everything else they do.

The “Mr. Yuk” award of the week goes to Kareo, whose “premium content” Medical Economics piece completely ignores the volume-to-value transition, admonishing physicians that “if you are not seeing enough patients each day, you will never be able to grow your practice.” Their guide gives “three key ways to increase the number of patient visits and the revenue that comes with them,” including an effective recall program, an online presence, and encouraging referrals. I was surprised to see someone pushing a clearly fee-for-service model without even remotely mentioning value-based care. It does talk about adding ancillary services such as a dietician, but mostly in the context of increasing the physician’s bottom line rather than as a quality maneuver.

I loved their advice to “don’t bring a dietician on payroll until they are at least 80 percent contracted with your payers. You don’t want to be paying that extra salary while they are unable to bill for seeing patients.” It seems they need a better understanding of how providers enter into employment arrangements. I’ve never met a provider who was willing to sit it out unpaid until the often unpredictable credentialing process reaches a certain threshold. Although you may delay a start date to allow for the paperwork to move through, clinicians will often begin delivering services to build their patient base or to start contributing to quality efforts. There are many things that providers do that aren’t about the bottom line, but apparently Kareo doesn’t get that.

They go further to suggest that practices should limit the slots for capitated patients “while leaving same-day and extended hours open for fee-for-service patients.” A couple of pages later they mentioned that providers can encourage referrals by “offering low wait times and great access.” I guess that’s just for the fee-for-service patients, though. Although many of their suggestions may appeal to the business side of our brains, I found the piece generally tacky and hope they’re more in tune with emerging software needs than they are with clinical transformation.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/31/16

There has been a fair amount of swirl and churn with my clients this week as they begin to digest the recently-released MACRA Final Rule. It was released with a comment period, which seems to be having some unintended consequences. Some organizations are interpreting the presence of the comment period as a license to continue to stall in their preparation efforts, as if some magical MACRA Fairy is going to swoop down and change the requirements.

It’s been tough to get some of them moving again, because they stalled after the Proposed Rule and took on other projects. I keep preaching the idea of taking baby steps. Even if we don’t think it is truly final, just pick some subprojects and get moving. It’s a hard sell for some groups, however.

Being in the trenches with small to mid-sized practices is tough. There are a fair number of groups out there who still can’t manage to tackle the basics that haven’t changed in years, particularly on the business side. I see groups with high days in accounts receivable, low net collections, and more. Most of the issues are due to process problems such as being unable or unwilling to adopt essential revenue cycle best practices.

You wouldn’t believe the number of organizations that still haven’t grasped the concept of collecting the co-pay up front, which results in a lot of chasing after the fact. Others aren’t performing insurance eligibility checks so that they know whether the patient needs to be self-pay or not. Yet others don’t have their contracts loaded into their practice management system, which makes it difficult to know whether insurers are paying as expected.

These business processes are fairly cut and dried and haven’t changed in quite some time, so when you see organizations that can’t handle them, it throws up red flags about their ability to handle change in their clinical operations. Medical billing systems were among the first pieces of automation added to the medical practice and quite a few vendors have extremely mature platforms. Compared to the relative immaturity of some clinical platforms and the constantly changing federal requirements, it feels like the business piece should just be more solid.

I also see a fair number of practices that don’t have disaster recovery figured out. No part of the country is immune from natural disasters and there are always the “small things” like power outages, disrupted data lines, water line breaks, etc. to potentially disrupt practice operations. At this point, everyone should have a business continuity plan and disaster recovery plan. For those practices that are still stalling around MACRA requirements, I’m trying to push them to go ahead and address those issues so at least they are doing something and creating some kind of positive momentum for their organization.

One of the practices I’m working with right now that is stalling the most is one where the owner is contemplating retirement just to get away from it all. He’s in his late 50s, so I wouldn’t exactly call him retirement age, but he isn’t sure he wants to move forward with all that is being asked of him. It would be one thing if he was waffling and he only had himself to consider, but there is a relatively new physician who joined his practice in the hopes of possibly buying it in a few years. They’ve dabbled in Meaningful Use in the past, but barriers like not having a patient portal block their progress. Even though their vendor offers one, the owner isn’t willing to spend the money while he debates his future.

I don’t have insight into their contract arrangement, but the junior physician has let me know he has been having second thoughts about staying in the arrangement vs. looking at other employment options. They are both aware that there are a number of large groups and health systems that have open opportunities that I suspect offer comparable working conditions, salaries, and benefits, at least for the younger physician who is still building his patient panel. Unless he’s similarly committed to practicing outside the federal incentive / penalty scheme, one of those opportunities may start to look pretty attractive, which I think is adding to the stall factor in this case.

I’ve been spending a lot of time with the both of them trying to create a strategic roadmap for the practice. Does the senior one plan to retire? Will he sell to the junior one or to a health system? Will they close altogether? Will the junior one eventually make a move to force his employer’s hand? It’s like a soap opera and I’m caught in the middle of it. It’s a blend of change leadership training and relationship counseling but hey, it pays the bills.

On a personal level, my own practice has been reviewing the Final Rule as well. Even though we’ve opted out of Meaningful Use, it’s prudent to review the next iteration and determine whether we still want to stay out of it. I’m fairly confident we’re going to continue to just say no, but it’s refreshing to know that you are working with leaders who consider the options at various turning points so that you don’t wind up simply doing things because you’ve always done them that way or because that’s how you decided to do them before. Our owners are very deliberative and data driven and it’s been refreshing to work in that kind of an environment compared to the highly reactive environments I see with most of my consulting clients.

We’re currently focused on growth and have three new locations under construction, poised to open monthly from now through January. It’s been an interesting ride. I’m not entirely bought in regarding some of the locations they’ve picked for expansion, so we’ll have to see whether their forecasts actually play out. In the meantime, it’s been fun to work with people that are so focused on processes and outcomes, independent of any regulatory shackles.

What’s your favorite Halloween candy? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/27/16

Hot on the heels of the MACRA Final Rule, CMS announced expanded opportunities for physicians to participate in Advanced Alternative Payment Models. One of the opportunities includes reopening applications for the Comprehensive Primary Care Plus (CPC+) program. This is a coordinated initiative that involves the participation of multiple commercial payers in addition to Medicare and Medicaid across specifically identified regions across the nation.

Although they initially said they would take up to 20 regions for the program, they only announced 14. It would be an easy thing to open applications for providers, but they’re also opening it for payers, which makes me wonder if they’re going to select additional regions for this new 2018 cohort. They’re also calling for new participants in the Next Generation Accountable Care Organization model for 2018.

I was on a CMS Quality Payment Program Overview webinar today. Although I give them props for nice classical hold music, it would have been better if they didn’t start late and then run over time. I’ve been on several CMS webinars lately and they tend to be overly scripted. As someone who does a lot of presentations, I appreciate their desire to make sure they deliver all the information, but there’s definitely an opportunity to be more engaging.

Because of the number of questions and the late start, they didn’t answer many of the questions posed by attendees. I understand that there were more than a thousand people on the call, and with that many questions, it illustrates how complicated these programs are and the level of concern felt by providers.

One attendee asked how CMS is going to manage the idea of patient free will and the fact that physicians are being held liable for patient behavior. The attendee gave the specific answer of a patient with lung disease who leaves the hospital and immediately starts smoking, which has the potential to skew quality numbers. She went on to ask what preparations are being made to address the possibility of patient dumping, where physicians refuse to treat patients who fail to comply with treatment plans and recommendations. Dumping (and cherry-picking, where clinicians go after the healthiest patients) has been a real issue in the past as various payer programs penalized providers for being quality outliers.

The Medicare Learning Network offers their version of a Quality Payment Program call on November 15th and interested parties still have the opportunity to enter comments on the Final Rule. Registration is open and space is limited. This is in addition to their “How to Report Across 2016 Medicare Quality Programs” call that is being held on November 1.

There are so many things that primary care physicians must advise their patients on that it often feels like there’s not enough hours in the day. This month, one more thing has been added to the list, and it’s an item that isn’t going to be a quick conversation. The American Academy of Pediatrics has endorsed new safe sleep guidelines that recommend that infants sleep in the same room as their parents (although not in the same bed) for the first year of life. Despite recent interventions, there are still 3,500 sleep-related infant deaths each year and the new recommendations aim to reduce that number. These are the kinds of conversations that take more time than the typical office visits allow, creating additional time pressure for clinicians.

Those time pressures challenge physicians who are  being graded on how we’re doing with patient engagement. My office uses a Web-based patient engagement platform that surveys each patient or caregiver who provides an email address at check-out. Our scores (on a scale of zero to five) are part of the formula that determines whether we receive a bonus and how much it might be. Usually my scores are fives with the occasional four. The scores roll in real time and I’ll often see results from patients I saw just a few hours earlier.

Today I got a three, which was strange because all the comments associated with the score were strongly positive. Our office calls each patient who gives us less than a four, so I’ll get additional feedback on the reason for the low score. Looking at the schedule, she was seen during a patient rush when our wait time was over an hour and while I was in the process of transferring two patients to the hospital for life-threatening emergencies. It’s likely that the wait time played a role in the score, but it’s certainly discouraging for physicians who provide high-quality care but don’t carry a magic wand.

Speaking of magic wands, I definitely need one for a current client. I’m doing some governance work for a mid-sized health system that has been struggling with their EHR to the point where they’re ready to start looking for a new vendor. They realized how expensive a system replacement might be, so they brought me in to do a thorough review and to see if anything can be salvaged.

I found an extensive list of issues ranging from defective hosting to absent physician leadership. There are also some configuration issues with the EHR, but nothing that can’t be fixed. I’m in the middle of a follow-up consulting engagement trying to get their leadership organized around a common vision and mission. I’ve struggled with one of their clinical leaders who keeps focusing on perceived EHR issues (which are largely self-inflicted) to the exclusion of everything else. I’ve been trying to get the leadership to focus on strategic planning and creating prioritized action plans, but it’s hard to get the clinical leadership to show up, let alone participate.

Today one of the most difficult clinicians graced us with his presence after several weeks absence and proceeded to try to hijack the agenda and pull us back into a discussion of EHR issues, most of which have already been corrected. I used my best facilitator skills to try to redirect him, to try to engage the group to self-police, and to place his various rants on my “parking lot” for later discussion. He insisted that “we can’t get strategic until we get past the issues.”

That definitely wins my quote of the day award, especially since under his approach, they’ll go nowhere fast. It’s hard to make a roadmap when you haven’t decided where you’re headed. And if you don’t know whether you’re driving to the beach or to the mountains, it’s going to be hard to plot out the fuel stops and tourist attractions along the way. I was ultimately able to thwart his attempts to block the group’s progress, but it wasn’t easy.

How do you handle people who are constantly stuck in the weeds? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/24/16

One of the family medicine journals recently published an editorial on preventing diagnostic errors in primary care. It advocates using diagnostic checklists and clinical decision support tools to make sure an appropriate differential diagnosis is considered. Although checklists can be helpful to make sure you arrive at the most likely diagnosis, sometimes physicians just want to know whether we were right and what happened to our patients.

Now that the MACRA final rule is out, we know that HHS plans to continue monitoring to see if EHR vendors are guilty of information blocking. I know I’ve mentioned this before, but I’m still waiting for someone, anyone, to come after the hospitals and health systems that are guilty of information blocking. Especially when treating a patient with an uncommon presentation or a rare diagnosis, follow-up is needed to understand whether the diagnosis was accurate and whether the treatment provided was appropriate or whether there was something more beneficial that could have been done. It’s also important for me to know whether my patients have any complications as a result of my treatment.

This week, I had a couple of rare cases and wanted to track down what happened. In both cases, I had to transfer the patient for further care – one went to a local community hospital where I was an attending physician for many years and from which I continue to receive (erroneous) patient test results. The other patient was refused by the community hospital due to the nature of his condition, so I had to send him to a tertiary referral center where I haven’t been on staff but where I know for a fact that I am in the referring physician database.

In each case, I called report to the facility, giving my name and the pertinent information on the patient’s condition. I also sent copies of the patient’s urgent care evaluation note and the CT scan performed at my facility, both with my name and credentials.

In both cases, when I tried to call for follow-up, I was stonewalled. One facility had the audacity to tell me that, “We have no idea of knowing you are who you say you are” despite the fact that I could accurately give them the patient’s name, date of birth, time of the transfer, and name of the nurse I spoke to when giving report. I urged them to look at the transfer and admission documents to verify my status.

The other facility told me they couldn’t even verify the patient had been admitted “due to HIPAA,” again despite my providing all the information including the name of the attending physician who agreed to assume care.

Last time I checked, HIPAA allows the disclosure of protected health information for treatment, payment, and healthcare operations. Even if you wanted to argue that I was no longer treating the patient, the definition of healthcare operations clearly includes: conducting quality assessment and improvement activities, including outcomes evaluation; care coordination; evaluating provider performance; and certification activities. Despite it being around for two decades, HIPAA is still misunderstood and various entities continue to cite it as a reason to prevent information sharing.

How is this not information blocking? Sharing information verbally and in writing is the precursor to interoperability. And in areas of the country like mine, where there is no consistent platform for EHR-based interoperability, it may be the only way to get information. Where are the HIPAA police when you need them?

If healthcare entities cannot understand a regulation like HIPAA after 20 years, how can there be any hope of everyone understanding MACRA and all its successor requirements that go into effect in a little more than two months?

Hoping that I was just dealing with overworked floor staff who may not understand the nuances of clinical follow-up, I decided to go up the chain and see if I could find another way to get the information I need. I ran a couple of reports out of my EHR and found out how many patients I personally referred to the hospitals in question, as well as how many patients our practice overall had referred in the last year. Knowing that the hospitals have programs where community physicians can have access to their clinical data, I decided to ask for courtesy access. If that failed, I planned to cite the transfer volumes and make a compelling case to be able to access the records in the name of practice-related quality improvement activities. We’re the largest independent urgent care in our metropolitan area and we generate substantial referral volume, so I was hoping they’d bite one way or the other.

Both of them gave me the same response. Unless I apply for and obtain medical staff privileges at the hospital, they have no way to give me access. Being on staff means that you have to actually admit or otherwise attend to patients in the hospital, which isn’t covered under my medical liability insurance since I’m no longer practicing traditional primary care. It’s the reason why I resigned my privileges during my most recent reappointment process to the previously mentioned community hospital, because I couldn’t meet the ongoing requirements.

Hearing the tertiary referral hospital cite the medical staff requirement was especially funny since I know for a fact that they have hundreds of students, researchers, and quality review staff who have access to their clinical data repository, as do payer claims auditors and others. I’m familiar with the fact that they have robust methods for auditing chart access since I helped lead the consensus-building around those methods in my former life. I may also know where the proverbial bones are buried since at least one of their executives worked to stymie our efforts to build a health information exchange.

Yet regulators are going after EHR vendors rather than going after hospitals that refuse to share information with relevant physicians and even with patients themselves. The same hospitals that have accepted countless millions of EHR incentive program money in recent years and who hope to continue drawing down federal dollars continue to be part of the problem despite some feasible solutions.

I’m not letting this go, but plan to continue working may way up the chain at both hospitals. I’m also going to ask at a couple of other area hospitals that receive our patients to see if they will bite and therefore create a precedent. I have a feeling I’m more likely to be blocked then allowed access to the clinical information superhighway.

How does your hospital handle records access and follow up for referring physicians? Email me.

Email Dr. Jayne.