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.

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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.

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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.

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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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EPtalk by Dr. Jayne 3/9/17

I’m still getting back into the swing of things following my recent adventure in healthcare. I’ve enjoyed the relative downtime, although I’m getting a little stir crazy. Hopefully I’ll be cleared for travel early next week so I can keep the good stories coming from the trenches.

In the mean time, I’ve been going through my post-HIMSS and post-hospital mail. A couple of vendors need to get some money back on their marketing efforts: the postcard from eClinicalWorks arrived on Monday after HIMSS had already started, with an invitation to “The Way of Tea” at the Vital Images booth arriving on Tuesday. The grade schooler who picks up my mail when I’m gone does an excellent job sorting and bundling so that I know what mail is the oldest. I can’t wait until he grows up – I see some serious potential as a process improvement specialist.

I’ve been working my way through loads of email. A special thank you to all of you who sent well wishes and good vibes for a speedy recovery. It was nice to have those little rays of sunshine popping into my inbox.

I was glad to have been on sick leave from my clinical position because I was supposed to be working the day the big Amazon Web Services outage hit. Our vendor sent quite a few emails apprising users of the status. They were apparently having a partial outage, where users could document visits but could not see images, forms, and letters. You can have a really great downtime strategy in the office, but you never know how things are going to unfold when an outage hits.

CMS has finally updated its website with Clinical Quality Measures information for the 2017 performance period. The Meaningful Use domains have been removed and now the measures align with the Quality Payment Program and its Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) tracks. CMS invites people to submit questions about the documentation, but I wouldn’t hold my breath waiting for a response. I’m still waiting for clarification on some Chronic Care Management questions from earlier in the year.

I’ve also had a ringside (couchside?) seat for the release of the American Health Care Act, with plenty of time to digest the back-and-forth commentary from politicians and healthcare leaders. I finally had to step back after a while because it’s going to go on for months as everyone tries to get their piece of the action with the usual wheeling and dealing, negotiations, and amendments.

The so-called “repeal and replace” legislation is only 4 percent the size of the Affordable Care Act (120-odd pages vs. 2,700) so the devil will truly be in the details. I’ve talked to a couple of friends who are OB/GYN physicians and their patients are still terrified about losing coverage for contraception and preventive services. One physician has a patient who is trying to import black market IUD devices from Canada. Apparently they’re made by the same manufacturer that makes them for the US market, but the cost is less than 25 percent of what they go for in the States. That’s a sad commentary on the state of healthcare in the US.

After the Affordable Care Act went into effect, my personal insurance plan was still grandfathered and didn’t have to offer all the mandatory coverage. Late last year, the trustees of the plan voted to un-grandfather and began to offer coverage for things that were previously not covered.

I finally began to pursue a genetic consultation to address some lingering family history concerns. After months of waiting and submitting genograms, results of relatives’ testing, and more, I finally have my appointment with the geneticist next week. Of course, it’s going to be better to know one way or another, but I hope my decision to get tested doesn’t come back to haunt me if there are changes to the protections and coverage for people who know they are at higher risk for serious health issues. (At least I know I’m at zero risk for gallstones or cholecystitis now, so that’s a plus.)

I had a strange experience as a physician this week. I received an email in my consulting business account containing a link to access a summary of care record. It was from a hospital where I haven’t been on staff since before I bought this domain, so I’m not entirely sure how my address came to be linked up to their system. Sure enough, it was a patient discharge record.

I cross-referenced it against my patient panel from the last year I was in a traditional primary care practice and found the patient. I’m not sure if it was a computer glitch or whether she really still considers me to be her primary care physician after all this time, but it was a nice memory. I called the hospital and they weren’t terribly helpful in trying to figure out how it got routed to me as it did, but instructed me to simply discard the message.

Physician readers familiar with “The Match” will cringe at this news story. The cardiothoracic surgery program at New York-Presbyterian / Columbia University failed to submit its resident ranking list, meaning it will not be able to offer residency slots as part of the traditional Match Day next week. Columbia can still fill its program through the Supplemental Offer and Acceptance Program, which makes unfilled slots available for residents who did not match. This could be a boon for students who didn’t get a spot via the actual Match process, but it means that the program will most likely not have access to its top-ranked candidates.

I still remember my own Match Day, and not entirely fondly. Although my placement was a sure thing, I was on the edge of my seat waiting for my turn to open my envelope in front of my entire class. For some, it was a barbaric way to do things as we watched people’s dreams get crushed in between happy Matchers jumping up and down. Schools still have formal Match Day ceremonies where this continues to happen, although applicants can now skip the envelope and find out an hour later via email.

What’s your Match Day memory? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/6/17

Jayne Goes to the Hospital

You may have surmised if you follow my Twitter postings that I recently spent some time in the hospital, but not in a patient care capacity. It was one of those unplanned, middle-of-the-night type of events that no one ever wants to happen to them.

Of course, the chain of events might be different when you’re a physician. You sit at home wondering if you are over-reacting and generally second-guessing yourself. At one point, I found myself in severe pain, wondering if I could hang in there until my urgent care opened at  6 a.m. rather than risking the emergency department during flu season. When those thoughts start to cross your mind, it’s definitely time to go.

Based on my symptoms (including the fact that the pain was so bad I couldn’t bend over to put my own socks on), I had a sneaking suspicion that I was going to end up with surgery, so I grabbed my travel necessity bag and threw it in the back seat of the car. That’s the advantage of being a frequent traveler, but you never want to be that patient who rolls into the triage area with an overnight bag, so I left it in the parking lot, perhaps as wishful thinking.

My worries about being in the ED during flu season were unfounded and I wound up being the only person in the waiting room. Registration was a snap since I had my insurance card and photo ID at the ready, wanting no barriers between myself and some serious pain medication. I had to endure five minutes of bad late-night TV (some dating show involving “baggage” that was truly, truly horrid) and was called back.

There are times when you are sick, especially when you are a healthcare provider, when you wonder if you’re over-reacting to what you fear might be going on. I knew when my blood pressure was in the 160s/100s range with an elevated heart rate that whether or not my brain was over-reacting, my body most certainly had an issue with what was going on.

The ED physician ended up being the spouse of one of my urgent care colleagues, who fully appreciated what it means when a physician rolls into the ED in the middle of the night when they’re supposed to be working that morning.

Tests were ordered and an IV was started. After receiving some pain medication, I very quickly understood why people abuse it. The phrase “magic carpet ride” doesn’t begin to describe what it feels like when you see the privacy curtain flowing to the left and the door jamb scintillating off to the right side of the room.

I was pleased that my pain immediately went from 10 to 2, but even more grateful that my blood pressure and heart rate started moving more towards normal as I rolled off to get my CT scan. Once those results were back, the physician returned to complete a more thorough history and physical to prepare my admission documentation.

This time he had a scribe, or at least who I thought might be a scribe since we weren’t properly introduced. Normally I’d make a point of saying something, but I was still surfing on my cloud of Dilaudid and just wanted to know what the plan was and call my COO so he could find someone to cover my shift that was supposed to start in four hours. I was totally ruminating on that detail because I didn’t want to be “that doctor” who just doesn’t show up.

There was a parade of different nurses through the room. I received some antibiotics and some different pain medication. Then it was off to the inpatient unit to wait for the surgeon to meet me before I was whisked off to the operating room.

I received a room assignment on a brand new wing (confirmed by the new paint smell) and arrived right before shift change. Both the outgoing and incoming nurses were wonderful, explaining everything that was going on and letting me know when my next doses of antibiotics and pain medication were due. The outgoing nurse got a chuckle out of administering my intake questionnaire since I knew the answers to all the race, ethnicity, blood product acceptance, and cultural pain practices questions before she was even done asking them.

I was trussed up with DVT-preventing sequential compression leggings so I didn’t get a blood clot. Thankfully, she showed me how to disconnect myself so I could get to the restroom without having to call for help. I guess there are some benefits to being a physician.

The surgeon came by promptly and said he wanted additional confirmation of the diagnosis in the form of an ultrasound, which was performed immediately at the bedside. You know when you’re in trouble when the ultrasound tech takes a bunch of extra pictures even if you can’t see the screen.

Not more than 20 minutes after the test was done, the nurse came in to announce that they would be coming to take me to the operating room sooner than later. She was followed by a patient care tech bearing a couple of packets of pre-op scrub wipes, who dropped them off with instructions on what to do.

By this time, I had non-medical family at the bedside. They were shocked that the staff would expect the patient to do their own pre-operative prep. I’m no expert on pre-surgical care, but I’m hoping if the patient wasn’t a relatively healthy and mobile person that they would assist a bit.

I went quickly to the operating room after that, rolling out the door while reminding my family where to find the healthcare power of attorney and living will if something went wrong. I didn’t have time to get a copy before then, but you can bet that it’s in my Dropbox now. I had my noon dose of antibiotics in my lap since it would be due while I was downstairs and my nurse didn’t want them to be late.

The weekend operating room staff was excellent. I woke up feeling like no time had passed and with all my teeth still where they belonged. I’ve always been afraid of general anesthesia and having my teeth messed up during the intubation, so it was the first thing I thought of. In hindsight it’s pretty weird, but healthcare people think of all kinds of weird things based on what we’ve seen. I had a happy little pillow from the hospital auxiliary tucked under my blanket to brace myself with in case I had to cough and was back in my room in a flash.

The next shift change signaled a change in the level of care I received. As the nurses rounded together, the incoming nurse commented about me deciding to “self-discontinue” the DVT-prevention leggings. Since I had just come up from the operating room and hadn’t left the bed yet, I had no idea what she was talking about. I still had the leggings on, but it turns out someone removed the controller and inflation tubing from my bed when they took me to the operating area. It didn’t occur to me in my post-anesthesia haze that they weren’t connected to anything. Blaming the patient for a process issue isn’t a good way to start a patient care relationship.

From there, things trended downhill. What I did have was a lovely private room with a (no kidding) 60-inch flat screen television and dietary staffer who personally went through the menu options with me for dinner and breakfast. What I did not have was timely antibiotics and pain medication or consistently visible handwashing or foaming. I also did not have a functional IV access site and had to argue to have it moved when it was oozing enough blood that it was leaking out of the dressing and onto my hospital gown.

It turns out that due to staffing and census issues, my nurse was split between two hallways. What that translated to was feeling like I wasn’t getting good care and that I was last on the list. I know hospitals are busy places and there probably were patients sicker than me, but when I’m on scheduled medications, I’m not giving you more than 15 minutes grace before I ring the call button. I was close enough to the nursing station that I could hear the call signal sounding at the desk when I rang it. I could also hear when it went into “alert mode” because it hadn’t been answered by the first-tier response time. Eventually a patient care tech answered and said she would contact my nurse, who didn’t come in.

This cycle repeated every 15 minutes until my antibiotics finally arrived. The nursing staff was equipped with Vocera two-way communications lavalieres, so there was really no excuse for lack of communications while I waited for my antibiotics to arrive over an hour and 15 minutes late.

Although she was apologetic and said she’d return in 30 minutes as soon as the infusion was over, she did not. That led to another 30 minutes of call light and alarming IV pump nonsense until someone came to the rescue.

By now it was 11 p.m. I was due for scheduled pain medication at midnight, but I was honestly afraid to go to sleep because I knew I couldn’t count on getting medications when they were due without being a call-light stalker. By this point, I wasn’t taking any narcotic pain medications, just scheduled NSAIDs, and I wanted to keep it that way. It’s a terrible thing for a patient to be afraid to sleep for fear they won’t get their meds.

As predicted, they didn’t arrive on time, leading to another 30 minutes of call-light tag before they arrived. She was happy to offer narcotics for breakthrough pain, but if a patient is doing well on scheduled meds and gets them on time, there shouldn’t be any need for breakthrough treatment. Needless to say, we had a few words about the timing of the medications.

I was finally able to sleep for about four hours, although it was restless sleep with the anti-DVT leggings pumping up every 30 seconds despite the fact that I had also received heparin shots for clot prevention and was ambulatory. The phlebotomy started at 5 a.m. I dozed a bit until vitals at 5:30. Surprise, after the last “conversation” with my nurse, my medications arrived promptly at 6 a.m.

I knew there was a good chance I’d be discharged that day, so I decided to wash up, throw on some mascara to look less pathetic, and make arrangements for a getaway car. Many surgeons round early and I was crossing my fingers for that kind of schedule. I was feeling really good, and after my Garmin registered 500 steps in the room and the administration of a second heparin shot, I decided the annoying DVT leggings really could come off.

Back when I was still delivering inpatient care at this hospital, we made a big deal about the discharge day and discharge planning and making sure the patient understood the planned schedule and would be ready to depart at the appropriate time. The primary care physicians were scolded if we rounded after 9 a.m. because that interfered with the 11 a.m. discharges.

Things must have changed because the discharge plan was significantly fluid despite my wishful thinking, lovely eyelashes, and fully dressed status. The dietary team came up to go over the lunch menu around 11 a.m. and I waved them off, saying I didn’t plan to be there for lunch. I was finally released from captivity a little after noon. I went home and immediately went to sleep, waking only when my alarm told me it was time for pain medication.

I’ve been recovering nicely with a steady diet of ibuprofen, Tylenol, and Pepcid. I’d kill for the martini that isn’t on the list of prohibited dietary items, but I’d rather wait until I can really enjoy it. Everything tastes strange, even a week out, and despite the lovely covered dishes that have showed up on my doorstep.

Urgent surgery is a heck of a way to get out of working your scheduled urgent care shift, so I wouldn’t recommend it to anyone. I’m just glad this little adventure in healthcare didn’t happen at HIMSS or on any one of my frequent trips across the country. I’m happy to be doing a little more activity every day, even though the score still stands at Gallbladder 1, Jayne 0.

I’ve mentioned my experience to friends who work in the process excellence realm at the hospital in question, so hopefully some change may come of it. I had to chuckle, though, on Wednesday, when I received a thank you card from the hospital: “It was our pleasure to provide your care throughout your stay with us. Our goal is to always provide you with quality care and excellent service.” Of all the people I interacted with, it was signed by the overnight staff who gave me the most concern about quality.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/16/17

One of my clients is going through some cultural change efforts and invited me to attend some of their management training sessions earlier this week. The first warning sign that things might not be as effective as anticipated was when I walked into the room and found the instructor arguing with some attendees, accusing them of being late. I thought it was odd because I was 20 minutes early. It turns out the calendar appointment was sent for the wrong time and the instructor was unaware. Once people showed her their calendars, she backed off, but that’s never a good way to start.

We had been told that we were expected to be “fully present” during the training sessions, to wear comfortable loose clothing for team-building exercises, and that we wouldn’t be able to use our laptops during the session, but that we’d be given frequent breaks to check in. What they didn’t tell us was that one of the facilitators would actually confiscate not only our laptops, but also our cell phones. Although I understood what they were trying to do, taking phones from a room full of physicians, some of whom were on call, isn’t a great plan. It also didn’t give a positive message about treating us like adults and trusting that we could avoid non-urgent texts and emails. What they didn’t realize is that half of the class was wearing smart watches, which still worked during the course. That was a good thing for a couple of the physicians, one of whom was called to surgery.

For the rest of us, though, we had to wait nearly three hours for a break, which I’d hardly call “frequent breaks.” Oddly enough, at the break I had a message from the CEO, who had forgotten my plan for the day and had been looking for me. He was extremely displeased at being unable to reach two of us that were in the training session. There must have been a phone call to the corporate training department after I checked in with him, because the “no devices” policy was relaxed after lunch. Guess what? Everyone acted like adults and there weren’t any more interruptions than there had been in the morning. We didn’t get out of our chairs the entire session, so I’m not sure what the request for loose clothing was all about, but I guess we’ll never know.

I’m a keen student of language, so enjoyed this Merriam-Webster announcement about the new words they’ve recently added to the dictionary. Healthcare and technology were well represented with additions such as: net neutrality; abandonware; EpiPen; and urgent care. The dictionary experts also remediated some items that I’d have thought were added long ago: ride shotgun, town hall, ping, and Seussian.

I’ve started getting some HIMSS-related marketing phone calls. Of course, they quickly turn into HIMSS-related voice mails because I don’t answer calls from weird area codes or people I don’t know. A couple of them have had people speaking so quickly I couldn’t figure out what they were saying or who they were working for without listening a couple of times – which is crazy, since I’m from a fast-talking part of the country and can usually keep up. I know exhibitors have access to our profiles, so it might be nice if you remotely coordinated your pitches with the interests of your target as well as making sure your callers can articulate so they are understandable.

The HIMSS-related mailing volume is down significantly this year. I’m sad to say I haven’t received anything truly eye-catching or even worth talking about. No poker chips, no oddly-shaped mailers to get my attention, no Orlando-themed marketing hooks. I suppose Las Vegas is an easier sell, but it would be easy to do a fun-in-the-sun theme. I’ve probably received less than a dozen pieces of mail total, but of course that doesn’t count the mailings that will arrive after I depart. It happens every year and you’d think they’d have figured out how to solve that problem by now.

HIMSS did send me an email with my “Corporate Member Focus Group Confirmation,” which was funny because I didn’t sign up for any focus groups. It just seemed like too much work this year, especially with their new policy around only allowing the first 12 arrivals to attend even though they may have extended more invitations than that. Planning to attend one takes a chunk of time out of your day. Although attendees receive a gift card for their participation, the invites I received weren’t compelling enough to make it worth the hassle.

I’ve also received some downright creepy emails from other HIMSS attendees, looking to build their networks or hawk their services. I don’t know what the exact agreements with HIMSS sharing data are, but one I received felt like an invasion of privacy. The sender must have had access to my mailing address as well as my email address because he made specific references to the part of the city I live in and how he would like to get together in town if I can’t meet with him at HIMSS. You can bet I’ll be paying better attention to any opt-out settings when I sign up for HIMSS next year.

What’s the creepiest marketing effort you’ve seen or experienced? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/13/17

I spent a couple of hours today getting ready for HIMSS. Priority one was outlining my agenda for continuing medical education sessions, which was tricky since it always turns out that there are multiple sessions I want to attend at the same time. The conference offers 22 hours of the specialized credit that informaticists certified by the American Board of Preventive Medicine need.

HIMSS delivers the sessions on demand as part of your HIMSS registration, but my experience last year was that some of the audio recordings were poor quality. There is also no substitute for attending a session in person and being able to participate in the discussion or connect with colleagues. I chose a primary and alternate session for each available time slot, but we’ll see what happens when I get to Orlando and the exhibit hall is beckoning.

I also worked on planning my social schedule, which also had too many overlapping offerings. I’ll be doing the exhibit hall booth crawl with at least four good friends. It’s always enjoyable to get other people’s opinions on new technologies and solutions. Of course it’s always a bonus to have someone help you scout out interesting shoes or create a diversion so you can photograph footwear or badly-behaved booth personnel without being too obvious.

Speaking of shoes, I spent some time looking for the perfect solution to get me through five days of nonstop walking. Last year I had some awesome pink running shoes from Edifecs as part of their #WhatIRun campaign. I’ve pretty much run those into the ground since then, but enjoyed being part of their campaign. I didn’t have much luck shopping, so I might have to pull out some sparkly running shoes to get through the week after all.

HIMSS is the virtual Super Bowl of conferences, so making sure I have a solid packing list was also part of today’s prep. I have a growing number of devices and various pieces of wearable tech that unfortunately involves a growing number of chargers. I have a universal adapter that takes care of the Android vs. iPad problem, but my Garmin watch has its own charger, as does my new favorite piece of wearable tech, my Ringly bracelet.

I had heard about Ringly more than a year ago, but am not big on wearing rings and was worried about the size of the stone being too much for me. I joked that if they ever came out with a silver bracelet, I’d be the first to order. Shortly after that, they came out with a stainless steel version, so I went on the waiting list last spring. I had to wait until the fall for it to arrive and have been putting it through its paces over the last several months. I’m pleased to say it’s HIMSS-worthy.

I’ve never ordered a piece of jewelry sight unseen, so I was a little nervous about it. It arrived in a big chunky cube of a box with the bracelet front and center. Sliding off the outer sleeve revealed the charging box nested underneath. The charger connects via USB to your laptop or USB transformer of choice. Not a problem for me since I usually end up charging things off my docking station anyway.

Advertising on the website at the time I ordered it said that the charging box had its own battery and would hold an 8-10 day charge depending on use. I was disappointed to learn that only applies to the ring version. For the bracelet, I’ll have to tote the charging box when I travel more than 2-3 days, which is what seems to be its maximum lifespan. I can forgive the lack of clarity on the website since they’re a startup and when I ordered they weren’t even shipping product yet. Still, having a battery in the box would be an improvement for those of us who travel.

Having to pack the charger, however, is a small price to pay for what the Ringly does. I don’t like carrying my phone in a pocket. It’s way too bulky even if I take it out of its protective case. If I put it in a purse, I have to turn the ringer on, which isn’t a great idea most of the time. I don’t like to carry my phone in my hands or leave it on the table when I’m out, which a lot of people do, but just isn’t my thing. The Ringly solves that problem – not only by providing discreet vibratory notifications, but best of all, it allows me to screen my calls and texts by configuring contacts in the Ringly app.

The Ringly app connects with dozens of other apps to provide notifications through a combination of vibrations and LED flashes. You can set it up dozens of ways, depending on how many buzzes and what color blink you associate with each app. For phone calls and texting, it links to your contacts and you can set it to either flash an additional color for certain people, or you can set it to only receive calls and texts from certain contacts. The LED is pretty subtle but helpful for giving you information on whether you need to dig out your phone or take other action.

I wanted to test drive it extensively before I decided to trust it. As a physician who is sometimes on call, I needed to know it was reliable, and it is. The connection screen in the app also shows charging and battery status.

There are a couple of quirky things about the Ringly. It likes your location to be turned on when it connects for the first time (or sometimes when it reconnects after a period of non-use). Every once in a while it doesn’t get along with my phone – usually first thing in the morning – and you have to “forget” it in your Bluetooth settings and then rediscover it. Sometimes it wants to be on the charger in order to connect.

Issues are uncommon, but you need to know the tricks in case it acts up on you. They’re also putting out app updates pretty frequently, and if it really doesn’t want to connect, usually it’s because there is an app update available. Another quirk is that Ringly does all their support through email and Facebook chats, so forget it if you like to talk to an actual person.

The other bonus of the Ringly is that it is an activity tracker. Based on how my phone identified it before I had the Ringly app installed, I suspect that it has Garmin innards. I tested it against my trusty Garmin Forerunner and found that it under-calculates by about 30 percent, however. That’s a pretty big margin of error if you’re into accurate distance traveled, but if you just want something as a relative indicator of activity, it gets the job done. The “silver” bracelet is actually stainless steel, so I’ve worn it running and to the gym with no worries. Not sure I’d do that with the plated gold-tone version.

We’ll have to see how it does on the exhibit hall floor. I’m counting on it to remind me of my appointments and to notify me when people are trying to track me down. It’s also pretty snazzy as a bracelet, so I can’t complain about that. The stone is smaller than I anticipated. If only they’d come out with a stainless version of the ring, I’ll be first in line.

What’s your favorite piece of wearable tech? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/9/17

Several readers asked whether I saw this article about Obamacare vs. the Affordable Care Act, so I feel compelled to respond. I don’t know about the exact statistics, but we’re having lots of conversations with patients in the office about their coverage and their concerns about what will be changing. Usually it’s in the context of their being grateful for our transparent pricing and low costs, but a lot of people are genuinely worried about pre-existing conditions and whether their insurance will still cover preventive services.

When patients complain about rising premiums or changes to insurance plan offerings, I typically mention that while the laws regulate doctors and hospitals, there hasn’t been much done in the way of insurance regulation. Whether or not you think enormous bonuses for insurance company CEOs are warranted, the sheer economics dictate that the money has to come from somewhere.

On the payer front, Centene’s recent report showed quarterly revenue and profit ahead of expectations, helped by growth in the individual coverage market and by Medicaid expansion. Net earnings for Centene were $261 million for the fourth quarter of 2016. Based on 11.4 million patients covered, it’s a small margin, but when you couple it with the administrative costs of running a health plan, it represents a tremendous amount of premium and tax dollars that are not being spent on patient care.

I’ve been inundated by requests from HIMSS for their corporate member focus groups. Some of the sessions are pretty drab sounding and others don’t work with my schedule, so I probably won’t make it to any this year. I was a little aggravated, though, that they can’t figure out how to blind copy the invitation – seems like a basic email skill.

Some of the sessions are vendor-specific and it’s obvious who you will be talking to or about, but others are a bit more vague. I was tempted by one that advertised discussion of precision medicine solutions, but I figured it would just irritate me. As a preventive and public health curmudgeon, I have a hard time talking about spending millions of dollars on focused gene-based therapy when we can’t fund the basics of health promotion and disease prevention.

I attended a service launch webinar for another consulting company this week. They’re not in the same space as me, but they’re a fun bunch of people, so I wanted to see what they’re up to. They’ve partnered with a third-party vendor for the tool, although they didn’t say it. If it’s not totally white labeled, I think it’s better to say you’re at least “powered by X vendor” rather than having prospects or vendors see “copyright X vendor” at the bottom of the screen and wonder what’s going on. The presenter also seemed nervous. Even if you’re a presentation pro, I’d definitely recommend a dry run when you’re launching something new or presenting in a new format.

For weird news fans: I stumbled across an article about a patient who lived for six days without lungs. She had been waiting for a transplant but developed influenza and sepsis along with organ therapy. After concluding that death was likely imminent unless there was intervention, physicians removed the source of infection – her lungs. She was placed on an external oxygenation device (Novalung) with rapid improvement and received donor lungs several days later. Four months later, she’s breathing normally on room air, although she does still have to have dialysis following kidney failure. Hearing about physicians pushing the boundaries and having success reminds me of the excitement of medical school, when it seemed like our faculty was making history on a weekly basis.

CMS has extended the submission deadline for 2016 clinical quality measure reporting required by eligible hospitals and critical access hospitals participating in the Medicare EHR Incentive Program or the Hospital Inpatient Quality Reporting program. Electronic clinical quality measures are now due March 13 rather than February 28. For 2017 reporting, CMS plans to start a rule-making process looking at modifications to the final rule. It’s always fun to wait for the rules to be finalized after you’re already playing the game.

The AMIA Mentor Match program is looking for informaticists willing to spend an hour a month for the next 11 months working with mentees. I’m thinking about signing up, but struggle with how to describe my experience and areas of expertise. Somehow I don’t think “Sassy former CMIO turned consultant seeks idealistic mentee to remind me how idealistic I used to be, before corporate healthcare and chaotic vendors drove me over the edge” is what they’re looking for. Some days I wish I had a mentor of my own to give me perspective on the bizarre work situations in which I often find myself.

I’m spending some extended time in the patient care trenches due to a colleague’s medical leave. We’ve started seeing some EHR performance issues during the times of peak patient volume. It’s bad enough when you’re overwhelmed with patients, but having your system fail you makes it intolerable. At times, the system is at a crawl.

I was spoiled when I was a CMIO because our EHR vendor had a SWAT team they would send out for issues like this. Even if you had strong resources in house, you could leverage the team to review performance and monitoring tools and make recommendations. My current vendor is on the smaller side and not terribly helpful when it comes to helping us manage the issues.

We use a third party to manage desktop and wireless solutions, so as you can imagine, there is a bit of finger-pointing between the access crowd and the application support folks. It always unnerves the IT team when you have a physician who starts asking about latency and Citrix load balancing, but I’m happy to give everyone a nudge to stop the blame game and get about the business of finding solutions.

The HIMSS mailings have started rolling in. Every year it seems like the marketing themes and giveaways get a little goofier. Physicians have long been scrutinized for regarding gifts from industry, but there’s no reporting for the majority of healthcare IT professionals. I hope the Open Payments system has fields available for tracking giveaways such as virtual reality goggles, scooters, art pieces, and more.

What’s the best trade show giveaway you’ve ever seen? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/6/17

I’m playing cleanup for one of my clients this week. They’re dealing with one of the most common management challenges I see – lack of redundancy for key positions or functions.

Due to some leadership personality issues, individual contributors were allowed to become “experts” on a variety of topics without any thought to backup, collaboration, or shared responsibility. When issues came up, it placed the experts in a position of being able to swoop in and solve the problem using their sacred knowledge, further solidifying the idea that only the rescuer had full command of the information. Instead of raising appropriate red flags about why only one person could solve a problem, previous leadership continued to groom these expert resources.

In reality, what some of the experts were doing was front line customer support, but because no one else had visibility into what they were doing, it appeared that they were doing a lot more than was actually going on. Now that a couple of them have left the organization, it has become apparent that some of them were doing very little, and others were doing work that could have been handled by appropriately training the practice call center employees who interact with the internal customers on a daily basis.

When I came into the situation, the organization was in a tailspin trying to figure out how they could possibly replace these people. The reality was that we were able to outsource it pretty quickly, along with selling them some consulting services to document the process, educate others, and prevent this from happening in the future.

In looking at the broader structure of the organization, however, there are much larger cultural factors at play that allowed this behavior to continue. There is a history of promoting individual contributors to management positions because there was no other career path for them. When you take people with no management experience and plop them into a management role, it often feels very uncomfortable. That can lead to the new manager withdrawing from those responsibilities and instead to try to create new individual responsibilities that are more in their comfort zones. Couple that with upper management that is too crisis-oriented and doesn’t budget adequate time to develop these new managers and you have a recipe for a mess.

My task with these folks now is to evaluate the depth and breadth of the experts and figure out what they were actually doing. Some of them have been doing obscenely little given their titles and pay grade. Others were trying to do more than anyone could possibly do well because of wheel-spinning and inefficiency. Once we identify the core body of knowledge and the tasks that need to be completed, I assign an external resource to first cover the acute needs, but second, to document everything and create a training plan to build out multiple resources to cover the needs moving forward. I’m unfortunately seeing a lot of resistance as members of the organization figure out that the emperor has no clothes and begin to worry that they might be next in being exposed.

This fear of being exposed leads to all kinds of bad behavior: information hoarding, siloing, manipulation, maneuvering, and more. People feel threatened when they’re worried others will figure out they have been operating outside accepted boundaries and will do anything to protect themselves.

My favorite strategy is blaming the consultant, who has clearly been brought in by the leadership to fix something that has been identified as a problem. There’s a certain level of trust (and money on the line) when you bring in an outsider and give them carte blanche to realign resources and shift roles and responsibilities. Complaining about it or pitching a fit only makes you look bad and potentially tees you up to be “realigned” outside the company if you are uncooperative enough. Couple that with the fact that the consultant was able to replicate your job duties at a fraction of your cost, and it might just be better to keep your head down and cooperate.

I’m on site this week doing stakeholder interviews, trying to sort out what people think about their role in the project and how the project is going overall, vs. what others have to say and what the leadership thinks is going on. It’s not looking good for some members of the management team who are behaving like cornered animals. Although downsizing was not an original goal of this consulting engagement, how they’re handling it is making it seem like losing a few people might be a good idea.

I enjoy doing stakeholder interviews and organizational assessments. Sometimes they can be enlightening, but often they’re fascinating journeys into the underlying psychological baggage that people carry around with them. Some of my standard interview questions involve the team, its goals, what people think about their participation, the overall health of the project, and how they think they’re contributing.

I conducted one interview this morning where the participant raved on and on about a colleague and how helpful she is, how much of an asset to the team, how she enjoyed working with her, etc. A few hours later, I met with the subject of the glowing commentary, who went on and on about how she thinks my previous interview subject hates her and is trying to undermine her within the company. This client has a fair number of “you can’t make this up” scenarios that I have to figure out how to deal with. I’m thinking I need to bring in a therapist in addition to subject matter expert consultants.

The leadership is not without blame here. Although they’re relatively new and inherited the bulk of the mess, they’ve been complicit in allowing some of the craziness to continue without stepping in earlier. They’ve allowed the process of making people managers because there’s no way to promote people in various job classes, which has compromised people’s effectiveness and weakened the organization.

Members of the leadership also project the air of being too busy to help the little people sort it out, which is going to be a long-term issue. They’d be much better served by at least appearing that they’re willing to roll up their sleeves and dig in to build the organization rather than making it clear that their main goal is to continue acquiring physician practices and everything else is secondary. Adding more practices (many of which are distressed when they’re acquired) when they’re struggling to support their existing practices doesn’t seem like the best strategy, so I’ll continue to work on that piece as well.

What’s your current project? Does it make you want to crawl back in bed every morning? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/2/17

It’s increasingly difficult to keep up with the literature when there is so much coming out and the pace of change is so rapid. This article in PLOS One regarding influenza vaccination for healthcare workers caught my eye. It looked at vaccination statistics in long-term care facilities and whether the “number needed to vaccinate” in order to prevent patient death was in alignment with what had been predicted based on previous data. Rather than the previously predicted number of eight vaccinations needed to prevent a single patient death, the number was calculated at somewhere between 6,000 and 32,000. Authors concluded that the four studies supporting enforced vaccination for healthcare workers “attribute implausibly large reductions in patient risk to healthcare worker vaccination, casting serious doubts on their validity.”

This is a great lesson in small data vs. big data and the need to keep questioning and keep researching as the healthcare knowledge base continues to expand. Through the magic of eBay, I once purchased a set of medical student notebooks from the 1920s. They’re half-legal sized bound notebooks that flip at the top, and it’s amazing to see what is written and what we knew then. My favorite page starts with the statement, “There is so much we still do not know about the thyroid.” I wonder what that medical student would think of our current knowledge base? Those notebooks also make me wonder what physicians will think of us 80 years in the future, especially given the current wrangling over whether we as a nation are committed to ensuring medical care for all.

I recently posed the question to my readers about what would their ideal jobs would look like.

From Sunshine State: “An optimal role would be leading several business units from a COO or similar position, with a focus on solving problems in our industry in a fast-paced and dynamic environment. A level of risk is attractive — as John Paul Jones stated, he who will not risk cannot win. How do we shrink an industry and not put people out of work while advancing care? With a generalist background, a greater contribution is possible with coordinating resources and goals across groups rather than leading a specific business unit or department requiring specialized skills.” I agree that the idea of having more than one business unit at your disposal might make it easier to solve problems creatively without the distraction or bottlenecks that occurs with more siloed organizations. There’s a temptation for leaders to protect their own rather than stepping out of their comfort zones in an effort to solve the bigger problem. Certainly figuring out how to reduce cost, increase quality, and maintain jobs is a challenge, even more so when you have limited financial or personnel resources.

From At Bat: “Funny you should ask about the perfect job because I happened into it several years ago. I worked at a large hospital for 30+ years in direct patient care, managed care, the physician organization, the health plan, patient safety, and at the last part of my career in evidence-based medicine. I’m not technical, but was involved system-wide in various projects. I was contacted by the executive for our data warehouse asking if I would speak at a conference on a particular topic. I replied, ‘No problem, any opportunities?’ and after a whirlwind of phone interviews and a quick meet-up at HIMSS, I was offered my dream job helping health systems with analytics initiatives. I have to honestly say that if you gave me a pencil and paper and said to write down the perfect job, this would have been the result. I work from home when I am not traveling, and while I do get a tad lonely, it is the most rewarding job I have ever held. I am slowly getting used to working in the for-profit vs. non-profit world.” The ability to wear fuzzy bunny slippers to work cannot be underestimated. It can be a drag, though, when you realize you’ve been wearing pajamas all day and have been so busy working that you’re not even sure you brushed your teeth today. I’m always happy to hear when people find something that really clicks and hope that it lasts for them.

From What The?: “I wrote you a couple years ago about the perfect job and thought you might appreciate an update. I had decided after being a healthcare IT consultant that I knew without a doubt that I wanted to be a doctor. I have a liberal arts degree and zero science background, but seeing how people like you approach healthcare convinced me that this was something I needed to do. I was accepted to my medical school of choice last fall and am doing contract HIT consulting work to save up money until I start classes. I just got an email about my white coat ceremony in July and could not be more excited about the opportunities ahead.” This put a big smile on my face. Although sometimes those of us in the profession knock it due to the hours, the stress, the external pressures, and more, being a physician is still one of the greatest privileges any of us can have. For patients to trust us in their times of vulnerability and weakness is truly something special. Even though there are tens of thousands of “healthcare IT people” who never go anywhere near a patient, we need to continue to remember why we are doing this. It’s about our grandmothers, brothers, sisters, and everyone else who relies on the systems we use to make decisions and deliver care.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/30/17

I’ve finally started getting excited about HIMSS. On Friday, my MagicBand arrived, personalized and ready for Disney to start transferring cash directly to their coffers. After learning hard lessons in the past about the need to book hotel rooms early, I was able to get a room at my hotel of choice. I planned to spend most of HIMSS with a good friend, but she tried to book a couple of days after me and wasn’t able to get a room. She does, however, have connections at Disney, where we were able to get significantly more posh accommodations for a fraction of what we would have paid at the official HIMSS hotels. Sure, we’ll have to deal with parking and traffic, but I’m looking forward to spending time with friends and getting away from the craziness of the show each night.

I was also excited to get my HIStalkapalooza ticket. Even though I’m guaranteed an invitation, I do have to register for a ticket just like everyone else and it’s always exciting when that email arrives. Now I have to figure out what I’m going to wear and of course find the right shoes, so that will be on my to-do list for the next couple of weeks. It’s nice to have a project to work on that doesn’t involve federal regulations, frustrated healthcare organizations, burned out physicians, or medical practices struggling to survive.

Things have also started to slow down at my clinical practice, with the near-epidemic of influenza finally easing up. Our fiscal year runs with the calendar year. Even though we monitor the numbers closely throughout the year, once we close the books, it triggers detailed accounting reviews and the beginning of discussions on our strategy for managed care and occupational health contracting negotiations. That dovetails with planning exercises and review of our recent growth and whether we should continue with our plans for opening new locations or whether we need to re-evaluate. Fortunately, our price transparency and the boom in high-deductible insurance plans continues to support our planned expansions. We have nearly triple the locations we had when I started, with several hundred employees.

I had an opportunity to sit down with our chief operating officer this week. Part of the meeting was a review of my personal metrics. It’s nice to work at an organization that understands the role of metrics and how to use them drive organizational goals. It’s a bit if a luxury to be able to set our own metrics and not be stuck with what CMS and other governmental bodies think we should use, regardless of whether they impact our internal or community-based goals.

We look at a variety of metrics that impact patient satisfaction, such as wait time, treatment time, appropriate referral for advanced imaging, procedural complications, survey results, and response to clinical follow-up outreach. Those metrics vary month to month, and in this cycle we saw a pretty significant impact due to the rate of influenza, norovirus, and other infectious diseases. At one point in December, we were seeing 50 percent more patients on a daily basis than we had ever seen, so it’s not surprising that patients would be a little less satisfied about wait times or congestion in the office.

We also look at quite a few financial metrics, including charges per encounter and the distribution of E&M codes among providers. As you would expect, most of our visits fall under a subset of codes, but there are some outliers that occasionally over- or under-code, so we have to decide how to deal with them. Is it just a blip or part of a larger pattern? Does it increase our risk for audit? Is someone trying to game the system by getting their charges up without appropriate justification?

We know that the cost of care at our facility is about one-eighth that of care at the area’s emergency departments, so it might be tempting for some providers to upcode. We also look at what the EHR suggested the code be, vs. what the provider or scribe actually clicked, vs. what the internal coders think. There is always some wiggle room depending on whether documentation elements were captured as free text or discrete elements, and our visits occasionally move up or down the E&M code spectrum after coding review.

Not surprisingly, I tend to fall at the lower end of the pack as far as charges per encounter, which makes sense with my primary care roots and all of the managed care red tape I’ve had to deal with. I tend to be less free with prescriptions as well, which is understandable given the risks of polypharmacy with patients you don’t know well. It was interesting to see the comparative data and what some of my colleagues are doing though – I average 0.64 prescriptions per patient encounter, where some of my colleagues are in the 1.6 and 1.7 range. Most of our group is in the 0.85 range, so I’m not that far off the mark. Given the range, though, I recommended that next month we slice that data a little differently and look specifically at newer vs. established colleagues, moonlighting residents vs. midlevel providers vs. supervising physicians, full vs. part-time provider status, and distribution by location.

We look at a lot of our data in aggregate, which makes it interesting when you know you have outlier data. Since we have our own in-house ultrasound and CT scanners, we look at the timeliness of referral for those modalities. Since I only work part time, any fluctuations in my practice patterns show up a bit more acutely than my peers who see many more patients each reporting period. My “timely referral for diagnostics” metric was significantly off from last month, and the COO got a kick out of the fact that I could recite the clinical situations of the patients whose visits drove the numbers. I had a flurry of cases that had to be transferred to the emergency department for higher acuity care (and in two cases had to go straight to the operating room) and let me tell you, those are the shifts you don’t forget.

The urgent care keeps trying to lure me into a full-time role, and it’s getting more difficult to resist its call. We agreed to talk again in a few months. In the meantime, we’ll have to see if HIMSS brings any new and exciting opportunities to light my informatics fire.

If you could have any job in the world, what would it be? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/26/17

CMS rolls out the MIPS red carpet for small, rural, and underserved practices with a webinar on February 1. CMS will be discussing eligibility, 2017 participation, data submission, performance categories, scoring, and resources available to practices falling into these categories. Figuring out a MIPS strategy is hard enough for large practices who have relatively greater resources, so I can’t imagine how a small independent rural practice might struggle. I’ve done some engagements with that demographic and many of them can’t even figure out how to afford a reasonably priced consultant given their payer mix (lots of Medicaid) and the challenges of treating the medically underserved.

Whether you’re a cash-strapped practice or not, CMS has also given some confusing messages when discussing the Medicare volume threshold for excluding practices from MIPS. There have been questions about whether providers have to meet the charge threshold AND the volume threshold, or whether it should be an OR function. The answer is that it depends on how you ask the question. If you’re asking who is excluded, it’s providers who Medicare Part B allowed charges are less than or equal to $30K OR if they see fewer than 100 Medicare Part B patients annually. If you’re asking who is eligible, it’s providers who meet the charge threshold AND see more than 100 patients. For those who think proper sentence construction is antiquated: case in point.

I just took a long-term assignment with a client whose basic business processes are in total disarray. They haven’t been looking at their staffing or expenses for months and have dug themselves into a deep hole. Originally, they thought there was some kind of embezzling or theft, but after a thorough investigation, it points to a total lack of management.

Looking at the “at your fingertips” reports available in their online payroll system, I identified a handful of employees who have been logging overtime daily for more than a year. In interviewing the employees and their direct managers, no one has ever noticed it, let alone discussed it or taken steps to mitigate it. When assessing one employee’s daily assignments, it turns out she has been doing various tasks that belong to three other employees and that has been eating up a good chunk of her time. It never occurred to her to discuss this with her manager, which is one issue, but the manager’s failure to notice the overtime is another. And accounting’s failure to notice a significant budget variance is a miss as well as practice leadership failing to notice that accounting didn’t call it out.

We discussed sitting down with the employees and working through their daily tasks to find out what was generating the overtime, but they were uncomfortable leading the discussion. I agreed to work with them, taking the “watch one, do one, teach one” approach to get them to a point where they were at least minimally capable of managing their own resources. It was a painful few days of discussions, coaching, reviewing, role-playing, and revisiting, but we at least stopped the bleeding with a new policy to prevent employees from logging overtime without a direct manager approval that is documented in writing. Although many of the overtime-inducing tasks were administrative, several of them were clinical in nature and we had to make plans to ensure that work didn’t fall through the cracks.

The bigger point here is that if a practice can’t handle Office Management 101, how are they going to handle the increasing data-gathering and reporting demands required as healthcare evolves? And if they can’t figure out how to resource current tasks or how to eliminate non-value-added processes, will the patients suffer? How will they create processes for team-based care, increased coordination with external providers, management of transfers of care, and more? There are plenty of vendors out there pushing technology solutions that will only automate bad processes and it’s challenging to have these hard conversations with organizations about how they do business. If they’re not managing their human resource overhead, they may not be managing their supply overhead, either. And it’s a safe bet that if they’re not on a cloud-based EHR, they’re not managing their servers and hardware, either.

Ultimately some of these practices aren’t going to be financially viable. My primary care physician’s practice recently disbanded. The partners had very different ideas about what “productive” looked like, which resulted in one partner carrying the lion’s share of the overhead. Over time this became untenable, and his aging partners weren’t willing to work harder or longer hours.

My PCP grew increasingly disillusioned and his partners couldn’t afford to buy him out, so they agreed to close. It’s been a culture shock as he moves into the ranks of employed physicians. Fortunately, he didn’t have to join a big health system group, but became an employee of a small independent practice. Based on all the things he no longer worries about, he has more time for patient care, but it’s been an adjustment. We’ve been friends for a long time, so I did a therapeutic intervention and used some of his free time for dinner and a movie. I think we’ll be able to get him through this.

It was interesting watching the wind-down from the patient perspective, however, since I had gotten used to having access to the practice’s patient portal for all my needs. I was glad to see that my records still remain on the vendor portal. They didn’t disable all the features, though, so it still allowed me to send an appointment request, a refill request, and a message to the physician, but I know for a fact that no one is monitoring it because the practice’s servers have been decommissioned and are in a box in his basement. I found the notification that the practice was closed and where patients should contact the physicians, but it was buried three screens deep in an “about our practice” area of the site.

I had taken advantage of their personal health record download functionality after my last visit so I already had what I needed, but it was good to know my records live on with the vendor. My new physician uses the same vendor, so hopefully it will all connect and be good to go.

How portable has your PHI been with system migrations and practice mergers? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/23/17

I wrote last week about a real-world curbside consult from my IT colleague, Jimmy the Greek. As promised, here is the second installment of Dr. Jayne’s Journal Club, where we will continue with our patient case presentation.

When we last left Jimmy, he had been referred from the physiatrist to an orthopedic surgeon. I didn’t go into detail about insurance or how much this has been costing him, but since it’s a new year, I’m betting he’s facing a new (and most likely daunting) deductible. When I was a CMIO at Big Health System, we always saw a dip in business during the first month of the year, but things picked up in February as people met their deductibles. I don’t have access to that kind of performance data any more, but I wonder what those curves look like given the expansion of high deductible plans.

At the end of my last piece, I had just made an appointment to review my MRI results with Dr. Professional himself. I arrived at the appointed time (15 minutes prior to the appointed time, actually) and after I explained why I was there, I received a terse “ID and insurance card” along with the outstretched hand of the front desk attendant (who, for reasons unbeknownst to this author, was the only one in the office wearing scrubs.)

After a considerable wait, I was shown to an exam room, where I met a physical terrorist … err, therapist. She took down the same history I had provided the doctor in previous visits, so either my records weren’t updated or she didn’t bother to read them. Finally, the doc comes in and pulls me out into the hall, where he has my MRI results pulled up. Yep, in the hallway, where anyone walking by can take a look. So much for HIPAA.

Dr. Professional explains that he sees some osteoarthritis and he wants me to consult with an orthopedic surgeon to see about laparoscopic surgery. I’m given a referral and sent on my merry way.

A friend of mine is an orthopedic surgical nurse at Big Hospital System, so I asked her about the guy who might shove soda straws into my hip joint (Yes, I watched the YouTube video. Yes, I now know I should not have done that.) She asks around and comes back with a consensus from the docs she asked: “He’s competent.” Not exactly a ringing endorsement, but I’m planning on a second opinion anyway, so I set up an appointment to see Dr. Competent.

Being a savvy healthcare consumer, I obtained Dr. Competent’s new patient forms from his practice website, printed them, and filled them out ahead of time. Confidential to all of you CMIOs and practice managers out there – fillable PDFs are a thing now, and if you don’t have them available for patients, you should. If you can’t figure out how to do it, I’ll do it for you – contact me through Dr. Jayne. I promise my rates are as reasonable as the amount of time I spend in your waiting rooms.

Upon arrival at Dr. Competent’s MegaOrthoMart Practice, I handed in my homework, forked over my ID and insurance card, and was promptly handed two additional forms to fill out, which requested much of the same information that I had provided on the phone when making the appointment and on the forms I filled out ahead of time. Then I got to wait until a registrar became available, and she more or less walked through the forms and asked me if each line item was correct. It’s now 35 minutes past my 8 a.m. appointment time and I’m still stuck in the lobby.

Someone finally comes to get me and the first thing they want to do is take x-rays. Remember the last installment? I’ve had x-rays and an MRI. Despite the fact that I brought the imagery with me, MegaOrtho insisted on doing their own because they “can’t be certain of the technique used to obtain [my] existing films.” I tend to believe the real reason they wanted to take more x-rays was more along the lines of, “This way we can bill your insurance company for more services.” When I get my explanation of benefits, I’m sure I’ll see an office visit from Dr. Competent, a facility fee from MegaOrtho, and imaging fees from MegaRadiology. At least MegaOrtho is independent and not part of Big Hospital System or they would be after their piece of the pie, too.

At 9:15 AM (a full 75 minutes past my appointment time), I finally get to see Dr. Competent in all of his frat-boy glory. Without introducing himself (what is it with doctors just assuming you know who they are?), he proceeds to explain what’s wrong, explains that surgery is an option, but a cortisone shot and physical would be a better first step. I’m all set to get the cortisone done, but he explains that he doesn’t do that for Dr. Professional’s patients. So now I get to make another appointment with him for an ultrasound-guided cortisone injection.

At this rate, I’m going to need to take a second job just to fund my co-pay habit (see “fillable PDF” offer above). The cynical part of me can’t help thinking that this is just a scheme to extract as much money from me and my poor, innocent insurance company as possible. I don’t begrudge anyone the ability to make a living, but this just seems excessive. (For those of you keeping track at home, we’re up to three appointments with Dr. Professional now.)

The one bright spot in this adventure has been the staff at the physical therapy place. Everyone there is friendly and efficient. Here’s to a speedy recovery and success in physical therapy. If I have to have the hip scoped it, it’s a longer recovery than I’d like, so keep those patient information forms coming my way; I’ll apparently have lots of time on my hands to create fillable PDFs.

Looking at this entire saga through my CMIO lens, the element of the story that strikes me most is the fact that we’ve spent billions of dollars trying to make healthcare better and we still haven’t solved the basic problems that patients face. Let’s look at customer service. In some situations, customer services has gotten worse as front desk staff are under increased pressure to ensure collections. Staff members are also encouraged to maximize throughput even if it doesn’t make sense and patients are filling out duplicative information. We haven’t mastered basic technology such as fillable online forms and practices are often reluctant to fully leverage patient portals, especially to collect information on new patients.

We still have clinicians who are too busy to read (or don’t trust) the history in front of them, so they ask redundant questions. We haven’t spent money transforming our office spaces to increase patient privacy or comfort and still show images in the hallway. Despite the advent of provider ratings and online reviews, patients still have limited information to judge a physician’s competency. We’ve also pushed providers and health organizations to the edge of financial viability, leading to increased reliance on provider-based billing and facility fees to get as much money out of the system as possible.

Despite the ability to exchange data or having images on CD in front of us, we repeat testing because we don’t trust our peers or are too pressed for time to look at the films before we decide whether the outside radiology group’s technique was adequate. Or maybe we’re just after the money. We have handshake professional agreements where a consultant doesn’t provide a service to a patient when he could, and instead sends the patient for another visit to the referring provider (and another co-pay and another day off work). I hope our patient’s cortisone injection and physical therapy does the trick because I would hate to see him panhandling for contract PDF work outside the next medical staff meeting.

Unfortunately, the continued push for more use of EHR technology and more metrics and more data points isn’t going to change human behavior. It seems like it’s getting harder to find organizations willing to spend money on the so-called “soft skills” or on truly transforming healthcare. They’re too busy trying to figure out how not to be penalized or worrying about when their vendor is going to release the next version of Certified EHR Technology.

What’s the answer to making healthcare something we can be proud of? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/19/17

CMS announced today that over 359,000 providers are confirmed for four CMS Alternative Payment Models in 2017. This includes over 2,800 primary care practices participating in the Comprehensive Primary Care Plus initiative.

Although CMS is celebrating this as a victory for improved quality and reduced costs, there are a couple of things to note about the numbers. First, CPC+ was originally opened for up to 5,000 practices and CMS recently expanded that to 5,500. The cohort is barely over half full, which could mean a couple of things.

First, it could mean that practices aren’t exactly clamoring to participate in these models, which require more documentation and increased compliance requirements in exchange for higher payments. Practices might be nervous that they can’t recover the increased outlay needed to participate. Second, it could mean that practices applied but weren’t qualified to move forward, which would be a sad commentary on the state of value-based care transformation. One would expect that at this stage in the game they’d be able to do better than half capacity.

The Medicare and Medicaid EHR Incentive Program attestation website is open for business. Participants have until the end of the day February 28 to attest to Medicare 2016 program requirements. State deadlines for Medicaid programs vary. There are plenty of resources out there and a handy dandy Attestation User Guide that I wish more of my prospective clients would read before they call me. It outlines the process in gory detail with lots of screenshots and answers a good number of the questions I frequently receive.

Lots of chatter around the physician lounge about Atul Gawande’s recent piece. His premise, that the US health system rewards “heroic” care at the expense “incremental” care is an issue that I’ve written about in the past. We’re always looking for the newest, most high-tech interventions, but we neglect to really advocate for (or fully fund) things like public health, disease prevention, cancer screening, and more. It’s not glamorous to sit in an exam room and have the same discussions over and over with patients about weight loss, smoking cessation, moderation in diet, and increased activity.

Gawande lays it out like it is: “As an American surgeon, I have a battalion of people and millions of dollars of equipment on hand when I arrive in my operating room. Incrementalists are lucky if they can hire a nurse.” That’s the unfortunate reality for many primary care and non-procedural specialists in our healthcare system. Technology and incentive programs are supposed to help us better manage patients and level the playing field, but for some physicians, it’s too little, too late. Two more of my favorite physicians retired at the end of the year and I think we’re going to continue to see attrition in the generalist ranks.

The biggest chatter, though, has of course been about the upcoming inauguration and the pending repeal of the Affordable Care Act. One rumor making the rounds is that MACRA will also be repealed, which is an entirely different situation. It doesn’t help that plenty of people don’t understand the difference between the two, which adds to the confusion. Patients are also extremely worried about the potential loss of insurance coverage and increased premiums, regardless of whether their coverage is through employers or individual purchase.

The HIMSS17 invitations have started rolling in, but I happened across the Salesforce Trailblazer Party at BB King’s Blues Club on Tuesday night. I’m guessing I might be out of touch with some pop culture phenomenon, but I’m not following what is going on with the character in scrubs with mittens and an animal suit. There are also plenty of one-off marketing emails coming in. Pro tip: please make liberal use of spell check and grammar check. The plural of customer is “customers” not “customer’s.” Don’t just say you’re revolutionary – tell me why and what you do.

An informatics colleague handed me an article about the new Forward clinic in San Francisco. They’re advertising “AI and doctors working together to better manage your health.” Billing it as a “Health membership” they charge $1,800 a year, which they cleverly market as “$149/month billed annually.” Although they say they have a world-class medical staff, I didn’t see any names listed on the website. They do have a body scanner to give a “rapid picture of overall health.” One article about the practice has some interesting premises. It talks about the ability to re-engineer the user experience at the physician office. One example is a “hidden alcove for urine samples in the bathroom, and no need for an embarrassing walk down the hall.” Many physician offices (especially those that perform a lot of urine testing) already had those, so not revolutionary.

It also mentions the body scanner: “a machine that takes a few cents of electricity to run replaces the traditional 20-minute examination for blood pressure, heart rate, and other vital signs.” I hate to tell the Silicon Valley folks, but if 20 minutes was their baseline, that’s terrible. Very few primary care physicians (at least those of us working on the hamster wheel) would tolerate a staffer that took 20 minutes to perform basic patient intake. The efficiency nut has already been cracked by vital signs monitors that integrate to the EHR and smart beds that perform weight when the patient sits down. The article does include a comment from a physician and former venture capitalist who notes that the complexity of the healthcare market is often underestimated and I would tend to agree.

Another article mentions that “people with longer term issues such as obesity, high blood pressure, or skin problems will go home with sensors that can transmit data back to Forward.” I get the obesity and blood pressure hook, but skin problems? What are they sensing? And is it evidence-based? Has it been peer reviewed or approved by the FDA? Or is it digital snake oil? Health policy expert Paul Ginsberg is cited in the piece and notes the risk of unnecessary tests being triggered by use of sensors: “The notion of scanning people who don’t have a problem has been very solidly dismissed by the medical profession for a while.”

What do you think of Forward? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/16/17

In the hospital, a curbside consult is an informal consultation between physicians that avoids the sometimes cumbersome request and documentation requirements for a “real” consultation. Of course, without the request and documentation piece, it also avoids the billing and payment piece, so it’s essentially a freebie given between colleagues.

Most of the time you never know who the patient is. It just starts out along the lines of, “I wanted to pick your brain about this guy…” Doctors get curbsided by their friends and family members as well, usually about a test result or a visit to the doctor. Most of the time the requests I get from friends are easy to answer. This week though, my IT colleague Jimmy the Greek asked me to translate his MRI and I was digging deep to find anything in my memory about a “pistol grip deformity” of the hip.

Thank goodness for eOrthopod, who was able to quickly answer my question so I could talk intelligently about his situation, which I had been following tangentially over the last few months. As we go boldly where no one has gone before with a new president and the impending repeal of the Affordable Care Act, I thought it was worthy of sharing and discussion. So get your popcorn, wine, tequila, or other beverage of choice and sit back for the first installment of Dr. Jayne’s Journal Club, where we will review a patient case presentation.

A year ago, I injured my hip in martial arts class participating in kicking-for-height competition with a 15-year-old whose flexibility would make Gumby green(er) with envy. I’ll have your loyal readers know that I won that contest, despite the fact that I seem to have lost the war, and have now been set adrift in the murky waters of consumer-driven healthcare. For months, my hip would hurt, so I’d rest it, but then go take another martial arts class, where I’d aggravate the injury again. I finally quit taking lessons in August and I assumed that without the thrice-weekly strain I was putting on the injury, it would heal quickly. Finally, in October, I couldn’t take it anymore and went to see my chiropractor. (Being a savvy consumer of healthcare services, I didn’t want to go see my orthopedist right off, as that’s like asking my barber if I need a haircut).

After a few weeks of adjustments, home exercise, and K-Tape, my chiropractor referred me to a physiatrist. I was warned ahead of time that, “He and his office staff are . . . a bit quirky.” My first impression of this highly-regarded doctor was formed when he blasted the exam room door open, pointed at me, motioned toward the hallway, and said “You – come out here.” While his bedside manner (and as I learned later, professionalism) left quite a bit to be desired, he seemed knowledgeable and capable, and really, that’s what’s important.

I was sent for an x-ray to rule out anything skeletal and told that the office would receive the results electronically and call me to discuss next steps. After completing the x-ray, I left a voice mail in the practice’s general mailbox to let them know. The outgoing message admonished me to wait at least 48 hours for a reply and not to call back before then, as doing so would drop me to the end of the line. I waited a whopping four days for a call back and finally decided to risk my place in line. The not-so-cheery voice on the other end of the phone told me that no, I would not get a call, and no, I did not need an appointment. All I had to do was show up on the practice’s doorstep, imagery in hand, and the doctor would see me immediately. I agreed to come in the next week, as I was on vacation from work.

Fast forward to Monday morning, when I darkened the aforementioned doorstep with my presence. Sadly, that’s all I could darken because the door was locked. It seems that this paragon of all that is good and right with the practice of medicine decided to take Monday off. The desk staff was working, however, and when I bent their collective ear about better communication with patients, I was (quite literally) screamed at for my trouble. For those of you keeping track at home, I had already been given two conflicting pieces of information about how to get my test results, neither of which I would later find out was correct. Dr. Professional reviewed my x-ray early the next morning and decided I was in need of an MRI with contrast agent.

This morning, I dutifully arrived 15 minutes early for the procedure so I could fill out the exact same paperwork I had filled out before the x-ray, despite the fact that I was merely at a different location of the same imaging firm run by the same hospital system. I was told by the technician who was getting me prepped for the procedure that the radiologist performing the arthrogram is notoriously late. When she finally arrived (15 minutes after her scheduled start time), she approached me with a needle that looked like a cross between a whaling harpoon and the drill bits that arctic researchers use to take core samples. Once the lidocaine kicked in, though, it didn’t matter. The staff tried valiantly to get me to use the standard MRI machine, but in the immortal words of Clint Eastwood, a man’s gotta know his limitations. Mine happen to include enclosed spaces. Off we went to the “open” machine, which, much to my chagrin, is about as open as Internet access in North Korea. I only required one break from my incarceration in the evil machine.

Instead of going straight home, I decided to drop in on Dr. Wonderful (CD in hand) to get his take on my MRI. While en route, I called the office to make sure he was there. It only took me three tries to get through to a human. When I told her why I was calling, she was astonished that I would ever think to just drop in, because as everyone knows, an appointment is required to review imaging results with the doctor. So now I wait until next week.

I am familiar with the physician in question, but hadn’t had any patients in common for nearly a decade, so decided to do some Google stalking. He’s on staff at Big Medical Center, so would have access to the clinical data repository at a minimum and most likely would have direct access to the PACS due to his specialty. He’s been recognized multiple times by his peers as one of the community’s “Best Doctors in Town” which can be confusing since patients don’t understand how those honors are usually bestowed. Our city’s magazine that runs the feature every year solicits feedback from other physicians, but many of us think it’s a joke because one colleague had moved away three years prior but continued to be on the “best doctors” honor list.

He’s got four stars on Healthgrades with 28 reviews and no disciplinary actions by the board of healing arts. But it sounds like his practice is disorganized and doesn’t take advantage of patient-friendly technology solutions like a patient portal or secure messaging, even though they have a portal link on the practice website. There’s no information on the website about the processes and procedures that didn’t work so well in this case, so a patient looking to do things the “right way” would have trouble confirming.

Of course, in consumer-driven healthcare, the patient’s main recourse is to vote with his feet, which is sometimes challenging to do when you’re partway into a course of treatment or into a diagnostic process with another provider. Fortunately, our patient has his imaging studies in hand, which sadly not every patient has. Our patient is also a well-educated IT guy with the flexibility to make time during the day to call offices and run down results, and many patients don’t have the ability to do those things, making their diagnostic and treatment course even more fragmented.

When I hear about situations like this, I think about whether technology would have made anything better. There were definitely some opportunities here, but the real issue isn’t something that the current focus of regulation or rulemaking is going to address, other than patient satisfaction scores, which I hope were appropriately low in this case, if they were even solicited.

Our patient has since been referred to an orthopedic surgeon, so we’ll have to check in with him down the line to see if the brave new world of high tech healthcare has done any better for him. As a consultant, I see these situations all the time, and typically the physician is resistant to change as are the members of the office team, who seem to be part of the problem here. The worst cases are often the hardest to fix.

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EPtalk by Dr. Jayne 1/12/17

The American Board of Preventive Medicine announced the retirement William Greaves, MD, who has been its executive director since 2012. Greaves helped guide the Board’s inclusion of the Clinical Informatics subspecialty. Benson Munger, PhD will serve as interim executive director. Munger was deeply involved in the creation of the AMIA Clinical Informatics Board Review Course and the informatics community is enthusiastic about his role as the ABPM begins its search for a permanent executive director.

Speaking of physicians considering retirement, Massachusetts General Hospital has a 100-year-old physician who is still coming into work after 65 years. Dr. Walter Guralnick spends his time teaching residents rather than seeing patients. With a strong belief in equal access for all, Guralnick led the charge for dental insurance and founded what became Delta Dental.

ONC has released the updated Certified Health IT Products List. In addition to the list of products on the “nice” list, there are now two pages for products that are no longer certified and developers who are blocked from certifying health IT products. The “developer ban” page is blank and the “decertified products” page has a lot of 2015 edition software, so it’s hard to know what you’re really looking at.

Lots of reader mail this week.

From Daredevil: “Re: E&M coding. My hospital made an interesting choice to bill facility charges but no professional fees in its busy (hospital-owned) pediatric urgent care. As such, the providers were not burdened with counting elements in their documentation. We could simply document items required for clinical care and/or general risk management. This made it easier to focus on managing the patient, especially during high-volume times. The providers were compensated based on covered hours and procedures performed. The providers were eventually incentivized for throughput and had plenty of opportunities to work extra hours at a reasonable rate, so things seemed generally equitable. I would love to see E&M billing go away. The surgeons have it right with global billing. Their notes — at least in the hospital setting and for post-op visits — while seemingly sparse, stick to the facts. There is no endless scrolling to see what they are thinking.” This flat-fee approach is similar to what many cash practices do and what my urgent care does for self-pay patients. It’s not hugely profitable, but it keeps the lights on and allows the staff to deliver valuable and often much-needed care. It’s an interesting approach and I will be interested to see what some of my local colleagues think.

From End of Shift: “Re: complexity of the patients at the end of a shift. I found more than once that the last patient on a Sunday evening was the most perplexing or complex for the day. The tendency to want to expedite that patient who made it in right before the doors locked was also met was often met with the reality that this patient / family was the one who was home all day debating whether their concerns warranted a visit to the urgent care. I saw more than a few who needed a trip to the emergency department. It doesn’t seem to matter which setting we are practicing medicine in these days, but there seems to be constant pressure to do more in less time. I think we would all be better clinicians with better outcomes if we had the chance to slow things down a bit.” Thinking about patients debating whether their condition is significant enough for a visit certainly puts a different spin on things. We’re also seeing patients holding off on care due to rising copays. Last year, most urgent care copays were at $50 but we’re seeing a lot this year that are $75 and $100, which means their ED copays are probably $150 or $200. The price point alone is going to have an impact in shifting where care is delivered, even if it doesn’t change the nature of the care required.

Illinois healthcare organization Presence Health has been fined $475,000 for lack of timely breach notification. The fine centers around an incident in October 2013 where paper operating room schedules went missing from a surgery center. They didn’t notify OCR until January 2014 and the investigation showed that patients were not notified within 60 days of discovery as required. Over 800 patients were affected, so a media notification would also have been required. Details of the investigation reveal similar notification delays from breaches in 2015 and 2016.

The new year seems to be bringing new jobs for many, at least according to my LinkedIn updates. I’m also seeing people update their profiles, potentially in search of new jobs. Pro tip: disable notifications before you start doing a bunch of updates so you don’t look like you’re getting ready to jump ship. I’m helping a client try to expand their EHR support team so I can offer some other job hunting tips based on the resumes I’m seeing:

• Be sure you meet the minimum qualifications listed in the job posting or explain what equivalent skills you have that make you an attractive candidate. I’ve had more than 40 people apply for a physician informaticist position who are not physicians. My client might consider a nurse or pharmacist, but these folks had literally no clinical credentials. Similarly, if the posting requires five years experience, you might squeak by if you’ve been in the field for four, but if you have never worked in the field, it’s a better idea not to apply and waste people’s time.
• Spell check your resume and have someone else review it for flow, consistency, and whether it makes sense. One candidate’s “summary” paragraph took up half a page and was a rambling incoherent explanation of why they appeared to job-hop every 18 months. Another’s was riddled with typos. Some include every job the applicant has had since high school, which just adds clutter.
• Don’t expect clients to relocate you if the posting doesn’t mention relocation assistance. I have an ambulatory client in a small Midwestern city that is looking for a full-time billing office manager. Several people have applied from across the country. Since they were good candidates, we did phone screens, hoping to hear stories about people looking for jobs because they were relocating to be close to family, move with a spouse, etc. At least two of them asked about relocation packages, which is out of character for a 10-doctor practice. Understand your audience and your potential employer.
• Make sure your contact information is professional. Your email address mustdrinkbeer@domain.com might have seemed like a good idea when you were in college, but it’s a terrible idea when you’re trying to be a professional adult.

What’s your best employee recruiting story? Email me.

Email Dr. Jayne.