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.

EPtalk by Dr. Jayne 4/13/17

I unfortunately had to spend some non-quality time this week at the Microsoft Store. The pen for my Surface Pro tablet has been acting up over the last month and all troubleshooting maneuvers have failed. Since I’ve been on the road a lot, I’ve spent more time than I care to admit perusing various support articles, blogs, and commentaries on how to get it back up and running. Although the button was working, the business-end was not, and then the tip started to actually disintegrate. I had to wait until I was in a city that actually has a Microsoft store, and until I had free time during normal store hours to address it.

The staff at the store was eager to greet me, but then when they found out I was (gasp!) an individual consumer and not a corporate or enterprise customer, it started going downhill. The fact that I bought my device at Costco rather than directly from Microsoft was clearly an issue for them, and they made a big deal about not being able to locate the purchase in their system and having to use another system to find me (which they did, in about 20 seconds, so I’m not sure why we needed the drama). They then informed me that I was out of warranty on the pen. Apparently it’s not hard to be out of warranty when the warranty is only 90 days, which is pretty short in my opinion.

The rep did all the troubleshooting I had already done, then replaced the tip, which didn’t make a difference. He then proceeded to tell me he’d have to make me a tech appointment, but didn’t explain what that meant or what the timeframe might be. I was treated like a child when I asked, as if I should know intrinsically what a “Microsoft store tech appointment” expectation might be. As a consultant, I’m sensitive to my hourly rate and how much time and money I’m burning with exercises like this. Knowing the pen was about $50 and that I had been down for weeks and getting to the store when it was open was an ordeal, I asked if I could just buy a new pen and be done with it. He acted like that was the strangest thing he ever heard, then disappeared “to see if there is anything else we can do.”

I appreciate the fact that he was trying to save me money and resolve my issue, but it felt like an odd piece of “service recovery” after the initial stumbles over being an individual consumer and having purchased from a reseller. Ultimately they agreed to warranty the pen and swap it out, which took an additional 15 minutes of paperwork and back and forth. Counting the drive, the trek through the mall, and the troubleshooting, then getting home and back to work, I spent an hour and a half getting a new pen. Adding in the hours of troubleshooting that I did before even going to the store, you can bet that if this one malfunctions in the least I’m going straight to an online order for a new one.

I mentioned a couple of weeks ago that I was working with a clinical informaticist that was learning the ropes of actually managing a team – dealing with expense reports, vacation approvals, and the other managerial functions that we don’t learn much about in medical school. This week we waded into the minefield that is the annual performance evaluation. I’m a firm believer in the concept that the annual performance review should never be a surprise. It’s important for managers to incorporate the concepts they’ve been discussing with the employee for the last year, and to make overall comments on progress (or lack thereof) but nothing should be a revelation. When there is a transition in managers or a change in job role, this is particularly tricky because one needs to incorporate any available feedback from the previous manager or role.

The good thing is that the time frame for the review process is usually clear, and shouldn’t be a last-minute exercise. Of course there are exceptions to that, such as when my previous employer decided to move everyone from “review on your anniversary date” to “review the entire company all at the same time, STAT,” which was a horrendous exercise I never want to repeat. But in this case, my managerial trainee had well over a month to track down information from previous managers, peruse previous reviews, assess completion of employee goals, etc. We had been talking about the process for a couple of weeks, and he seemed like he was with the program, so I was surprised when I met with him in person and he looked like a cornered animal. He said he had no idea what to do with some of the feedback he received from employees.

The company asks employees to write a one-page summary of their growth and accomplishments over the last year, highlighting successes and what they have learned from challenges. It’s the employee’s opportunity to offer specific details that can bolster a high-scoring review or give a new manager more flavor for what the employee has been working on and how they see themselves. However, it has the potential to be a mine field, because “one page free text” can apparently mean different things to different people. He has more than 20 people on his team, and let’s just say the variability of the personal narratives was striking. The most effective employees provided bulleted lists or well-organized statements, often with supporting quotes from other employees or customers. Those were easy to get through. The ones he wasn’t sure on handling were frankly ones that I wasn’t sure on handling either.

I’ve done a lot of performance reviews, going back to my time as Chief Resident. I can definitely say I’ve never encountered an employee or supervisee who decided to use the annual review as an opportunity to roast the company or provide openly hostile comments about management in writing. Until now, that is. The employees were clearly informed that their statements would be part of their records as part of the annual review process and would be seen by second-level approvers, yet still elected go down this path. Needless to say, after seeing their statements, their objective rankings on “insight” and “professionalism” just went down the tubes. Additionally, if there was a score for Tasseography, they’d score low on that as well. When you openly throw your manager under the bus, and fail to appreciate that your manager has a significant amount of executive support, you’re not doing yourself any favors.

These are the things that as a consultant make you say “hmmmm,” and also ensure the ability to propose ongoing engagements and assistance for your clients. We definitely need some coaching/education for these two employees, as well as creation of performance improvement plans. It’s also the opportunity to assist with the hiring process should they not be able to right themselves. In the short term, I’m going to continue supporting my new manager, and help him build the skills to get through this, manage these folks objectively, and not give in to his emotions. It’s also an opportunity to reflect on giving direction for future reviews. The idea that a review should not be a surprise goes both ways when employee comments are involved.

What’s your wildest performance review story? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/10/17

Physician burnout is always a hot topic within informatics circles, especially since clinicians frequently cite the rise of EHRs as a key reason for stress and burnout. In reality, though, it’s difficult to prove causality, especially since increasing requirements for EHR use have generally been timed with governmental regulations, demanding payer programs, and the overall shift from fee-for-service to value-based care. I’m always looking for ideas to help physicians at the breaking point, and a friend recently shared this article about using military training concepts to help physicians build resiliency.

According to the American Psychological Association, resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress – such as family and relationship problems, serious health problems, or workplace and financial stressors.” As physicians, we’re assaulted by these kinds of stressors all the time, and they often cross work/home boundaries as working hours become longer or as physicians bring work home with them, now that they can access charts from anywhere. During residency training, many physicians develop the skills to adapt to the intermittent stress that being a trainee brings – long call nights, resuscitations, emergency surgeries, high-risk procedures, and more. For the most part, residency training doesn’t prepare young physicians for the daily grind of being in an office setting or dealing with the stressors of owning a practice or being an employed physician.

The article discusses statistics for physicians – that depression hits nearly a third of residents, and that physicians have higher suicide rates compared to the rest of the population. It goes on to look at how some Canadian hospitals and medical schools are using training based on US Navy SEAL programs to help build psychological skills. Both populations are under ongoing stress with overlaying episodic stress, sometimes involving life and death situations. I think the latter element is important – the life and death situations. Although many think of those as being in-hospital, emergent-type situations, I see more and more of my primary care colleagues experiencing that “life and death” level of stress even within the boundaries of office-based medicine. When patients can’t afford their medicines and physicians have to cobble together plans to try to ensure compliance, we are in effect fighting for that person’s life.

The diabetic patient who came into my urgent care last night with a blood sugar of 434 wasn’t sick enough to be admitted to the hospital, since his sugars had been high for months and his body had been trying to compensate for it. Yet, he needs intensive therapeutic interventions to get his disease under control. I can send him back to his primary care physician, but then she has to battle to get him to see the diabetic educator, get him a new blood glucose meter to replace his broken one, and try to help him figure out how to get to appointments and take care of his disease when he’s working long shifts as a municipal bus driver. Those situations, which sometimes border on hopeless depending on the patient’s insurance coverage (or lack thereof), job situation, and social supports add to the ongoing level of stress faced by physicians. This is worse now that the primary care physician is going to be penalized for this patient’s lack of blood sugar control.

This problem isn’t unique to our US system. According to the article, studies show that as many as 75 percent of Canadian resident physicians experience burnout. One can anticipate that those burned-out residents are going to carry that baggage into practice. The resiliency training created for the Canadian trainees is delivered as a four-hour course. It encourages trainees to identify how they’re faring on a mental health or stress scale. They grade themselves as green, yellow, orange, or red depending on their current level of stress and dysfunction. Similar to the kind of asthma action plan we provide patients, it also details recommended steps the trainee can take to reduce stress. Another component of the training includes skills to help the body process physical responses to stressors, such as the fight-or-flight response. It seeks to move decision making away from the emotional response and to instead harness the rational thought process.

The article also mentions that “discussions around physician mental health still remain very taboo.” Unfortunately, this is also true in the US. I know of quite a few physicians who have untreated mental health conditions who are afraid to seek help and have it on their records. Our state still asks a question during the license renewal process about treatment for mental health conditions, and people don’t want to risk whatever process might arise from checking “yes” on the affidavit. A friend of mine who is a psychologist specializes in physician care, and doesn’t bill insurance for those patients so that there isn’t a record of treatment.

Although the article doesn’t specifically mention it, we also need to work on skills for physicians to understand that doing their best really is good enough. We can’t really give it more than our best, can we? Although the quality metrics might not support this approach, the idea that we can save everyone or ensure all our patients are compliant is ludicrous. As quality increases, it’s more and more difficult to be “better” when everyone is already earning an A. I’ve lost two colleagues to suicide in my career, and both were brilliant, caring individuals who unfortunately felt their best wasn’t good enough, that they should have been doing more. No one in their lives, including spouse or fiancée, realized how bad things were or that they were at high risk for suicide.

Additionally, this discussion doesn’t just apply to physicians. It applies to all of us working in the patient care arena regardless of your title. Most of my support staff at my patient care sites are paramedics, and many have migrated to urgent care as a solution to the stressors in the field. For those readers not in the patient care space, ask your organizations what they’re doing to address caregiver burnout. Ask your friends and colleagues how they’re doing and offer support when you can. Their lives might just depend on it.

How does your organization address burnout? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/6/17

For people breathing easy after completing their 2016 Medicare-related attestations, it’s time to start gearing up for next year. Organizations need to register or update their information via the CMS Web Interface  prior to June 30 if they plan to participate as a group. Organizations that plan to use the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey also need to register. There are many other details on who does or does not need to register, so consulting the website and making sure you know whether an ACO or registry will be reporting on your behalf is recommended. For those not breathing easy because they’re still completing 2016 Medicaid-related attestations, good luck! Some states have extended their attestation windows into May.

CMS has also been busy promoting the value of Chronic Care Management, launching a new Connected Care program to raise awareness through the Office of Minority Health and the Federal Office of Rural Health Policy. Connected Care will focus on racial and ethnic minorities along with rural populations who statistically have higher rates of chronic diseases. The new website includes toolkits with detailed information about CCM, resources for implementation, and patient education resources. CCM requires a patient copay, and that has posed a barrier to adoption in my area. Patients already think physicians should be providing these services for free and don’t always understand the value of why CMS is making a push to specifically address the need for services. Although the copay is small, patients living from Social Security check to check and who may be choosing between medication and food are often reluctant to consent to enrollment. Sadly, those can be the patients who most need the services.

CMS has also been busy with its Social Security Number removal initiative. I’m working with my first consulting client on a project to look at how it uses the SSN within the organization and to assess vendor plans to remove the SSN from software systems. There is a new provider webpage, in addition to the main page, for the initiative. Although this program impacts Medicare beneficiaries and the use of the SSN as the de-facto Medicare ID, organizations use the SSN in a variety of different ways. Not everyone is excited about the removal program, as the SSN has also become a proxy for an individual identifier to a large degree. Kind of makes you think about our lack of a national healthcare identifier, doesn’t it?

ONC has updated the SAFER Guides, which are designed to help organizations assess EHR safety and best practices. Topics include organizational responsibilities, contingency (downtime) planning, interfaces, patient identification, clinician communication, and test results reporting/follow-up. I really wanted to review the latter topic, but received an error. There are plenty of practices that need this information. I can’t believe the number of groups I run across that either don’t track their laboratory and diagnostic orders from ordering through completion and patient notification, or track but don’t notify. The era of “no news is good news” should be long gone by now. Patients should never be expected to assume results are normal unless they hear otherwise.

Medicomp Systems announces its Medicomp University event, to be held starting April 24 in Reston, VA. Attendees will gain in-depth knowledge of the Quippe products and how to integrate them into EHRs. I’ve enjoyed watching the Quippe offerings evolve since I first saw it at HIMSS11. If you haven’t seen them, they’re definitely worth a look.

I’m way behind on email again, but it’s been fun to go back and weed through all the premature commentary about the repeal of the ACA. What had us hanging on tenterhooks now seems like a long time ago. For those of you who have never seen them, this is what tenterhooks look like. I’m also catching up on some educational webinars. My new pet peeve is people who use PowerPoint for presentations, but fail to put it in presentation mode, forcing the audience to review shrunken versions of the slides while being distracted by the thumbnail navigation.

I came across this article about what hospitals waste and it’s startling to think about. When patients are discharged, many supplies are thrown out due to concerns about infection control or potential contamination after they’ve been left accessible to patients or visitors. Policies vary dramatically from facility to facility across the country. I’ve worked at places that toss everything and at those where supplies are restocked, and seen all kinds of variations. There’s also the issue of hospitals getting new equipment and needing to get rid of old devices. I once assisted with an effort to send a “gently used” MRI machine to South America – now that was a project.

Scholarly research has been done looking at the problem, with findings that when hospital staff are appropriately incented, waste can be reduced. Many surgeons in one study were unaware of their operating room costs; when they were asked to reduce costs, they met goals where the control group’s costs actually increased. Getting people to be conscious of the true costs of the care provided is central to the concept of value-based care, especially when those costs are obscured, such as costs that are included in a hospital room charge.

During my recent hospitalization, most supplies were kept in a secured cabinet inaccessible to patients and family members, which not only controls costs but reduces contamination and the risk that something would have to be tossed for fear that someone had opened it or otherwise ruined it. Other items that are placed out for every patient (shower products, toothpaste, etc.) are discarded after each patient whether they were used or not, since it’s too difficult to determine if they’ve been opened or used. I specifically asked the staff about this prior to discharge – I hadn’t used anything, since I brought my travel kit with me. But they were going to toss everything, so I grabbed it for a community drive that gathers non-food items to be distributed to food pantries for their clients. You’d think hospital leadership would have considered that when crafting their policies and reached out to a local organization. Maybe they did, maybe they didn’t, but I’m trying to connect the two for some potential community benefit.

What does your hospital do with discarded or excess supplies? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/3/17

I’ve been doing a lot of thinking about my work lately. I’ve been doing consulting for a while now, starting with side work even when I was a CMIO. I left that ersatz glamour to do consulting full time and it’s been an adventure.

My clients are generally good to work with, and that is a side effect of being your own boss and having the ability to terminate clients who are difficult or want to play mind games. Still, they get stressed out like anyone does, and often the consultant is expected to try to fix issues whether they’re in scope or not. That creates some tension around whether I should allow them to change the scope of work or whether I need to send them in another direction, especially when they try to game the system to get their new problem included for free.

Everyone is under significant economic pressures and I understand where they are coming from. Just because you’re in healthcare, though, doesn’t mean that we can give you services for free. Especially as a small consulting firm, even small discounts can make a big dent in our bottom line. We’re in the purest of “eat what you kill” models and even though we have low overhead, we still have bills to pay like everyone else. Fortunately, my partner and I are both fairly frugal and we’re not in this business for the money (although it is nice at times). But with increasing financial pressures due to the shift from volume to value, many more of our client-facing conversations are about money rather than vision, mission, or strategy.

Our clients feel increasingly like they’re in the crosshairs with payer audits, federal and state regulations, anti-kickback worries, medico-legal issues, and legislative uncertainty. Not to mention there are also decreasing contract rates, more bundled payment initiatives, and the ever-present worry about the inefficiencies of EHR. For the most part, we can help clients tackle many of their stressors, but the fact that healthcare delivery continues to be in a state of rapid change is something that we can’t do a lot about. Of course, we can help the clients with strategic planning and trying to future-proof their businesses, but that’s a big change for clients who thought they would be independent practitioners forever.

I work for myself, which has a lot of perks. I can generally control my travel schedule and have no problem saying no, although clients have been less flexible the more they are stressed. We have a solid plan to divide and conquer when our clients have needs for specific expertise, although we can cross cover each other enough that we don’t ever feel we are working without a net. Still, I thought we’d be at a different place by now in the evolution of healthcare. Unfortunately, we’re still grappling with some of the same concepts that we grappled with decades ago. They were challenging then, but throw the technology piece at them as well and they can be even more messy.

I’ve been in the healthcare technology leadership space for more than a decade and I’m still fighting the fact that my clients (and their patients) don’t have full access to their medical records. In a lot of ways, they can’t even cobble together a medical record because of the barriers to sharing that are all around them. I’m personally enrolled in four patient portals. One has two of my physicians on it, but they don’t share any data. It might be better that we’re not sharing data, though — my new primary care physician sent me a summary of care record, but unfortunately it has multiple family history errors and even gave me some new diagnoses that I never knew I had, including a pulmonary embolus and clear cell carcinoma.

Because of the crazy way our payment system works, many providers game the system to gain the maximum reimbursement possible. Anyone who has experienced provider-based billing knows what I’m talking about, as do those who have pushed the boundaries on time-based services to achieve higher codes. This creates a lot of stress in the ambulatory space as everyone struggles to figure out how they’re going to add headcount for care management and preventive services while fee-for-service payments are decreasing. Although there are some programs seeking to provide those payments up front, such as the Comprehensive Primary Care Plus program, providers are constantly under the threat of missing some kind of documentation, reporting deadline, or other hurdle that might mean they have to pay back those monies even though they were trying to do the right thing by their patients and communities.

We’ve thrown a lot of precious time and billions of dollars at a healthcare system that isn’t generating the return on investment that we need it to. Divorced from the payment scheme by insurance and other third parties, the majority of patients have no idea whether their providers are gaming the system or not. Is the price they’re charging fair? Is the patient receiving value? It’s hard to tell. In many parts of the country, the only entity that has even close to a full picture of the patient is the payer, and that’s a shame. I’m watching my friends who are only 20-25 years into their careers plan for early retirement when they realize selling out to a big health system wasn’t the answer to their struggles with independent practice.

When physicians are together, we talk about the predicaments we’re in and whether the primary care physicians can hold on long enough for the balance to tip in their favor, helping them come off the hamster wheel and be able to truly connect with their patients again. I know of many physicians who have gone into politics – talk about going from the frying pan into the fire. Although most of them are altruistic, one in my state makes spectacularly poor decisions about a variety of issues. For those in the trenches, especially after the last election cycle, there is plenty uncertainty around tomorrow even if they make it through today.

Some days it’s harder than others to grind through the muck. Whether you’re seeing patients or whether you’re trying to help practices and organizations survive an obstacle course that would make an American Ninja Warrior take cover, it’s tough. I miss the days when we were adding technology to our lives because it solved problems, not because we were forced to and certainly not if it added hardship. Although I see the bigger picture and try to translate it to our clients, it’s getting harder to convince people to hang in there and keep moving forward.

I relish my office days, when I put on my hourly employee hat and just see patients to the best of my ability. For the most part, I make patients’ bad days better and they’re grateful. It reminds me of why I wanted to be a doctor in the first place. But I know that behind the scenes there is still a seedy underbelly of coding, billing, modifiers, and more. I’m spoiled by how well my partners run our practice and spend a lot of time thinking about how much I’d like to bottle their leadership skills and atomize their fortitude around my clients.

Although it feels like healthcare is behind where it should be, it also feels like we’re on the verge of something big. We do things every day that no one had heard of when I was in medical school, and that’s a good feeling. It makes me want to stay in this game another month, another year, another five just to see what happens.

If you could bottle one thing and spread it all around healthcare, what would it be? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/30/17

I spent some time this week coaching a physician informaticist on some of the less-exciting aspects of running a team. At first, he was very excited to be the leader of a team of optimization specialists to work with clients across the south. He didn’t understand what he’d have to deal with as far as the actual logistics of managing people though – vacation approvals, travel authorizations, and the dreaded expense reports.

We talked through the idea of creating some team policies and procedures beyond the standard corporate policies in an attempt to manage the chaos. He has more than 20 people on his team, which is a lot to handle when you’ve never managed people.

Some of the problems were simple solutions. For example, processing the vacation requests 1-2 times a week based on a published timeline for the team, and then ad-hoc for last-minute issues. For travel authorizations, processing daily at mid-day so that his team could complete booking tickets before the travel agency closed. That way he felt less fragmented and less like he was in and out of different software applications all day long.

Creating a strategy to manage his team’s expense reports became the highlight of my day. I have to admit that in reviewing some of the problems he is dealing with, I developed an appreciation for the level of shenanigans his employees were putting forward. Several were pushing the limits of the daily meal allowance, logging the wait staff gratuity as a separate line item under “cash expenses” so they could expense an extra cocktail on their dinner checks without hitting the cap.

Another’s expense reports can only be described as stream of consciousness. Despite traveling to the same client every week, he files reports in a random way that doesn’t seem to line up with any of the scheduled trips. A third consultant included airport hotel bills for the night prior to his travel, “just in case the weather was bad” even though he only lives 20 miles from the airport.

The winner, though, was the consultant who repeatedly stops to purchase a single beer at the gas station next door to the rental car pickup. The timing seemed a little odd, especially since he stays at a hotel where you can purchase single beers in the lobby. It makes me wonder if he is drinking it in the car as he heads to the hotel. All things considered, and especially working for a healthcare company, I’d probably just pay for that out of pocket and not try to expense that $2.85 worth of my day. Not to mention that my client may want to encourage his employee to purchase his beverages at the local package store and pass the cost savings onto their customers.

We had to do some back and forth with the corporate expense people to find out whether some of the outlier expenses were prohibited or acceptable but just tacky. Not all of his employees were gaming the system, though. Several use coupons for their airport parking to save the clients’ money, and at least five of his team members were spot on with their expenses. We’re using those good corporate citizens as an example to the rest of the team and plan to leverage a couple of them to teach the others how to file an expense report that doesn’t drive the reviewer mad.

Another challenge was coaching him on what to do with some of his new employees who are having challenges with professional behavior. That’s always rough when you inherit a team from someone else, or when candidates are hired without your input.

One is struggling with professional dress. My client mentioned that he never thought he would have to tell a field trainer that wearing a fishing hat to the client site isn’t appropriate. That was mild compared to the employee that he described as a “predator” based on reports from multiple clients. Apparently, this trainer would meet members of his training classes at bars after class, with all the imaginable bad decisions taking place. Whether you go to medical school, business school, or any other school, nothing prepares you for having to deal with employees on the prowl, especially when they’re propositioning your clients. The employee is currently on a performance improvement plan, but it’s surprising that people are having to deal with that type of behavior after all the stories we hear about sexual harassment and inappropriate behavior.

One of the most egregious examples of unprofessional behavior was the team member who asked a client physician (the CMO no less) whether he could write her a script for some Ambien because she left hers at home. Her previous manager left the incident hanging out there for my client to deal with when he inherited the team, an act which is unprofessional in its own right. Clearly the employee didn’t find asking a client to write a controlled substance script to be a problem, so it’s likely to be an interesting conversation when the inevitable counseling occurs.

I could never work in human resources because I don’t have the poker face to deal with some of the things that come through the door. One of the funniest books I’ve read in the last few years is Let’s Pretend this Never Happened by Jenny Lawson. There’s a chapter about her past life as a human resources staffer that will make your head spin. (Warning: language may be inappropriate for the workplace, although common.)

I sincerely enjoyed working with this new client this week and look forward to several more sessions in the coming months. It’s always fun to see someone who is idealistic and enthusiastic who hasn’t been beaten down like so many of the rest of us. I’ve enjoyed teaching him my favorite Jedi tricks around email management and getting through days with high volumes of meetings and little productivity. I hadn’t imagined myself as an elder statesperson in the realm of corporate survival, but it seems that I may have arrived there. It’s definitely a new adventure.

What’s your best story about bogus expense reports? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/27/17

After my recent adventures in healthcare, Mr. H asked me my thoughts about “playing the doctor card” when a physician becomes the patient.

I’ve had some experience with it at multiple times in my career and have chosen different strategies depending on the nature of the situation and the potential risk/benefit equation. It’s definitely more straightforward when you’re dealing with an emergency situation or if you’re in a situation where you’re seeking care at a facility where you are on staff vs. just being a physician. If you’re at your own facility, depending on how large it is, the odds that someone will recognize the fact that you’re on staff are higher, so sometimes it’s better to just identify yourself and avoid awkwardness.

I’ve done that when calling ahead to the emergency department to let them know I’m bringing in a close family member who has an emergency, and also to ask who is on call for whatever specialty care might be needed in case I want to go somewhere else based on the call schedule, or call a colleague and ask them to come in when they’re not on call. To be honest, though, I would do the same thing for one of my patients, so I’m not sure how much that really is playing the doctor card.

If I’m having difficulty scheduling an outpatient appointment, or want a certain time slot (first patient of the day, something like that) I may mention to the schedulers that I’m a physician and looking for a particular time so that I can accommodate patient care hours. I wouldn’t ask them to double book me or work me in, though, but rather add the physician component just so they understand I’m not trying to be difficult, but just need the first available appointment that meets my criteria so we don’t waste time looking at slots that I won’t take. Sometimes this is an issue when offices are performing practice improvement activities, when the staff is pressured to get patients on the schedule quickly, but I need to wait.

When I was recently in the emergency department for acute abdominal pain, I didn’t play the doctor card until I was in the room being seen by the physician. It was more for context since I wasn’t going to mince words about my symptoms and didn’t want to put him in the position of trying to figure out why I was spouting medical jargon. It seemed the best way to expedite care and also to give him the picture that, “Hey, this must be bad if she’s a physician who is going to have to call in for her shift because she’s here” as far as the severity of my symptoms. It turned out that his wife is one of my colleagues, so it was a bit of a bonding moment as well.

The decision to mention you are a physician or not can often be difficult. On one hand, you want to be able to interact with your treating clinicians at a higher level. But on the other hand, you don’t want them to leave things out because they assume you know more than you really do about an issue.

My recent appointment with the genetic counselor was a great example of a visit that went well. Since the patient history forms asked for occupation, I’m certainly not going to hide it — it’s a fact of demographics and social history just like my education level. The counselor asked open-ended questions about why I was there and what I hoped to get from the visit, which let me explain what I knew and didn’t know, and which allowed her to figure out where I was coming from. When we arrived at the discussion of the risk model, she asked if it was OK to skip the overview of genetics and inheritance and go straight to the details. I appreciated the fact that she asked, as well as the fact that we could have a deeper and more specific conversation due to the fact that I already knew most of the background information.

My recent inpatient stay had a couple of interesting interactions around the fact that I was a physician. The nurse who did my intake on the med/surg floor specifically asked if I wanted to be called “Dr.” or something else. I said to use my first name and she made a point of saying she just wanted to check, since I had “earned it” and she was happy to honor my preference. I appreciate that her statement was beyond just the, “How would you like us to address you?” question that all patients should be asked.

Once she put my name on the whiteboard, though, I was back to being Jayne, and no one asked again. I didn’t have to mention it until the craziness with the overnight nursing staff who had difficulty administering scheduled medications on time, and I attempted to be a “normal patient” until the delays became ridiculous and then I played the MD card. In that situation, however, they probably should have been more worried about the fact that my brother is a personal injury attorney rather than the initials behind my name. Fortunately there were no negative outcomes, however, so I didn’t have to play that card.

I’ve also been very upfront about being a physician when I’m about to do something that would be perceived as unusual for a “typical” patient. For example, rolling into a seemingly routine outpatient procedure with a copy of my healthcare power of attorney and living will. It’s more of a, “I’m a physician and I know things can go south even for the smallest procedures, so here are my documents” statement rather than a request for special treatment. I feel pretty strongly about my end-of-life wishes and want them honored, so I’m not afraid to play the card there.

My general thought process around when I say I’m a physician or leave it out is this. Does the person I’m interacting with really need to know? Is it germane to my care? Would I be mentioning it just to mention it, potentially creating an awkward situation? Or would mentioning it help diffuse an awkward situation? Is there something inappropriate going on where it might help correct the issue? Will I get better care if I mention it?

I’ve only had a negative reaction once when mentioning that I’m a physician, and that was in a situation where the care missed the mark so badly that I wasn’t surprised. It was a last-ditch effort to improve the situation and their response to it was very telling.

Putting on my physician hat, I’ve had multiple experiences where I have cared for other healthcare providers and wished they’d revealed their professional background sooner in the encounter. Case in point: I tend to have detailed discussions with my patients about why I’m choosing one medication over another and how it’s going to work to take care of their problem. I wish the patient who was a faculty member at the local pharmacy school would have jumped in earlier when I was discussing the relative effectiveness of various antibiotic families and why I was recommending one drug over another. When he finally did, though, he had a sense of humor and said he would give me an A+ on my explanation.

I’d be interested to hear from other clinicians on their experiences, positive and negative. Being on the front lines of healthcare delivery is like being part of a somewhat bizarre fraternity. No matter where you trained or where you work, you’re still linked by that underlying kinship and by subsets of shared experiences. Sometimes mentioning that you’re a clinician is in lieu of the secret handshake and just intended to say, “Hey, I’m one of us, it’s OK, I understand.”

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/23/17

I get a lot of junk mail in my Dr. Jayne account. Most of it is marketing and public relations related, with varying degrees of personalization.

My favorite ones are those that attempt to sound all chummy and personal, but make it clear that the writer has never read HIStalk. “I was looking at your website that mentioned a mental health topic and am curious if you’d be open to me writing some unique content for your audience on the subject?” shows no grasp of your marketing audience. Of course, it’s easy to hit delete, but sometimes they’re just so bad you have to read them and laugh.

I’ve also recently been inundated with survey requests from HIMSS Analytics. Half the time I can barely make it through the fresh items in my inbox, so I’m not likely to be induced to finish a survey of questionable merit.

Hot topic in the physician lounge this week: the looming physician shortage. These reports come out nearly every year and always predict a shortage, although with variable numbers. Our local paper ran an especially Chicken Little version of the story, promising long wait times for appointments, but failing to interview anyone from the multiple medical schools and training programs we have in town.

As a former primary care physician, I’m not sure how much of a shortage we really have vs. how much of an incentive misalignment problem we have. I’d consider going back to primary care at some point if it wouldn’t mean working far more hours and taking a significant pay cut. Until then, I’ll stick with the wild and crazy world of urgent care and healthcare IT.

I’m already tired of everyone’s marketing tie-ins to March Madness. The MGMA ad featuring “insane savings” was a little tasteless – as a health professional, I don’t typically find insanity funny. I do still like (and highly recommend) my urologist friend’s March Madness promotion. His practice figures there are a lot of men doing a fair amount of sitting and watching basketball during the tournament, so he offers complimentary pizza delivery for patients scheduling their procedures in that time frame. It’s a significant business booster and he’s been doing it for more than a decade, so it must be effective.

Maybe it’s just the blogs I read or the people I follow in Twitter, but I’ve seen a spike in discussion of physician burnout. There are many stories about physicians retiring from medicine in their 40s (often to choose another career entirely) or going part time as soon as their loans are paid off. A recent study looks at another consequence of burnout – the loss of the sense of medicine as a calling.

The study defines “sense of calling” as, “committing one’s life to personally meaningful work that serves a pro-social purpose” and surveyed over 2.200 US physicians across all specialties. The study had a 63 percent response rate, with 28.5 percent reporting some degree of burnout as measured by responses to six true/false statements:

• I find my work rewarding.
• My work is one of the most important things in my life.
• My work makes the world a better place.
• I enjoy talking about my work to others.
• I would choose my current work life again if I had the opportunity.
• If I were financially secure, I would continue with my current line of work even if I were no longer paid.

According to the authors, physicians who don’t see medicine as a calling see it more as a means to learn a living. That’s what most of us call “having a job” or “earning a paycheck.” Physicians who are burned out are less socially motivated as well.

The authors go on to note that physicians who don’t see practicing medicine as either personally meaningful or as a service to society may see performance impacts, including negatively impacted quality of care. They also interestingly note that monetary bonuses to improve performance may backfire, as they undermine professional autonomy and physicians’ sense of competence.

Due to the study’s construction, it’s not clear whether burnout itself reduces that sense of calling or whether physicians with a higher calling are somehow protected from burnout. More research is needed.

I did some anecdotal research myself, asking physicians if they would stay in practice if they inherited a large sum of money or won the lottery. The only ones who said they would stay in practice would move to a cash-only model and/or work only part time. There were several comments about dreaming of the opportunity to tell Medicare and commercial payers which parts of the posterior anatomy they can kiss.

My friends who happen to be physicians have a variety of strategies for trying to avoid burnout, although some ultimately do leave practice and that’s a shame. Every day there are articles about the catastrophic events that happen to physicians and other healthcare providers: sleep deprivation-related accidents; pre-term labor and birth; stress and anger management issues; and suicide. We lean on our families and friends to try to help us cope or to find a little slice of ‘normal’ among the chaos.

Several of my physician colleagues have taken up traditional handicrafts to try to relax. Two guys I went to medical school with do crochet – I sometimes see them at conferences with their projects. I have three friends who make soap. There are a couple of woodworkers (not surprisingly, neither are surgeons). At least if there’s a collapse of the world’s infrastructure, I know who I can barter with for socks, furniture, and toiletries.

As for me, my knitting skills are marginal, but I wield a mean cast iron skillet, so you’ll find me in the outdoor kitchen if the dystopian future arrives. Until then, I leave you with a recent revision of the Hippocratic Oath for today,courtesy of Paul Simmons, MD:

I swear by Epic, by eClinicalWorks, by Allscripts, by Athenahealth, and by all the coders and accountants, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.

To hold my mouse in this art equal to my own hand; to make it right-click as well as left-click; when my ACO is in need of money to share an “at-risk” portion of mine with it; to consider Joint Commission inspectors as my own brothers, and to answer their questions, no matter how obscure, without hesitation or resentment; to impart coding, billing, quality measures, and all other vital instruction to my own sons and daughters, the sons and daughters of my teacher, and to indentured employees who have taken the physician’s oath, but to nobody else competing with my health system.

I will use mouse clicks to help the sick according to my ability and judgment, but never trusting my own judgment over that of guidelines, directives, policies or best practices. Neither will I administer a poison to anybody when asked to do so, unless the poison is properly linked to a diagnostic code and reconciled in the medication list.

Similarly, I will not give to a woman a pessary to cause abortion, especially if the pessaries aren’t covered by her insurance plan. But I will keep pure and holy both my problem list and my billing codes. I will not use the knife unless credentialed by a committee, not even, verily, on sufferers from the stone, but I will give place to such as are craftsmen therein, and will do my best to decode their two-sentence notes should they choose to leave one.

Into whatsoever houses I enter, I will enter to help the sick, without expectation of payment because no one pays for house calls. I will abstain from all intentional down- or up-coding and premature closing of encounters, especially from abusing the computers on which I labor, for they are my true patients. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets, but mainly because HIPAA says so, and that comes with monetary fines and jail time.

Now if I carry out this oath, and break it not, may I gain forever reputation among all men for my mad abilities to click boxes and buff the chart; but if I transgress it and forswear myself, may the opposite befall me, and may I be banished to a Third World nation where I might labor in obscurity to help truly sick people with my medical skills.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/20/17

I’ve had a couple of questions about my other “unplanned trip to the hospital.” I was due last Monday for my post-op clearance visit. I had seen patients the day before and had been having some leg pain and swelling that was bad enough that I had to sleep with my leg elevated.

As a physician and knowing all the bad things that can happen to a post-operative patient, I didn’t want to just assume it was from being on my feet all day. There’s a small but real risk of deep venous thrombosis after surgery, and that risk can go on for a couple of months. Anecdotally speaking, physicians have bad luck with complications, so I wasn’t taking any chances and wanted to get it checked out.

By mid-morning, most of the swelling was gone, although I still had some weird leg pain. Other signs of DTV were absent, so I decided to not head to the urgent care since I had a post-op visit in a couple of hours and would see what the surgeon thought since I’m fairly low risk.

I headed to the office a little early since it was snowing and I knew I was the first patient of the afternoon and didn’t want to make my surgeon start his office hours late. What I didn’t know was that his last operating case of the morning had taken a turn for the lengthy. Of course, the office staff didn’t mention this when I checked in, so I was treated to 15 minutes of bad infomercials in the waiting room while they answered lots of phone calls but acknowledged no one in the waiting room. I finally learned that the surgeon was still in the OR when I overheard someone mention it to a phone caller.

Just about the time the makeup infomercial was driving me crazy, another patient arrived and signed the clipboard. He was hand-carrying his records and he and his wife sat and read physician notes aloud and generally second-guessed all the care he had received thus far. He was clearly there for a second opinion and I couldn’t help but pity my physician for what he was about to endure. They were loud and opinionated, even when they admitted they didn’t know what they were taking about. It was entertaining to watch them pull out the copies of the scans and try to interpret them against the waiting room lighting.

Finally when I was called to the window, the receptionist argued with me about not having signed a records release. She said I needed to send my records to my PCP. I told her I didn’t have a PCP and she continued to insist that I put someone down to receive the notes. I finally wrote “no PCP” on the release and just handed it back. She finally got the message.

At the bottom of the hour, the TV programming changed to some daytime interview program and the topic of the day was post-traumatic effects of sexual assault. Although I have utmost respect for the topic, it’s not what you expect to have playing in the waiting room and doesn’t set the stage for a calming, healing environment.

The receptionist called me up again to fill out a post-op form, which included questions about my pain, how much pain medication I was taking, etc. Some of it was pretty standard, although the pain scale ran from 1-10 instead of the normal 0-10. As the questions progressed, some of the scales were inverted, with 10 being the least and 1 being the most, which I’m sure might be confusing for many patients. I was confused enough that I missed the back of the form, resulting in me being called to the window a third time.

The surgeon finally arrived and I was called back. He was apologetic. He mentioned a little about his previous case and I understood why he was late. I felt bad that I was about to make him more late after I threw out the leg pain and swelling complaint. Although he agreed I was low risk, I was scheduled to fly in less than 48 hours, so he wanted to proceed with the ultrasound.

His staff called down to the vascular lab, where apparently only one technician showed up due to the snow. He asked for a favor to work me in, which I appreciated, although they said it would likely be a two-plus hour wait. You can’t complain when you’re a work-in, so I took my form and headed downstairs. I guess if your physician doesn’t call in a favor, you would have to wait until the next day, which isn’t an ideal situation for patients with potential blood clots.

When I finally made it to the imaging department, I realized it was nearly 2 p.m. and I hadn’t eaten lunch. The receptionist confirmed that I was an add-on and asked if I knew it would be a couple of hours’ wait, and I said yes, and could I pop out to the cafeteria and come back? She said that was fine. 

When I returned from the café (where only the salad bar remained), I was shamed by the registration clerk, who had apparently been looking for me while I was gone. Despite all my time in healthcare, it didn’t occur to me that this was going to be a quasi-inpatient experience until I was sitting in the registration booth and they had asked the fall risk questions and were getting ready to slap the hospital band on my wrist. Although I had only been discharged two weeks prior and my information should have been up to date, I discovered that my emergency contact had been changed to a peripheral relative who in no way would I want to be my emergency contact. It was baffling until I realized (days later) that he had been in the hospital in the interim and had put me as HIS contact. Still, that should not have changed MY contact information.

It’s unreal that you have to go through the hospital admission process for a straightforward outpatient test. It’s also unreal that there is no accommodation for people’s potential illnesses in the waiting room. How about a footstool for the patient with the swollen leg to prop it on? I got the evil eye from the receptionist for using an empty chair to elevate my leg. While I was waiting, though, I did receive my surgeon’s email message welcoming me to his patient portal (yay, another one!) and inviting me to peruse my records. I now have a total of five portals that I can log into and view my fragmented charts.

After a couple of hours, the tech appeared to take me for my test. I apologized in advance since I knew I was an add-on and said I appreciated that she was having to stay late for me. She was pretty cool about it, although she mentioned she hadn’t had a lunch break and hoped to be able to make it out of the hospital by dinnertime.

I felt bad as a former member of the medical staff that this is how the hospital runs, that two people can fail to show up for work and the third remaining staffer gets crushed with no help in sight. One would think that in a hospital system with nearly 30,000 employees there would be systems in place to prevent these kinds of events from happening. Of note, by 1 p.m., the snow was melting, so bad roads were no longer an excuse.

I didn’t end up having a blood clot. Not surprisingly, once I started treating my leg like a musculoskeletal problem, it got better. Heat and NSAIDs work wonders, but they don’t keep deep clots from breaking off and killing you, so I’m glad I had the test for my own piece of mind.

It will be interesting to see what the hospital charges for an ultrasound vs. what we charge at my urgent care. Rumor has it our prices are about 80 percent less than the hospital, so we shall see. Hopefully this will be the end of my medical adventures for a while, at least until the bills start arriving in a few months.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/16/17

It’s been a whirlwind of a week with two more trips to the hospital, one planned and one not. Long story short, though, I’m back in the air and off to see clients, which is a good feeling.

I’m also headed somewhere warmer than my current snowy state, which is definitely something to look forward to. Many of my spring plants were up or blooming when the snow hit, so the garden will have a bit of a setback this year. I’m just glad I’m not traveling to central Florida, where CNN reports that a cobra escaped captivity and is now in the wild.

In follow-up to my post about having a partial EHR outage this weekend, the vendor never did send an update about the situation. We also had an outage today of the patient portal, and again after 12+ hours, no follow up. If they’re not going to follow up, their emails shouldn’t say they will send follow-up emails as further information becomes available.

In healthcare IT, we tend to think about our work within the contexts of inpatient vs. post-acute vs. ambulatory vs. community vs. population health, etc. As humans begin to spend more time in space, that’s going to be the next frontier of healthcare IT. NPR recently reported on microbiologist/astronaut Kate Rubins, who was the first person to sequence DNA in space. I was interested to learn about the microbiome of the International Space Station, something you don’t hear about much but that opens the door for some unique research activities.

In other news scientists in China have completed gene editing on viable human embryos using the CRISPR technique. Although the study was small and the results were not perfect, they were promising. Gene editing could reduce the incidence of heritable diseases, but we have a lot to learn about the technique, impact, and ethics of doing so.

I’ve certainly got genetics on the mind following my consultation with the genetic counselor earlier this week. Although she didn’t give me the initial speech about the science of genetics, I appreciated that she didn’t assume that I had done a ton of research or had preconceived notions about what we were talking about. We talked about my specific concerns based on family history as well as what kinds of testing are available and the ramifications of having positive testing.

Although the Genetic Information Nondiscrimination Act of 2008 restricts the use of genetic data in health insurance and employment issues, it doesn’t prevent issues with the underwriting process when you’re talking about life insurance, disability, long-term care coverage, and more. One of the first questions she had for me when we were talking about testing was whether I had addressed those types of coverage or not.

Although I’ve worked out the life insurance and disability pieces, I haven’t addressed the long-term care coverage issue. Still, I decided to go forward with the testing, but on a limited basis, looking only for a couple of specific mutations. There are plenty of panels available that test for up to 80 genes, but I’m not going to go looking for something that isn’t a concern and wouldn’t potentially change my management plan for preventive screenings.

Based on the dramatic increase in our knowledge of genetics over the last decade, we agreed it would be prudent to meet again in a couple of years and discuss whether there are new recommendations for testing someone in my situation. To answer the previous reader question, she uses panels from Myriad Genetics.

We also walked through a couple of risk models based on my family history without the genetic testing component. This is where the discussion quickly became academic, because one of my personal risk factors is considered a “borderline” risk factor in that some models consider it a risk and others don’t. When the model is run with the risk factor in place, my lifetime risk of breast cancer is pretty alarming. Without the risk factor, the risk is cut in half. Even with the diminished risk of the second model, it was enough to qualify me for a high-risk screening program, which seems like a reasonable option compared to the alternatives. We’ll have to see what my insurance thinks, however.

Being in the high-risk program at the medical center is tied to their imaging center, which of course involves hospital facility fees for the studies. In my area, though, the cost difference for a screening mammogram isn’t much more than at the independent imaging center where I had my previous studies, so I opted to get mine done at the hospital while I was there. I realized as I was getting dressed, however, that moving my care to the hospital meant giving up the “real time” reads done at the independent center. I hadn’t thought of that prior to the test, which made me wonder how many other patients might not have thought of it. It really is amazing to me how easily your reasoned clinical and analytic process can go out the door when you become the patient.

My experiences as a patient over the last few weeks have given me a better understanding of how hard we make it for patients and their caregivers and how much individual variation there really is in our healthcare system. It also made me realize that despite thinking I had a pretty solid handle on my family history, there were quite a few questions I couldn’t answer. Most patients probably don’t have as much information as I walked in there carrying and that certainly impacts the patient experience and the specificity of the counseling.

It will be a while before I get the genetic testing results back, and in the mean time, I’ll be reading up on some novel genes that the counselor mentioned may have interesting implications for my family but that aren’t being commercially tested yet.

Friday is Match Day, when thousands of medical students learn which residency programs they’ll be headed to for the next three to seven years. Good luck to everyone waiting for their envelope. And to those who didn’t match to the residency of their dreams, keep your chin up and learn all you can wherever you go.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/13/17

Even though I haven’t had my post-op clearance visit, I returned to patient care work today. Since I only see patients part time, our medical liability insurance is in the form of a “slot policy,” where multiple physicians share a single policy. Although it’s a cost-effective way to handle coverage for part-time physicians, it can make scheduling complex since you have to avoid exceeding the allowable hours for each physician on the policy.

My partners have been covering my shifts and I know it’s been a strain.Since I’m theoretically being cleared tomorrow, I figured I’d work. It helped that I was scheduled to work at one of our less-busy sites, so I wasn’t too worried about being physically overwhelmed.

No good deed goes unpunished, though, because I was greeted with a partial EHR outage. It was very similar to the recent Amazon Web Services outage in that we could document and scan images but couldn’t view any images or letters. The vendor did promise to keep us posted, but after 10 hours we had heard nothing.

Fortunately, we were able to keep documenting and seeing patients, but it’s annoying that they didn’t at least follow up every couple of hours with a status update. Overall, it was a slow day and I had brought some other work to do if things were quiet. Usually that’s a guarantee that you’ll stay busy, but not so much today.

My backup plan was to do some continuing education and watch some of the “on demand” sessions from HIMSS17, but they’re not posted yet. I instead started to enter my CME credits, and was reminded that the system is less user-friendly than I hoped. First, when you set up your transcript of courses you want to claim credit for, there are some usability challenges. When you select a class, it blanks the screen, forcing you to re-select the day every time you select a class. Second, you can’t select more than one class per time block. Once you select a course in that block, the rest of the options disappear. That makes sense for a live-only conference, but not so much for a conference where you can also earn CME from on-demand sessions.

I suspect it probably has to do with the requirements for CME approval. I think HIMSS was only approved for 22 CME hours this year, despite there being well over 100 sessions approved for credit. Many physicians struggle with the cost of CME, which makes me wonder why they don’t approve the conference for more than 22 hours, especially with the availability of on-demand courses. The content is broad and personally I prefer watching the sessions at home because I’m more focused than when I am in a group setting, especially if other attendees are distracting.

Although volumes were small today, they reminded me why I enjoy practicing medicine. When I first went into informatics full-time, I had about a year and a half gap where I didn’t see patients. Not from lack of interest, but from a lack of options for part-time family medicine docs with inflexible schedules. That’s when I started practicing urgent care and emergency medicine.

What we do certainly fits into the “life is like a box of chocolates” category. Where else can you see a patient roster that includes chief complaints of “fall on ice” and “poison ivy” in the same day after temperatures dropped from 70 to 20? Where else do you get first-hand knowledge of the aftermath of mechanical bull riding? (For those playing along with the home game, today’s answer was a fractured sesamoid bone in the thumb rather than the head injury you might expect.)

I also enjoy practicing medicine because I’ve finally found a spot in an organization where people are truly held accountable. Even in our state of rapid growth and geographic expansion, our leadership hasn’t wavered from their mission and vision. They’ve taken steps to reward employees who support those ideals. As a privately-owned practice, they are relentless in their ability to weed out slackers or those who aren’t committed to the mission. We run in a near-military culture and it’s not for everyone, but knowing your staff has your back (and most of the time is out in front of you getting it done before you even get there) makes being at work almost joyful.

We recently implemented a new bonus system. Instead of getting quarterly or semi-annual bonuses, staff members receive bonuses on an ongoing basis. Each month, every employee is given an allotment of “bonus bucks” to award to colleagues who are living the values. Although providers are on a different bonus structure (based on timeliness of care, quality, patient satisfaction, etc.) we have an allotment of bucks to give to staff. Each bonus award has to include specific commentary via hashtag of why the employee earned the bonus. Since providers have a large bank of bucks to give each month, people are eager to work quickly and efficiently and to operate truly as a team. We were doing well with the old system, but the new immediate recognition scheme has really pushed some people’s efforts over the top.

All employees can view a real-time suite of analytics showing top receivers, top givers, percent participation, and more. Bonus flow can be visualized as an activity network or via a word cloud that summarizes all the words used in the hashtag award notices. It’s pretty cool to watch how things flow over the course of time and across various teams – clinical, reception, radiology, and providers. Employees can cash in their bucks for gift cards, workplace swag, and even months without late shifts or in exchange for holiday shifts. Maybe it’s a bit gamified, but it’s working.

I’m glad to be back in the saddle and hope I’m fully cleared tomorrow, so I can get back in the air for my clients. My next two trips are to some of my favorite parts of the country and I’m looking forward to not being grounded any more.

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