EPtalk by Dr. Jayne 6/15/17

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

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

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

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

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

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

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

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

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Curbside Consult by Dr. Jayne 6/12/17

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 6/8/17

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 6/5/17

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/1/17

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/25/17

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/22/17

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/18/17

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/15/17

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Have a good go-live story? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/11/17

The CMS Quality Payment Program website has been updated with an “Am I included in MIPS?” feature. Providers and organizations can search by NPI (sorry, no bulk search feature for groups yet) to determine if they are included. The site also doesn’t flag whether you’re participating in an ACO, but rather tells you to talk to the leaders managing your participation.

Forbes posts an article about the Internet making us lose trust in our doctors. I think many of us agree (at least anecdotally) that things have changed over the last decade, and exponentially so after the rise of the smart phone. The piece details a study looking at whether screenshot content can prime a pediatric patient’s parents to be biased towards a particular diagnosis. When the physician diagnosis didn’t match the Internet diagnosis, parents were less likely to trust the physician diagnosis and were more likely to say they would seek a second opinion. The researchers’ conclusions note that “conflicting online information could in some cases delay necessary medical treatment. Physicians must be aware of the influence the internet may have on parents and ensure adequate parental education to address any possible concerns.”

Physicians in the patient care trenches have known this for a while, that it can take a significant amount of counseling and discussion to counteract what “Dr. Google” or a number of other websites may have said. When it’s the occasional patient arguing with you about your clinical expertise, it can be managed, but when it feels like every patient is coming in the door with a preconceived notion about what is going on, it is a direct contributor to physician burnout. I don’t believe physicians are omniscient or that our opinions should be absolute, but sometimes you just wish your patients would trust your decades of experience and the many dollars and hours you’ve expended to arrive at your level of clinical judgment. Even a seemingly straightforward diagnosis like “contact dermatitis due to plants” can suck time out of your day when you have to engage around smart phone photos of poison oak, ivy, and sumac. Bottom line is, it doesn’t matter what plant got you, we’re going to treat you the same way regardless of botanical factors and you need to avoid coming into contact again with whatever it was.

Sometimes it’s hard for people to understand what it’s like to be a physician and the pressures we’re under outside of dealing with payers, metrics, regulations, etc. I’m talking about the actual clinical pressure to be 100 percent accurate. If you’re a good physician, it weighs on you and it’s hard to keep in balance. I recently had a situation where a patient perceived a poor outcome based on my diagnosis. She had come to the urgent care on a Saturday with back pain, which had some distinct muscular features and no acute findings on an x-ray, and was diagnosed accordingly. Our practice always has a second reader for films, and my colleague agreed with my reading. The patient was instructed to follow up with an orthopedic specialist on Monday (two days from the visit) if she was not improving. She followed up, and the orthopedist sent her for advanced imaging and diagnosed a vertebral compression fracture, then performed an expensive procedure. She came back to us demanding compensation for our missed diagnosis.

Our standard practice in this case is to convene a peer review and to also have the films re-read by a radiologist, who also failed to appreciate the compression fracture. Peer review found my treatment to be appropriate given the history and exam and the setting (urgent care). The patient was given appropriate follow-up instructions and her pain was managed adequately. Of course, we don’t have access to the advanced imaging results showing the fracture, so it’s hard to tell whether the specialist is taking advantage of a marginal finding or whether something was really there. The patient’s treatment wasn’t even delayed by my supposed misdiagnosis since she would not have been able to have advanced imaging until Monday anyway due to her insurance and its requirements. Getting a pre-certification for a non-emergent ambulatory procedure on a Saturday just doesn’t happen in our world. Assuming you agree there was a fracture, she received definitive care in a timely fashion that was more impacted by the fact that she came to care on a weekend than it was by a potential misdiagnosis.

One also has to consider the role of the urgent care, which is to rule-out any life-threatening conditions and to provide treatment for illnesses and injuries that require immediate care. Sometimes we’re also just there for convenience, for patients who don’t want to wait to see their primary care physician or whose schedules don’t mesh with their primary physician’s office hours for refills on maintenance medications. There are numerous situations in which we do not provide definitive care. Most fractures are merely stabilized and then the patient is referred for orthopedic management. For most urgent care centers, anything requiring imaging that is more than a plan film x-ray has to be referred back to a primary physician to coordinate authorization, scheduling, and follow up. We’re not in the position to order complex studies and follow up on them, and most of the time we do strive to get you back to your primary care physician for follow up.

Even when a physician feels he or she has done the right thing, and their care has been validated by a peer review and supplemental evaluation of diagnostics, it still weighs on us. There is the nagging sensation that we should have done something different, and that the patient thinks we’re bad doctors. It’s hard for people outside our world to understand what that does to a person, and culturally it’s difficult for us to find people to talk with about our experiences. It’s also legally difficult, sometimes, when you think the patient is going to sue. We end up stuck with only the risk management team to talk with and they’re not exactly caring nurturers who want to help you work through the psychological ramifications of a poor outcome and subsequent lawsuit.

Keep this in mind next time you encounter a physician who seems aggravated and preoccupied. Or any health care providers, for that matter. We’re all walking around with some baggage, and sometimes a malfunctioning EHR or one more regulatory hurdle is all it takes to break us.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/8/17

Readers who have followed Curbside Consult for a while might remember that I teach at an outdoor classroom program a couple of times a year. It’s a lot of fun, because you get people out of their normal environments and challenge them in different ways. It’s also great working with people from different industries and segments of the working world rather than the usual healthcare and IT people I encounter on a daily basis. One of my fellow instructors is a preschool teacher and we often commiserate around the fact that there are quite a few “everything I needed to know, I learned in kindergarten” nuggets that we inevitably have to address during the weekend.

This session, we had around 40 students organized into six teams. Each team is challenged to come up with a name and motto, then elect leadership and assign roles and responsibilities. They are then tasked to not only make it through the weekend (some of them have never been camping), but also to attend a rigorous educational program. Team-building, project planning, cooperative learning, feedback, and continuous improvement are woven into the curriculum along with camp cooking, knots and lashings, and more.

We had some extra challenges this weekend, with torrential rains in the week leading up to the course and a boil order being in effect for our facility throughout the weekend. We also had a couple of instructors unable to make it for the weekend due to flooding near their homes, which led to some scrambling to cover presentations. Fortunately, most of us have been doing this for a while and can teach the content without too much trouble. We’re lucky that we’re not teaching for mastery, but trying to give the participants an overview of various outdoorsy topics. It’s not like we’re going to drop them in uncharted lands when they’re done and expect them to survive.

This particular session, we had an exceptional group of students. Usually there is at least one team that has some level of dysfunction ranging from mild to severe. This time, however, the teams had their acts together. Any forgotten equipment was remediated by sharing with other teams, everyone had plenty of drinkable water, and the percentage of people wearing knee high rain boots was high. (Nothing spoils a weekend outdoors like wet feet, so that was a particularly good sign.) We talk about the stages of team development and it seemed like most of them went straight through forming and storming and on to norming and performing.

What we did have this weekend, however, was some breakdowns on the instructor team. I took a new role with the program this year, and in the middle of the first day, was informed by another staffer that I wasn’t fulfilling my duties despite the fact that no one had told me those duties belonged to me. The person telling me this wasn’t even in my chain of command, so that was another problem. She had done something similar during the prep work for the course, which I quickly took care of with my supervisor, but this time things were a little trickier.

I approached the colleague who previously held my position and he said he had the same issue and confusion when he held the role. Yet, nothing was resolved, and it was just handed off to the next person as a ticking time bomb. I also mentioned some frustration with the documentation for the role and how I had to redo a lot of it to align with our updated curriculum. He mentioned that he had done all the updates before handing the documentation back to leadership, so there was no reason why I should have had to do the updates again. Apparently our course director sent me the same documentation that he had sent to my predecessor without incorporating or acknowledging the updates.

Needless to say, that was pretty frustrating. When you’re used to being part of a high-performing team and it starts breaking down, one of the first things people tend to do is to doubt themselves. I went through that a bit and had to keep running my mental checklist making sure I had done everything I was asked to do to as well as I could. I also kept thinking of whether there was anything I should have done differently. Should I have asked more questions? I couldn’t come up with much I would have changed since I was essentially emulating what the previous person in the role had done to the best of my knowledge and ability.

Another thing that tends to happen when you’re being impacted by a leadership breakdown is that you want to withdraw. People don’t want to confront others. I know I didn’t want to go to the person accusing me of non-performance and have a focused conversation about why she felt I wasn’t getting it done and what we were going to do about the situation. That’s how I ended up talking to my predecessor rather than addressing the issue directly.

Although seeking expert guidance is a valid strategy, one has to be sure we’re not doing it as an avoidance mechanism. Having those difficult conversations is also hard when you’re in a high pressure situation, or when schedules don’t align. It was rare that both of us had more than two minutes of free time at the same time, and trying to slip in that kind of conversation wouldn’t have been the right thing to do.

There were some other leadership breakdowns this weekend, with the course director not following through on a couple of agreed-upon actions. It’s never fun when your boss slacks off, particularly when you’re left holding the bag. Coupled with a schedule that ran late, very little sleep, and being cold overnight (planning fail!) I wasn’t in a good place on Saturday morning. Fortunately, some attention from a camp cook staff that worked around my food allergy was enough to start boosting my mood. It’s amazing how the little things can make a difference when people are struggling, and a nice reminder that what might seem like no big deal to you might make a difference for someone else out there.

Once the program moved into full swing and we started interacting with the students, I was in a much better mood. Their enthusiasm was contagious and their willingness to tackle the challenges they were given was impressive. Several of the teams went above and beyond in ways I hadn’t seen before, with a couple writing songs or poems for the staff. Not everyone loves a kiss-up, but this weekend we certainly did. It was also good to see that regardless of what was going on behind the scenes, it didn’t trickle down to our students and they were able to get the most out of the weekend. They say you’ve never really mastered material until you can teach it, and that’s often true. It’s also true that even those of us that teach are constantly learning and there will always be something our students teach us.

By Saturday afternoon, I was back on my game with a plan to make up for my packing failure and stay warm overnight. I threw myself into cast iron cooking and slinging the best “pigs in a blanket” out of my homemade box oven the staff had seen in recent memory. I clapped when people were able to start “one-match” fires, giggled at campfire skits, and watched our students grow in their knowledge and appreciation of the outdoors as well as their readiness to be leaders back at their home organizations.

I came home Sunday exhausted but gratified, which will help get me through the difficult conversations I still have to have with some of the staff. There have already been some post-session emails that have been less than productive, so the discussions need to happen sooner than later. We’ve got another course in the fall and things need to be hashed out so we can move on. Good principles to live by regardless of whether you’re at work or in these situations elsewhere.

Have a favorite cast iron recipe? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/4/17

A recent ONC blog post mentioned efforts to “demystify patient matching algorithms.” Patient matching continues to be challenging to many interoperability projects. The blog post makes the point that although matching is critical, there isn’t much transparency around how well current algorithms perform. There’s been a lot of debate about a universal patient identifier, and despite the restrictions around any federal initiatives to move towards such an identifier, many of us would like to see one move forward. Even if it’s voluntary, I’d rather take my chances with ID theft than risk misidentification. I’ve had recent issues with someone else’s data in my chart, so maybe that adds to my bias.

To aid in finding a solution for matching issues, ONC launched the Patient Matching Algorithm Challenge, which aims to develop new algorithms, benchmark the current state, and help organizations find common metrics. There will be six prize winners with a total payout of $75,000. There are several webinars upcoming and registration for the challenge opens next week, for those that are interested.

My pet peeve of the week is meetings that start late. I’ve been on multiple conference calls where I’ve heard phrases like, “Let’s just wait a few more minutes, there might have been some people with meetings before this who have not yet arrived.” It’s extremely disrespectful to those of us who adjusted our schedules to be on time, who get to sit there and wait. During several of the offending meetings, the latecomers never materialized, so it truly was a waste of time.

I’ve said it multiple times, but organizations that want to be high-performing need to look at how they schedule meetings and make adjustments if people are constantly late or double booked. Condemning people to daily runs of back-to-back meetings is not only inhumane, but non-productive. The best organizations I’ve worked in have policies in place to limit meetings to 25 or 55 minutes so that participants can transition to another meeting if needed. They also have active agenda management within their meetings to ensure that time is used well and that they don’t run over. I preach this constantly during my consulting engagements and can usually get my clients to make progress. Lately I’m involved in projects, though, where I’m just a small piece of the puzzle, so I’ve been feeling the pain of poorly managed meeting schedules.

US prescription drug spending continues to rise, potentially crossing the $600 billion mark in the next four years, according to a Reuters article. The annual increase of 4-7 percent is less than the 6-9 percent increase in spending growth that was originally forecast, partially due to fewer approvals of new medications and pharmaceutical companies facing pricing pressures. The piece mentions that “several drug makers have pledged to limit annual price hikes to under 10 percent.”

I understand price increases have to keep up with inflation and manufacturing costs, etc. but it seems most manufacturers are going to keep increasing prices as much as the market (and public opinion) will bear. I continue to cringe when I review patient medication lists during patient care shifts. It’s increasingly rare to see patients on fewer than 10 medications unless they are pediatric patients. I see people on the “latest and greatest” branded medications when generics are available that have virtually identical side effect and risk profiles.

It takes a lot of work and effort to have conversations with patients around whether switching from medication X to generic Y is a good idea and what the cost savings could be over the course of a lifetime of chronic treatment. Patients with low health literacy aren’t going to understand relative risk reductions and how a medication being 1-2 percent more or less effective is going to make a difference for them. Physicians often don’t have the time to have those conversations, either.

The best resources I’ve seen for these conversations are pharmacists who are embedded in the clinical practice, but we don’t see a lot of those in the workforce. We also need to get past the cultural idea that being on the latest and greatest medication is best. How many drugs have we seen that have serious issues that aren’t found until they are on the market for a year or two? More than I care to remember.

It’s also more of a challenge to have the conversations and interventions around lifestyle modification than it is to just give another medication, especially when physicians are being graded on their outcomes. I’d like to see insurers or pharmacy benefits managers providing these kinds of direct-to-patient interventions. They could keep a share of the savings from the lower-cost interventions to motivate them. Of course, it would cut into the overall profit margin, but it would be better from a societal standpoint because polypharmacy is a real issue. It’s easier though to push the work to the physicians and other front-line providers, who I guarantee aren’t getting payment increases that are hovering under 10 percent.

Lots of people were impacted this week by a Google Docs phishing scam. When I saw identical emails come through from almost a dozen unrelated people in the course of a few minutes, I knew something was up. It quickly made its way through several local school systems that use the Google Classroom applications, and from there to their parents and out into the community. It’s a good lesson for the younger set, that there are bad actors out there and they have to be suspicious.

The things that kids have to worry about in this day and age are sad, however. My local school district just announced a program starting in the fall where every middle school student will be issued a personal Chromebook for use at school and at home. Although it might keep family computers from being impacted by scams accepted by unsuspecting children, it increases the burden for tech support for the schools.

The rapid growth of technology is also a bit of an experiment on our society as a whole. Social media creates stress for adults and youth alike, and the social media-related suicides and bullying are truly tragic. I was fortunate to grow up in a location and as part of a generation that could run around the neighborhood until the street lights came on, and most of our worries were around flat tires on our bikes. Even in middle school, the pace of bullying was limited by the passing of folded pieces of notepaper and whispering in the hallways between classes, where now hundreds of people can be involved in negative interactions at the touch of a button. Add in the recent boom in murders, suicides, and assaults broadcast live for the world to watch and it makes you wonder where we’re headed. Maybe patient matching challenges aren’t such a big deal after all.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/1/17

I’m doing some work with a health system that is migrating multiple hospital and ambulatory systems to a single instance of Epic. They have contracted with a number of third-party vendors to keep the proverbial lights on with their legacy applications while the core teams are incorporated into the Epic team.

At times, it’s been heartbreaking to watch. The Epic project team forced longstanding qualified employees to go through rounds of personality testing and interviewing, only to be denied an opportunity to join the Epic project. I’m personally happy to have these so-called “rejected employees” as part of the team that’s keeping things running because they have extensive experience and knowledge as well as being good people. It’s a shame that the health system has some mold they’re trying to fill for the Epic team because they’ve missed out on some talent.

I’m handling some clinical and regulatory work for the ambulatory applications, but another third party is handling any development work that is needed. There’s more development than I would have expected this close to a migration. The health system continues to purchase independent practices and wants to bring them live on EHR for reporting reasons. They are developing specialty-specific documentation templates that I’m pretty sure are never going to get used because they are for high-dollar subspecialists who prefer to dictate their documentation and aren’t going to sit and do a bunch of clicking just because an administrator asks them to. I’m confident their acquisition contracts didn’t include data entry, so the template development is a bit of a wasted enterprise to begin with.

The third-party development partner uses offshore resources and availability for meetings is an issue. I’m watching the stateside analysts pull their hair out because they’re being asked to get on calls at 10 p.m. local time to accommodate the offshore analysts, who have contractual limitations regarding calls during non-working hours. The US managers are aggravated because the most expensive resources are being stressed out by the hours. The analysts fear for their jobs if they don’t comply since they’ve already been passed over for slots on the Epic team and are likely to be candidates for a layoff after the go-live.

Apparently no one thought about these factors when they signed the agreement with the development partner, but I bet they will think about it next time. It’s just particularly sad because, again, they’re spending a lot of resources on templates that aren’t going to be used (and even if they are used, it will only be for a few months). They’re also burning out dedicated workers who have served the healthcare system for years and have a lot to offer.

I’ve made the suggestion that they should halt the development project, create a stripped down data entry template, and then hire a couple of medical students or nursing students to do the data entry from the providers’ dictated notes each day. It would be more cost effective and create better goodwill for everyone involved, but of course no one is listening to the person who is best positioned to understand provider psychology, habits, and workflows.

I have to say that one of the more frustrating aspects of being a consultant is being expendable. If I was the CMIO or a medical director, my opinions might have more impact. But when you have two consultants contradicting each other, there’s some cognitive effort required to untangle the issues, which it seems some health systems aren’t eager to do.

I find this situation particularly ironic. Where I’m trying to save them money, aggravation, and employee morale, the other consultant is trying to sell them something that’s going to cost money, time, and frustration. It should be an easy decision, but healthcare decision-making is often less than straightforward. It seems to be an easier decision to do what has already been started rather than raise questions.

This situation also illustrates something I’m seeing more often, which is organizations that have so many consultants in the mix that they need resources just to manage the consultants and their activities. Different parts of the organization may have their own consultants doing the same work, or it may be contradictory. I’ve watched the office equivalent of a steel cage match when consultants hired by the finance team face off against those hired by the clinical team. One of the combatants will inevitably tag out to the IT team, which may be allying itself with one or both of the other teams depending on which way the organizational winds are blowing.

There is a lot of time, money, and energy wasted in these non-coordinated approaches, but I’ve seen multiple situations where no one is willing to step in and stop the madness. I try to do my best (within the confines of my engagement and the personal relationships I’ve built at the organization, of course) to calm things down where I think I can make a difference, but it’s definitely challenging.

When I see these situations, it generally points to a larger problem with organizational leadership and a lack of executive sponsorship at the appropriate level. When organizations are having functional leadership meetings and various teams have a common understanding of organizational goals and budgetary and time constraints, the situations are much more productive. Teams with potentially competing initiatives can actually talk to each other and work together for a solution that creates common ground rather than succumbing to an “us vs. them” mentality.

With my current client, I’m hoping that while doing engagements to support their legacy software, I’ll be able to build relationships and the political capital needed to approach them with an engagement around the change leadership and management challenges that are the root of many of their struggles.

Unfortunately, it feels like they see the move to Epic as the be-all, end-all that is going to solve their problems. It may solve some problems, but it’s going to create new ones that they’re not expecting, or exacerbate underlying issues that they may have overlooked. History tends to repeat itself in these situations and I would love to see greater information sharing among those in the trenches so that they can avoid the pitfalls that I see over and over. There’s only so much I can do from the consulting perspective, but I’m going to keep trying.

How many consultants are involved at your organization? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/27/17

I attended the Physician Compare Benchmark and 5-Star Rating webinar this week. The team shared information about their new ABC Benchmark methodology and asked for physician feedback on the proposed approach.

Frankly, after attending the webinar, I’m disheartened. What they are proposing is complex and there is debate about whether a cluster method or equal-ranges method should be used to assign the ratings. There is also debate on what to do when providers are so high performing they can’t determine how to allocate fewer than five stars. For those measures, they’re discussing only displaying those providers who had five stars vs. not displaying those measures at all. It seems counterintuitive to not report something that people are good at. Not to mention, if it’s this complicated, it’s going to be less meaningful for patients.

At the beginning of the webinar, the speaker specifically stated that sometimes when they use a five-point scale, that people see it like school grades: A, B, C, D, F. But that’s not what they’re trying to do here, etc. I challenge the people involved in this to understand that most of the public is still going to see this like school grades. Regardless of footnotes or explanations on the website, people see three stars and think you’re a C performer.

These ratings become even more complex for measures where everyone is doing well. So how about this proposal: set benchmarks related to a grade scale and let patients truly compare not only from physician to physician, but across measures. Say we want 100 percent of diabetic patients to have a foot exam. Ninety percent is five stars, 80 percent is four, 70 percent is three, etc. Or heck, just use letter grades to make it easier. Maybe your physician gets As and Bs on everything relevant to your needs and you’re good to go. Maybe they get Bs and Cs and you need to look for someone else. Maybe all physicians get a C on some measures, which helps you understand that it’s difficult to achieve. It certainly would save the millions of dollars they’re spending to put this together and would create a system that fits into an already accepted cultural schema rather than creating something new that takes a statistician to explain.

The slides are available here if you want to check them out yourself, and if you want to share feedback, it can be sent to PhysicianCompare@westat.com with a subject line of “5-Star Rating Feedback” prior to May 10.

NCQA announced a new Oncology Medical Home recognition program, following the Patient-Centered Medical Home and Patient-Centered Specialty Practice models already available. They’ll host a webinar on May 5 to discuss the new program and how to achieve recognition. I’ve assisted several organizations through the NCQA recognition process and it’s not for the faint of heart (or the light of pocketbook).

Regenstrief Institute, along with the American Medical Association, has launched a mock EHR tool for use by medical students. It contains simulated patient data and allows students to practice documentation along with processing information in a typical EHR format. These kinds of tools are increasingly needed as hospitals institute fragmented policies around whether students are allowed to document in the EHR, and if they are, what kind of user rights and training they receive. My hospital allowed students to use the EHR, but didn’t give them full rights for ordering, writing scripts, or many of the other functions they had in the paper world.

The Regenstrief EHR Clinical Learning Platform tool was co-developed with Indiana University School of Medicine and is also in use at the University of Connecticut School of Medicine and the University of Southern Indiana College of Nursing and Health Professions. AMA will assist in its distribution.

Given the expansion of patient-generated health data through home monitors, fitness trackers, and more, ONC has created a challenge to find solutions to the problem of capturing data provenance. I know many physicians who are reluctant to allow patient-generated data into the EHR due to concerns about reliability as well as quantity. Anyone who has been faced with home blood pressure logs documenting five or six readings a day for three months knows what a burden this data can be. ONC recognizes that reliability and trustworthiness of data are issues.

The $180,000 challenge is in two phases, the first involving submission of white papers describing current methods with the second phase requiring winners to develop and test their solutions. Information about the challenge can be found here and phase 1 submissions are due May 22.

I’m enjoying reading Mr. H’s coverage of Missouri’s ongoing failed attempts to create a Prescription Drug Monitoring Program. Hopefully they’ll eventually arrive at a workable solution. Opioid addiction continues to be a national issue and CDC recently launched an online training series around opioid prescribing. The first of eight modules is now available. Future modules include patient communication, non-opioid pain management options, dosing/titration, and risk reduction. I’m still slogging through a bunch of online CME, so let me know if you’ve test driven the module and what you thought.

I subscribe to dozens of communications from various governmental organizations in an attempt to keep up with all the warnings, alerts, proposed rules, and dictates that impact physician practices. Every once in a while I see an email subject line that truly catches my attention, as did this one about “Mixing Kentucky Spirits with Food Safety.” We think about the FDA as regulating medications and foods, but it also has jurisdiction over veterinary issues. Grain byproducts of brewing and distilling are often used as livestock feed. The 20-member FDA team found their visits to various production facilities (including Woodford Reserve, Wild Turkey, and Jim Beam) to be “extremely productive” with there being “no substitute for actually seeing how these beverages are produced.” I can say that I felt the same after a recent pilgrimage to the distillery responsible for my favorite adult beverage. However, I wonder if the FDA tour ended with a complimentary drink and a souvenir glass, as mine did? I also wonder if the FDA sends as large of a contingent to less-exciting venues such as sunscreen manufacturers.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/24/17

I’ve been working with several challenging clients over the last several weeks. All of them have been playing various versions of the blame game: clinical blames IT, IT blames operations, operations blames clinical, some blame the consultant, most blame the government and payers, and everyone blames the vendor.

I think I’ve finally put my finger on the underlying problem: learned helplessness. Essentially, learned helplessness happens when a subject undergoes repeated painful stimuli and loses the ability to employ escape or avoidance behaviors. The subject feels they have lost control and ultimately stops trying.

In the case of healthcare IT, the repeated painful stimuli have taken the form of multiple rounds of governmental regulations, reduced physician payments, increasing numbers of risk-bearing arrangements, and shrinking organizational pocketbooks in response to greater uncertainty. The complexity of the environment in which healthcare organizations are asked to work makes it difficult to manage all the details unless one has full-time teams dedicated to doing so. Most smaller organizations simply can’t afford that kind of infrastructure, so they try to cobble together resources from local and state medical societies, professional organizations, and their IT vendors to try to make sense of all of it.

Many of these organizations are struggling to make sense of it themselves, depending on their size and level of funding. Based on my clients’ experiences, the amount of information put forth by EHR vendors ranges from comprehensive to zero. One vendor was even worse than zero, putting out information that was incorrect and therefore placed their clients at risk. Clients who use web-based platforms where the vendor upgrades them automatically have one set of issues, where they have to keep up with the vendor’s plans and be ready to roll out workflows over which they have little control. At the other end of the spectrum are clients who can choose when to upgrade and which features to enable, which can lead to analysis paralysis.

Provider organizations are understandably worried about the certification status of their vendors. A recent surfing of the Certified Health IT Product List shows a shrinking number of vendors who have completed the most current certification. Those organizations that need 2015 Edition software installed before January 1, 2018 are understandably nervous, especially those that are large or complex. These are the kinds of organizations that are finding their way into my client pool, trying to completely avoid the pain of an upgrade by outsourcing the entire thing.

I’m not sure what other consulting organizations do, but the first thing I explain to these potential clients is that it’s very difficult to entirely outsource an upgrade (or a go live, or many other IT processes). There will always be parts of the project plan that require ownership and involvement by the client for best results. These steps may include decision-making around new features; training schedules; whether or not demonstration of mastery will be required; and user acceptance testing.

Regarding the latter, I’ve found that no matter how good your test scripts might be, there are always undocumented (and often aberrant) workflows that no one will know to test that will cause you heartburn on go-live day. The best way to avoid issues is to have actual end users perform user acceptance testing, rather than analysts or contractors.

Clients also need to have active involvement if there are decisions to be made around customizations. Whether to retire or retain customizations depends on whether the vendor’s workflows are equivalent to the customization or will create issues. Although a third party can make an objective analysis of the pros and cons, we sometimes don’t have the understanding of organizational culture that is needed to make the ultimate decision. I’m not saying we can’t do the majority of the heavy lifting for our clients, but we’re not going to allow them to completely abdicate all responsibility.

Another critical piece of upgrades that often involves organizational culture is the training plan. Clients need to take ownership of whether providers and end users will be pulled out of clinic for training, whether they will be compensated for training, whether it will be mandatory, etc. Although we as consultants can execute on whatever is decided, we can’t force an organization to mandate training for providers and ensure they actually show up. Sure, we can beg, plead, cajole, and even put monetary incentives around getting a client to perform one way or another, but ultimately the client has to participate in the process.

I went through the discovery process with a potential client last week, who has some major barriers between them and an upgrade. They’ve had near total staff turnover during the last two years and are three versions behind on their vendor’s software. They can’t find any previous project plans, testing plans, test scripts, or training plans from previous upgrades. They want to hire someone to “just take care of it,” but are reluctant to pay for the time it would take to document their existing workflows, create a testing strategy, determine a training plan, etc.

They keep mentioning that they are a community health center with limited budget, but don’t seem to appreciate that third-party vendors can’t give away their services for free. It makes for a very challenging business relationship, and with this particular prospective client, I’m not sure we’re ever going to have a relationship.

I’ve also run into some passive-aggressive clients who expect EHR vendors to spoon feed them information on various governmental programs while taking no accountability themselves. Although vendors can be good sources of information, clients still have to create their own policies and procedures and operationalize them to ensure compliance with regulatory programs. Your vendor isn’t going to stand behind your staff and make them perform medication reconciliation. Ultimately, provider organizations have to ensure that their staff members do their jobs and meet expectations.

My team provides first-line support for a handful of small practices. Sometimes there are basic workflow questions, such as, “How do I document XYZ?” Other times they’re outside of scope of EHR support.

One of those came in this week from a provider. He wanted to know how to document in the EHR that he disagreed with the nurse practitioner’s assessment and plan, and how to reject it and send it back to her. My team escalated it to me since it had medico-legal ramifications, so I got on the phone with the provider. I asked how he would have documented it in the paper chart and his answer confirmed what I suspected: he wouldn’t have documented it in the paper chart — he would have had a conversation with the NP, asked her to adjust the treatment plan, and then documented his review after the patient had been notified, etc.

I asked him why he would now want to have that liability-rich conversation in the electronic record rather than verbally. It took a few beats but he finally got my point, that there are certain things that just need to be done outside the EHR. But in some ways, he had become unable to think it through on his own, instead relying on the EHR’s workflows to direct him what to do.

I’m not sure what the answer is in these situations, but it’s good for those of us in the trenches to be able to commiserate.

What examples of learned helplessness are you seeing? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/20/17

The Leapfrog Group released the most recent iteration of its Hospital Safety Scores, grading over 2,600 hospitals from A to F. Transparency is a good thing, but I was surprised to see how some of my local hospitals (including a world renowned tertiary care center) fared. In going through the detail, it looks like there were several areas where they declined to report, but another is confusing. They scored low on “specially trained doctors care for ICU patients,” which is funny because they have one of the leading critical care fellowship programs and all patients are cared for by intensivists. The average patient isn’t going to be knowledgeable enough to dissect the rankings. Several smaller hospitals in town received A rankings but I still wouldn’t go there for a cardiac procedure or other specialized surgeries.

CMS announces upcoming webinars regarding the Achievable Benchmark of Care (ABC) and five-star rating programs. The data will appear on the Physician Compare website, so clinicians should become familiar with what their patients are seeing. I have need of a new specialist, looked up the physician I am considering, and didn’t find any information that helped support (or contradict) my choice. The webinars will be hosted:

• Tuesday, April 25 at 11:00 am ET/ 8:00 am PT
• Thursday, April 27 at 3:00 pm ET/12:00 pm PT

I’ve been receiving encrypted summary-of-care records from one of my local hospitals, for patients who used to be mine when I was in traditional family medicine practice. The most recent one was over 145 pages long and contained every single laboratory test performed on the patient, including bedside blood glucose testing performed four times daily. Somehow I’m still listed as the primary care physician of record for this patient, which is surprising because he lives in a group home and has to have orders reauthorized every six months, so he must be seeing someone in the community who should have received this document instead of me. A call to the hospital wasn’t helpful, and I’m planning to call the group home to try to straighten it out myself. I assume that if this data was directly imported to my EHR it would make sense, but as a 145-page PDF it’s pretty overwhelming. The best part of it was the discharge diagnosis: “Recent Acute Hospitalization.”

I recently had lunch with some of my physician colleagues and the recent approval of direct-to-consumer genetic testing was a hot topic. Since I just went through genetic counseling and testing, I decided to investigate the 23andMe process. It’s easy to order the testing package – no more challenging than ordering something on Amazon. However, I got to the “enter your payment information” screen without any mention of some of the critical things that patients should consider before they have genetic testing: Do they have adequate disability and life insurance in place, should something be found? Is there a concern regarding long-term-care insurance? Are there concerns about a specific disease process or does the patient want a “shotgun” approach? I’m not sure the average person is going to think about these things and I would have liked to have seen them at least mentioned before consumers plunk down $199 for a testing kit. I opted to proceed conservatively with my recent testing and only test for a single mutation, which ended up being present. I was able to use the results to justify why I need early screening. I wonder if insurance carriers will accept data from 23and Me to justify early intervention. The panel that they offer to consumers looks a little scattered. I’d be interested to hear from anyone who has had testing with them.

I’ve been working through some continuing education and maintenance of certification (MOC) activities over the last week and have come to the conclusion that sitting for my family medicine board exam next year is going to be more of a challenge than I thought. The MOC activities are making me crazy with their “which is the most appropriate intervention” questions when all of the choices present are appropriate interventions. The definition of appropriate can be nebulous. Which is the most appropriate from a cost/utilization perspective? From a patient satisfaction perspective? From a patient acceptance and compliance perspective? Does the patient have insurance? Are they working three jobs? Determining the appropriate intervention for a given patient takes many more factors into account than statistical minutiae. Is the difference between 28 percent and 33 percent statistically significant enough to merit spending time on analyzing what the right answer is supposed to be?

It’s also particularly challenging for those of us that no longer practice what our board certifying organization considers to be full spectrum family medicine. Although I delivered over 150 babies, the last one was more than 15 years ago, but I’ll still have to field OB questions. Even if I wanted to give up my clinical certification and keep my informatics certification, I can’t do that since informatics requires primary certification from another board. Losing board certification is the kiss of death for insurance credentialing, so if I want to play the game and keep seeing patients, or keep being a board certified clinical informaticist, I’ll need to comply.

Wisconsin has designated this week as Healthcare Decisions Week and encourages people to complete an advance directive to document their wishes for end-of-life decision making. It’s unfortunately not enough just to have the document, but people need to talk to their loved ones about their wishes and why they have made particular decisions. We had one of these conversations at a recent family gathering and it was instructive, with revelations about what people did or did not want as far as medical treatment and funeral arrangements. As a physician, I’ve seen many arguments about care, and having both the conversation and the documentation is the best way to make sure your wishes are honored. It’s also not just for older people – there are plenty of things that go wrong with routine happenings like childbirth or small elective surgeries, so everyone should be prepared.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/17/17

Several of my friends in medicine, engineering, and other high-tech fields participate in decidedly “traditional” craft projects in their leisure time. I’ve got a handful of friends who make soap, and many others who knit, crochet, quilt, sew, cross stitch, needlepoint or do woodworking, stained glass, or paper crafts. I see a fair amount of people at professional conferences who are knitting or crocheting during sessions. I have a lot of respect for them, because those are two skills I can’t master. My grandmother tells me I used to be a proficient knitter as a child, and even made a set of golf club covers, but based on recent attempts to master knitting I can’t imagine how the club covers came to be, despite the fact that one or two of them are still in my garage.

Except for the yarn-related projects, several of my friends use technology to augment their abilities. When you spend a good chunk of your life pursuing a professional career, there’s not a lot of time to build leisure/hobby skills. Many of us spent our teens trying to get into competitive colleges, then our college years trying to get into graduate programs, etc. If we’re physicians, we may have a three to seven year “black hole” called residency in our lives from which no free time escaped. Now that we have leisure time, we want to be able to make cool-looking projects without waiting years to hone our crafts.

Over the past year, I’ve gotten deeper into a hobby that requires a bit of computer assistance, and it’s been a great stress reliever as well as a lot of fun. I’ve met some great people, several of whom are former healthcare types who have gone into the hobby as a business in part to get away from the stress of healthcare. There are also some former teachers, who are happy to take relative youngsters under their wings and point us in the right direction. Being in a competitive “day job” world where collaboration isn’t always valued, it’s been great to have people I can call or text when I get stuck or need a few tips. Thank goodness for the night owls, who are up crafting past midnight just like I am.

Over the past month or two, though, I’ve seen several parallels to healthcare IT. The equipment I purchased to do my hobby work is from a manufacturer that dominates the market. They value their customers and understand that the work that they do is a big part of what has built their reputation as a vendor. They’re a company that started from small-town roots and grew by word of mouth and then regionally, and now have customers all over the world. They also know they have people hooked, and that the cost to change to another vendor would be significant, not only from the equipment standpoint but due to downtime, lost knowledge, etc.

Every couple of years, they issue a major software release. I came into the market in 2016 on what was then the latest and greatest software, which honestly I have very few complaints about. More than 90 percent of the time when I’ve run into trouble, it’s been due to user error or some other problem between the keyboard and the chair. Still, I am looking forward to the new software and the potential that it might bring, especially as a relative newbie to the hobby. In releasing the new package, the vendor took a couple of departures from its previous practices but that from my IT viewpoint are pretty common place. They released a list of hardware specifications required for the new software. They also distributed a beta version to the client base, along with a list of features and enhancements, and a list of known issues. They gave clear direction that formal training would not occur until general release, and set up a process for reporting defects.

As in informaticist, I followed this process closely, particularly with regard to how the end users would adapt to this. Most of the end users are in their 50s or 60s, and many began the hobby in a non-automated fashion, transitioning to automated methods when they became available. In so many ways it parallels what we see in healthcare IT. I wanted to understand how they would react to change and what similarities or differences there would be from clinical end users. I belong to a couple of independent online support groups, as well the vendor-sponsored blogosphere, so I could see the dialogue in multiple venues.

It’s been surprising how similar the user psychology is to what we see when we’re talking about an upgrade or update to an EHR system. The user community is going through the cycle of grief, lamenting the process even though they’re being allowed to stay exactly where they are, if they want, without penalty. The vendor is committed to supporting every user on every version across the globe, which is largely unheard-of in the world of certified healthcare IT. And yet, people are yelling that the sky is falling, despite the fact that they don’t even have to change at all. I’ve worked with users who have been on the same old software since 1998 and they produce beautiful work that I couldn’t even dream of creating with brand new equipment. They’re efficient, productive, and creative yet are balking at the mere idea of an upgrade that they might have to or want to consider.

The biggest issue is the hardware requirements – the vendor is requiring that users move to a vendor-supplied PC to drive their hardware, which probably 80 percent of the customer base is already on. For those who don’t want to upgrade, they can stay right where they are and be supported, or they can buy the latest and greatest. There has been a great deal of angst among people who don’t understand the difference between Windows XP, Vista, 7, 8, and 10, and also some outright resistance to knowledgeable individuals who try to explain the difference and the various benefits of upgrading. At times, when I read the conversation threads, I feel like I’m right back in healthcare IT.

I’m not a huge fan of installing beta software, especially for a hobby at which I’m just becoming proficient. I decided to wait for the general release, until I had the opportunity to attend a class fairly close to home. One of the certified vendor trainers was going to be an hour and a half away, so I decided to go despite wanting to have my first look be a GR version. The class was an all-day affair, and again, I looked at the parallels to healthcare IT. At Big Hospital, providers balked when we asked them to be out of office for a half day to learn about a pending upgrade, even though it was going to change their workflow and they’d benefit from formal training. Many tried not to go and the decision ended up haunting them. Instead, I was surrounded by people who chose to close their businesses for a day to learn the latest and greatest, or to at least see what it had to offer them. Despite the turmoil on some of the online communities, in person people were very reasonable and willing to learn. How different would some of our EHR upgrades be if we had people willing to put in enough time to learn about software changes?

In addition to learning about the upcoming changes, one of the greatest benefits of going to training was meeting new people and creating new networking opportunities so that I can be better at what I’m trying to do. The same benefits could come from EHR training, if we could get people to acknowledge that just because it has to do with the EHR it’s not inherently undesirable. I met some serious super users who were happy to share their knowledge with a new user, and also learned some tips and tricks that I can do immediately without waiting for the upgrade. I was also gratified to learn that I must not be the only person making a mistake I make commonly, because the vendor has tweaked the software to reduce the impact of that particular workflow issue. Like many EHR vendors, they’ve also done a fair amount of usability work (some very formal, according to our instructor). Where people were surprised by the seeming blandness of the user interface, the instructor explained why they did it the way they did, and how other features were added to address users with low vision or other functional limitations.

If I wasn’t experiencing some serious déjà vu then, I really was when she mentioned that it wasn’t just an update of the workflows, that they had completely gotten off their old code base and had rewritten the program on a new platform. Then we launched into a discussion about making sure you are on the right version of the .NET framework, and I knew I had truly fallen down the rabbit hole. I did walk away from the experience with some new ideas about how to train and how to reduce anxiety for end users, which will translate nicely from the craft space to the healthcare IT space. I met several professional educators who experience similar challenges as I do, that I can stay in touch with ongoing. I got some great ideas about different ways to use my equipment, and some workarounds that I had never thought of for sticky situations.

All in all, it was a good opportunity to see that what we deal with in healthcare IT isn’t as unique as we think it is. Sure, there are some nuances, but there is a lot we can learn from other industries, processes, and people. What’s your favorite craft project? Email me.

Email Dr. Jayne.