EPtalk by Dr. Jayne 11/10/16

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/7/16

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/3/16

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/31/16

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

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

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

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

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

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

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

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

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

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

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

What’s your favorite Halloween candy? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/27/16

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/24/16

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/20/16

It’s been a busy week as people begin to digest the contents of the MACRA Final Rule. Most of the physicians I’ve spoken with are worried specifically about what they need to do in order to meet requirements for 2017. It would be a mistake, however, to not spend some time planning for 2018 and beyond. CMS will increase the number of outcome metrics as time passes, while also increasing the weighting applied cost measures. CMS is also making changes in the Medicare Shared Savings Program. Although 2017 may seem to be a low-risk year where providers can take it easy, in reality 2017 should be a year where providers work to maximize their performance in preparation for future years.

Providers are going to be increasingly graded on performance and if they’re not honing their skills they’re going to be behind. Our favorite Geek Doctor, John Halamka, weighed in on the Final Rule as well:

Think of MIPS not as four separate categories (quality measurement, cost control, practice improvement, and wise use of IT) but as a single program focused on rewarding clinicians for improving quality and penalizing clinicians for non-participation. There are only a few ways to change clinician behavior – pay them more, improve their satisfaction and help them avoid public humiliation (like poor quality scores posted on a public website). MIPS pays them more, consolidates multiple other government programs, and provides flexibility to give clinicians every opportunity to make their quality scores look good.

As much as everyone has been waiting for the Final Rule, it’s not entirely final. It was released as a final rule with comment, which means that we have 60 days to continue to weigh in. There’s still the opportunity for our feedback to be heard by those who will make subsequent rules and those who will tweak this Rule as it is applied. We’ve seen from previous iterations with Meaningful Use and other federal programs that the only constant is change.

I had the privilege this week of lunching with some former co-workers. We all worked together on a large health system’s EHR implementation project starting more than a decade ago. Although we try to get together quarterly, it gets more and more difficult unless we plan it months in advance. We’re all still in healthcare, although we’ve branched out into consulting, quality improvement, program management, and interoperability roles. Two of the group have come full circle and are again helping the large health system with an EHR implementation as they perform a massive rip-and-replace of all clinical and financial systems.

It was gratifying to learn that although much time has passed and it’s a different system, many of the processes we created are being dusted off and used to help the practices navigate the transition. Regardless of the type and scope of the project, the change leadership and governance pieces are essential and fairly timeless. It sounds like it’s been a bit frustrating for my colleagues who are on the ground, as the organization has lost some of its institutional memory. The current project is being handled as an IT project that has a couple of clinical advisors, rather than as a clinical / operational project with IT support as we had done in the past. They’ve already experienced massive scope creep, delays, and cost overruns.

There are also issues with IT leadership not understanding the needs of a large provider organization. They actually tried to tell the provider group that they “won’t be allowed to onboard any new physicians or practices during the transition period,” which is over 18 months long. That statement alone shows a fundamental lack of understanding of what is going on in healthcare today, as providers are being consolidated into larger organizations either willingly or in response to fear. I can’t imagine telling a CEO he can’t onboard new physicians, but apparently it happened. I’m betting the follow up phone call to the CIO was interesting, to say the least. When you’re spending upwards of a third of a billion dollars on a project, impeding strategic growth probably isn’t the best idea.

Back when we were doing our original implementation, we needed a full-time person to go around and do some periodic retraining for providers. We had the opportunity to hire a retired IT staffer who had been a physician liaison and was dearly loved. The powers that be told us we couldn’t justify a full-time position, so we brought her on as a contractor. I laughed out loud when I heard today that she is still there, eight years later. Maybe that position would have been justified after all.

The health system is wrangling with the same issues that we fought with the original EHR, including how to handle private/community physicians that want to be on the platform but don’t want to pay for it, as well as how to support the infrastructure. Where we were worried about making sure everyone had adequate bandwidth via DSL or T1, now they’re working to upgrade everyone to fiber. They’re still dealing with patient consent around interoperability as well as difficulties with patient matching and provider attribution. Although they’ve made some headway on those issues, the core problems still remain tricky.

Another theme with the group was trying to maintain some kind of work-life balance given the continuing chaos that healthcare reform and ensuing technology requirements has created regardless of role. I remember when we started, the understanding was that we’d do this rollout for 18 months and then go back to our original jobs. The organization quickly realized that it was unlikely for that scenario to play out. A decade later we’re not only still at it, but most of us are leading teams of people dedicated to the ongoing support of healthcare IT and clinical transformation. Some of us are still burning the candle at both ends, which although sustainable for a few years, starts to wear on you when you’ve been doing it nonstop.

By the time we get together again, it will be 2017 with all the MIPS and APM-related excitement that brings. It will be a new year for penalties and incentives, with new clinical quality measures, new carrots, and new sticks. It’s been great to have a core group of friends who can support each other as we go through this, venting about our respective situations and the challenges we face. Looking at what’s coming down the road, we’re going to need each other to stay sane.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/17/16

Everyone in informatics circles has been buzzing about the release of the MACRA Final Rule. As is typical for CMS, it came out on a Friday afternoon. I know a lot of people were hunkered down reading it, me included. I did what I could with it Friday, but on Saturday I had a previous commitment to teach some team-building sessions as part of a local outdoor classroom program.

The type of change that MACRA is trying to drive and the stresses it is going to place on healthcare delivery organizations will require that organizations have high-functioning teams. They’re also going to require intense project management and active management of resources and outcomes. Although many organizations have already figured this out and have robust programs in place (or have hired consultants to do the dirty work), there are numerous organizations that are just trying to figure out what their first steps should be.

When you place stress on teams like these MACRA-related projects are certain to do, teams will either rise to the occasion or they will fall apart. Although some people throw their hands up and just watch things devolve, there are active ways to manage team dynamics and to get your people in the right place so they’re well prepared to take on new challenges.

The program I staffed this weekend brought out many of the types of issues that organizations need to be thinking about as they evaluate how they will handle MACRA-related tasks and who will be responsible for executing them.

Our program brings together people from different backgrounds and throws them into a situation that is unfamiliar for most of them. This year’s group had about 50 participants from all different disciplines – healthcare, manufacturing, communications, technology, and a couple of college students. Even if we have participants coming from the same organization, we mix them up so they’re not working together.

They’re placed in group of five to eight with people they’ve never met and they have to handle a variety of objectives. It’s outdoor classroom with camping and survival skills. Some of the participants may not have done so much as roasting a s’more, so we provide several coaches for each group to help them through the process.

The course starts with an indoor session with a few outdoor elements where they practice basic team skills, and then we follow up with the actual outdoor weekend portion. Their first task was to come up with a team name and motto. We use a variety of exercises to work them through the stages of team development – forming, storming, norming, and performing.

My team definitely had some forming issues because only two of them had arrived by the time the session started. The ability to get to meetings on time continues to be a major issue for a lot of people, which makes it challenging to be a high-performing team. Once the rest arrived, we had some rehashing and revising of the team name, but the team was able to eventually move forward once the late arrivals understood that they couldn’t complain about decisions that were made when they failed to perform.

The teams learned some basics of outdoor cooking and assigned members to roles, identifying leaders and supporting members. When you’re headed out into the woods for a weekend, it’s key to know who is responsible for what. Just like complying with federal regulations, if someone drops the ball, everyone suffers, and having clear chain of command and documented responsibilities makes things easier. The teams are provided with a series of tasks that they have to complete prior to the outdoor portion, and I thought I lucked out when I had someone who immediately volunteered to set up conference calls and meetings to get everything taken care of in the interim.

They met once by phone and once in person during the two-week gap, learning some important lessons on logistics when only half the group showed up in person. The other half was at another meeting place, because leadership failed to recognize that “meet at the XX restaurant by the mall” wasn’t specific enough since there were four different locations of the chain in close proximity, including one actually in the mall. How many times do we have situations like this in healthcare IT? The team thinks they have a clear plan and everyone voices understanding, but it turns out there were multiple ideas about how things were actually going to happen. Although it wasn’t that big of a deal when you’re just dealing with a voluntary team-building program, it’s a huge deal when you have miscommunications around federal requirements and regulations.

There was some last-minute planning, but it appeared they had everything figured out prior to their arrival for the weekend. Unfortunately, one-third of their team was late, leading to delayed setup since people were bringing different pieces of equipment. Across the meadow, the other team I was cross-coaching had arrived and began to set up in a disciplined fashion. Their only glitch was not having their team tee shirts done on time, which they remediated with some ad-hoc spray painting. I was doubtful when they pulled out the cans as to how well it would work, but when they pulled out a drop cloth, rubber gloves, and pre-cut stencils, my doubts were laid to rest. It may have been last-minute, but it was well planned and well executed.

In working with both teams, it was clear that one was more successful. In trying to dissect the reasons behind that success, the major factor was that they put the good of the team beyond their individual needs. They were up early each morning to take care of team tasks, where my team had issues getting out of their tents. I definitely earned my coaching stripes this time around since I had to roust grown adults out of their tents two mornings in a row. I also had to pull out some camping magic when my team failed to follow some of the cooking instructions and their dinner was in jeopardy. Luckily my other team had prepared extra charcoal and had extra supplies, which I was able to borrow to bail my team out. Again, in most of our organizations, we’re running so lean we can’t count on a bail-out. We have to be organized and in command of the situation.

I was hoping that my primary team would see what was going on with the other team and rise to the occasion. Although some team members started to get the message and get with the program, others either didn’t see the possibilities in front of them or maybe just didn’t care. Sometimes we see that, when organizations have enrolled wary participants. Hopefully those that didn’t fully embrace the program learned something along the way and can find elements of the program to take back to their home organizations. I know I learn something every time I put on this program and there are always different challenges to be overcome and different personalities to work with. I come back to my work energized with new tricks and techniques to try to motive my teams.

We’re definitely going to need energy and motivation to make it through MACRA-related reforms and all the sub-projects that will entail. Although I was tired from a couple of nights of sleeping on the ground and herding cats, I’m ready to tackle the rest of the Final Rule.

What kinds of strategies do you use for team-building? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/13/16

Several of my clients applied for the CMS Comprehensive Primary Care Plus initiative. One reached out to me after receiving a letter from CMS that required a response in an extremely short time frame. It sounds like practices that offer services other than just straight primary care may have been flagged in the application process to provide additional information. CMS was concerned about whether they could isolate their primary care providers and data if they were selected to participate in the program.

I understand the need to make sure applicants can meet the requirements, but the short turnaround time and unexpectedness of the letter created a lot of stress for my client. We were able to gather the required information for the response, but it was a good example to remind them that if they’re selected, they will be even more at the beck and call of CMS.

Speaking of CMS, a friend of mine who works for a vendor mentioned her concerns about the Social Security Number Removal Initiative. This is a big deal for people who are worried about identity theft since Medicare patients have long been identified with their Social Security Numbers. During 2019, Medicare will issue new identification cards to all beneficiaries. This also means that vendors have to adjust their systems to accommodate the new numbers while preserving the old numbers for historical purposes, rebilling, etc. Depending on the timeframe for mailing the new cards and what portion of a practice’s payer mix is made of Medicare patients, we could see some serious check-in delays and billing issues. I’m not sure if contractors have been selected to deliver the cards, but I hope it goes better than Healthcare.gov did.

Pet peeve of the week: I had mentioned previously that people who try to share Web addresses verbally (unless they’re really short, like “Amazon.com” or “CMS.gov”) drive me crazy. I was on a conference call this week where the panelist not only read enormous Web addresses aloud, but also didn’t know the difference between slash and backslash. I hope the people who were on audio-only connections wait for the slide deck to be distributed before they try to reach any of those sites.

The Wall Street Journal a piece this week about physicians “deprescribing” when patients are taking too many medications or risky combinations. For all the pressures on physicians and other healthcare providers to cut costs, this is an often overlooked solution.

There are many cultural factors at play with individuals preferring to take a pill to making the effort to change their habits and lifestyle. Patients don’t want to believe that they have a virus that will take 10 to 14 days to run its course — they want it cured now. Some of our love of pharmaceuticals is also generational, with older patients who came of age with the advent of penicillin and other lifesaving medications believing that pharmaceutical advances are heaven sent.

Unfortunately, there are too many people who are overmedicated. My grandparents, who are almost 90 years old, are on multiple medications for diabetes prescribed by a physician who advocates tight blood sugar control even in their age group and even with newer literature saying this might not be a good idea. It doesn’t make sense medically and they could certainly benefit from a reduced prescription bill each month, but they don’t believe in questioning their doctor.

Speaking of technology advances, there have been tremendous strides in caring for premature infants over the last several decades. A friend of mine who works for Proctor & Gamble clued me in to the recent release of a new diaper for micro-preemies who often weigh in close to 500g. That’s roughly one pound. Years ago I laughed when my friend, who is a mechanical engineer, took his job at P&G right out of school and told me enthusiastically, “You would never believe what goes into a diaper.” Having changed quite a few, I thought that was funny at the time.

It’s definitely true of the new release. The P-3 diaper is three sizes smaller than the regular newborn size and was created after three years and 10,000 hours of research, including input from over 100 neonatal intensive care unit nurses. Sometimes it’s good to be reminded that often technology and innovation brings us new problems that we never even thought of and that require solutions that are outside of our expertise.

Pet peeve, part 2: I was on a call this week waiting for key attendees to arrive. One participant announced that another would be “at least 30, maybe 40” minutes late for the meeting, which was only scheduled for an hour. I appreciate that the delayed participant called someone to say she was going to be late, but since she was the CIO and this was an executive briefing, it would have been helpful for her to indicate whether she wanted us to go ahead without her, wait for her, or reschedule. Instead, we were left guessing and trying to reach her by phone, which went straight to voice mail.

From Nurse Engineer: “Thanks for the heads up on the Healthcare Data Analytics course (Free!!) through OHSU. I am through four modules and thoroughly enjoying the class. I went into informatics way before it was chic – so far it has been a good review with very timeline information. I hope to complete the course next week before work travel interferes.” I appreciate the way they have it formatted. You can either watch the videos or read from a transcript, which allows people who learn in different ways to leverage the content in the way that most meets their needs. It also lets students make progress while traveling on flights with abysmal Wi-Fi.

One of the joys of being a consultant is experiencing life in different parts of the country. Sometimes that involves trying new foods (cheese curds anyone? Nashville hot chicken?) and sometimes it involves trying to translate the local vernacular. My Texas client shocked me this week by mentioning that in their city, “You can’t swing a dead cat without hitting a barbecue place.” I must have had a horrified expression on my face because they asked me if I was OK while I sat there trying to figure out if I really just heard what I thought I heard or whether I was on Candid Camera or being set up by PETA or something like that. I’ve traveled a lot but somehow missed that phrase before now. There are various theories on its origin and my client spent the next ten minutes schooling me on other colorful expressions they felt I needed to know. My thoughts go out to any cats, real or imaginary, who might have been swung.

What’s your favorite local or regional expression? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/10/16

I picked up an additional clinical shift this weekend to help out one of my partners whose travel was interrupted by Hurricane Matthew. Weekends in the urgent care world are always busy, especially on Sundays when people who have put off care earlier in the week decide they can’t wait until Monday to try to get an appointment with their regular physician. Others don’t have a regular physician and just see us when they’re sick. Another subgroup of patients tries to use us as their primary care home even though we’re really not equipped to do so.

When you’ve seen 40 patients in the first six hours of a shift, that’s a bad sign. Even with a scribe I couldn’t keep up, so we had to send up the bat signal and try to get more reinforcements. Flu season is moving into high gear, overlapping with a bad run of hand/foot/mouth disease for kids in our area. Most of our patients were acutely ill and we always try to move patients into exam rooms rapidly so that they’re not cross-contaminating each other in the waiting room.

For a while, things were backed up, though. Looking at the roster of patients in the waiting room, I couldn’t help but think that telemedicine would have been a good option for quite a few of them.

There are many conditions we treat regularly that can be diagnosed with accuracy based on the patient’s history and some targeted questions. Important data points are the duration of the illness, the specific symptoms, anything that has made it better or worse, and the patient’s health status and other existing conditions. Although the physical exam can confirm a working diagnosis, it usually doesn’t make a difference in the treatment plan for these patients.

Offering telemedicine services would have keep these patients at home where they could be recovering rather than potentially exposing them to other communicable diseases. In my area, however, insurance doesn’t cover telemedicine services, so they’re not being offered.

Assuming insurance would cover the services, our EHR isn’t equipped to handle telemedicine. It’s not just this system, though. The last three platforms I have used for patient care wouldn’t have supported it very well, either. The closest workflow they could offer was to couple the documentation pathway for a telephone call with some of the elements of a standard office visit. It certainly wasn’t a streamlined workflow and there wasn’t a good way to include video links or patient-provided pictures of rashes or other findings.

Although the new federal programs seem to encourage these types of alternative visits, it seems to me that many EHR vendors are just trying to keep up with all the reporting requirements and specifications of the new certification scheme and don’t have many development resources to shift into these kinds of nice-to-have workflows.

Some of the cases I saw today really made me think about how our country is addressing (or not addressing) healthcare delivery. We’re so focused on cost reform that we’re missing other significant factors that influence care-seeking behavior.

Many of our patients come to the urgent care due to access issues – they can’t get a timely appointment with their primary care physician or they can’t leave work during the hours the office is open. Although many employees have sick time benefits from their employers, the reality for many of the patients we see (as well as many of my friends and colleagues) is that it’s often difficult to use that sick time.

Employers put a variety of strategies in place to keep people from abusing the benefit, but those strategies can also function as a barrier to care. The rise of high-deductible health plans is also a barrier to care, and we sometimes see people with serious illnesses who have deferred coming to care because they can’t afford the deductible. It’s not an overall cost savings if the patient has to have an amputation because they didn’t have a $90 visit that could have mitigated the condition weeks ago.

We try to engage our patients and encourage them to follow up with a continuity physician, providing them View/Download/Transmit access to their note as soon as the physician completes it. We also have nearly-real-time surveys of patient satisfaction, which can be a bit unnerving when you receive an email with your rating before the patient is even out of the parking lot. It’s definitely a different world than what I thought I was getting into when I went into medicine.

I’m not sure how many patients actually engage via a records download, though. Although we can accept and consume inbound records, I’ve not seen any in the two years I’ve been working with this organization. I have had a couple of patients who have personal health records that they access on their phones during the visit and many who have accessed their pharmacy records to tell me about previous treatments if I can’t download them via our EHR’s pharmacy management link. But I’ve never seen a C-CDA and I’m betting that my staff would be confused if one turned up.

Our organization is growing steadily. We’ve doubled in size in the last two years. Although it’s great from a business perspective, when you really think about it, it’s terrible from a patient care strategy standpoint. Although patients come to us because it’s convenient and we’re fast and economical, we’re not a primary care office and we don’t handle preventive screenings or other universally recommended services.

I firmly believe that patients do best when they’re cared for by a physician and/or care team that knows them well and can manage their issues over time, looking for trends or linked events. This is what old-school family physicians used to do, before insurance companies pushed patients into networks based on costs and contracts. When I was in solo practice, I had patients who were forced to change primary physicians every year or two because their employer would change insurance plans or the insurance plan would change their roster of contracted physicians.

With the rise of the medical home movement in the last decade, you’d think this trend would be somewhat reversed, but we’re not seeing as much change as we need to solve the healthcare delivery problem. Physicians are stressed and don’t want to provide after-hours services without additional compensation and patients don’t want to pay for it.

We’ve thrown billions of dollars of technology at it, but it doesn’t feel like we’re much better off than we were before. Physician practices have been disrupted. Once they settle in, there is a tremendous opportunity to harness the technology, but now we’re seeing a second wave of disruption as providers and organizations change EHR vendors, often sending provider workflows back into chaos.

Programs such as the Comprehensive Primary Care Initiative and its successor CPC+ are trying to shift care delivery to the medical home model through additional payments and support, but it’s still tremendously difficult for organizations to make these changes, especially since they’re already coping with additional federal and payer regulations.

I’m not sure what the answer is, but it feels like we’re reaching the breaking point. Is anyone building the killer app that will help providers and care delivery organizations truly transform how we care for patients in the 21st century? Or will the regulators just keep tightening the screws? As we sit here on the edge of our chairs waiting for the next Final Rule, it feels more like the latter.

What do you think is the answer to truly reforming healthcare delivery? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/6/16

At my clinical practice, we frequently use scribes to document in the EHR while we focus on patients. While most of our scribes are cross-trained emergency medical technicians or medical assistants, some are college or graduate students who are looking for experience in the field while they apply to medical school.

My favorite scribe was recently admitted to medical school. Since he doesn’t have any family in town, he invited me to sit in for his family at his school’s white coat ceremony. We didn’t have that ceremony when I went to medical school, but quite a few schools have them now. Often in their first year of training, students are presented with the traditional white coat and may take an oath.

Schools have gotten away from the traditional Hippocratic Oath (mine used the Declaration of Geneva), but his school encourages each class to write their own oath. It was quite moving to see the students promise to keep the patient at the center of care and to deliver care equitably regardless of gender, race, religion, or sexual orientation. I didn’t hear anything about sacrificing patient care time to address burdensome regulations and reporting requirements, but they’ll be learning about those aspects of medicine soon enough.

October is Health Literacy Month, aimed at helping promote the importance of understandable health information. Greater health literacy can lead to improved health status and may be more of a contributor than other factors such as race, ethnicity, or socioeconomic status. Although many EHR vendors try to increase health literacy by making sure their patient education materials are at an accessible reading level, there are other factors at play. The National Patient Safety Foundation is promoting its “Ask Me 3” program that encourages patients to ask three questions to better understand their health: 1) What is my main problem?; 2) What do I need to do?; and 3) Why is it important for me to do this? I’d love to see more EHR-generated patient plan documents that address these questions in a readable format rather than just spitting out codes and canned phrases that may not make sense for patients.

The rising cost of health care and subsequent attempts at reform are impacting care delivery across the country. My local school board just voted to investigate the possibility of onsite health clinics for employees and their families. They’re not ready to address health clinics for students, but the employee clinics are seen as a possible way to not only get employees back to work more quickly, but to control costs. We perform similar corporate health services at my clinical practice and can generally get patients treated and back to work with their medications in under 45 minutes. I’ll be interested to see how it turns out and whether the promise of efficiency and cost-control outweighs any privacy concerns.

Nearly 180 members of the House of Representatives sent a letter to CMS claiming that recent payment reforms announced by the Center for Medicare and Medicaid Innovation (CMMI) exceed the authority of CMS and are therefore illegal. The legislators contend that voluntary programs are acceptable, but mandatory participation in programs such as bundled payment programs can “commandeer clinical decision making and dramatically alter the delivery of care.” They go on to “insist CMMI stop experimenting with Americans’ health.” I’ve spoken with many of my peers who feel that MU and other programs are out of control experiments with no requirement for institutional review board approval. It remains to be seen if using financial incentives against providers will really drive the needle on patient outcomes.

I wrote earlier this week about some downtime/disaster recovery adventures I had with one of my clients. A reader commented on my mention that “since crossing to the IT dark side, I’ve had more late night phone calls for database disasters than I’ve had for patient care issues, but the steps are surprisingly similar,” wanting to know more.

• Getting to the root cause of an information technology misadventure can be a lot like trying to diagnose a patient who presents with vague symptoms or a complex condition.
• Like a person with a stroke, it’s important to know when was the last time that the system was normal, what the presenting symptoms were, and how quickly it progressed.
• Similar to a person having a heart attack, you have to act quickly within a limited time frame so that more extensive damage doesn’t happen.
• You have to assimilate data from a variety of sources and try to put it all together in the hopes of figuring out what happened, what is currently going on, and how you can identify the best intervention.
• Sometimes you try maneuvers that are both diagnostic and therapeutic. They may or may not work depending on the status of the patient/system.
• It’s important to have a skilled team that can work well together and has common goals.
• When we teach CPR and advanced cardiac life support, we talk about closed-loop communication and following algorithms for prescribed interventions. Both of those apply to downtime and disaster recovery situations.
• Not unlike medicine, sometimes you lose a patient. But when you make a save, it’s extremely gratifying.

Mr. H recently polled the reader base on desirable qualities for sales team members. He mentioned that military service ranks #1 on his list. I work with numerous veterans and have to say they’re high on my list of desirable employees and co-workers as well. I recently finished reading a book called CONUS Battle Drills by Louis J. Fernandez. Subtitled “A guide for combat veterans to corporate life, parenthood, and caging the beast inside” it also offers good perspective for those of us who hire or work with people who have been through situations we can barely imagine. I’m grateful for all the men and women who have served and who have continued to serve and look forward to having them on my team.

I’m going to put my physician hat on for a minute and remind everyone to get a flu vaccine. There was some buzz earlier this year about whether receiving the vaccine too early can reduce its effectiveness, which may have led some people to wait. Although some think the flu is no big deal, it kills nearly 24,000 people in the US every year, including 100 children. It can also cause life-threatening complications. The vaccine used to be recommended only for high risk patients, but now vaccination is universally recommended for everyone over six months of age. Let’s roll up our sleeves and get the herd immunity going.

Does your employer mandate flu vaccinations? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/4/16

The last 43 hours has been some of the most agonizing time I’ve spent in the IT trenches in recent memory. I’ve been working with a client on a small CMIO augmentation project, mostly helping them get organized from a governance and change control standpoint. It’s a mid-sized medical group, roughly 80 physicians, but none of them want to take time away from patient care to handle the clinical informatics duties. I suspect that this is because they’re mostly subspecialists and there’s no way the group would be willing to compensate them for the time they would miss from their procedural pursuits.

Until I arrived on the scene, the IT resources would just build whatever the physicians wanted, regardless of whether it made sense for everyone. This in turn led to a whole host of issues that is impacting their ability to take the upgrades they need to continue participating in various federal and payer programs.

I’ve been spending eight hours a week or so with them, mostly on conference calls as they work through a change control process. Much of my work has been in soothing various ruffled feathers and in trying to achieve consensus on issues that have to happen regardless, but I hope to get them in a good place where they can be well positioned for the challenges of shifting to value-based care. Nothing at their site has been on fire from an operational standpoint, and other than telling the IT team to stop building whatever people ask for, I haven’t had much interaction with them.

I stayed up late Saturday night working on a craft project (curse you, Pinterest), so I was awake when they called me in the wee hours of Sunday morning. It was the IT director. I could immediately tell he was in a panic. It took several minutes to calm him down. I was able to figure out that something had gone very, very wrong with their ICD code update.

Hospitals and providers have to update their codes every October 1 to make sure they have valid codes that can actually be sent out to billers. Most cloud-based vendors do the updates themselves and push it out to their clients, while non-cloud vendors that I have worked with provide a utility that allows the client to update their systems. Usually it’s no big deal, except for the vendors who are habitually late sending out their update packages and whose clients are cringing on September 30.

This particular client is on a non-cloud format and had planned to run the utility on their own. Although they had a solid plan with a lead resource and a backup resource, they never really anticipated having to use the backup resource. On the evening of the 30th, the lead resource became seriously ill and wasn’t able to do his duties. They decided to wait it out a day since they weren’t open on the weekend and see if he could handle it later in the weekend. When he was admitted to the hospital with appendicitis, it was clear that they would have to engage Plan B.

Although the backup resource had gone through the documentation, he had never run the utility or even seen it run. Apparently there was some confusion with a downtime playbook. Users were supposed to be dropped from the system before the backup cycle started and then were to be allowed back on the system after the code update was complete.

Somehow the users weren’t forced to exit and ended up being on the system while the backups started. Once the analyst realized users were still on the system, he attempted to halt the backups, but instead, the ICD update was started. I’m not sure what happened next, but the bottom line is that the database became unresponsive and no one was sure what was going on. To make matters worse, the fail-over process failed and they couldn’t connect to secondary/backup database either.

A couple of analysts had tried to work on it for a while and couldn’t get things moving, so they tried to reach the IT director, who didn’t answer. I can’t blame him since it was now somewhere near 1:00 a.m. After working their way through the department phone list, somehow I got the call. I’m not a DBA or an infrastructure expert, but I’ve been through enough disaster recovery situations to know how to keep a cool head and to work through the steps to figure out what happened. Since crossing to the IT dark side, I’ve had more late night phone calls for database disasters than I’ve had for patient care issues, but the steps are surprisingly similar.

Things were a bit worse than I expected since they couldn’t tell if the transaction logs had been going to the secondary database since we couldn’t connect to it. Even worse, I looked at the log of users who were on the system when it crashed and the senior medical director had been in, potentially documenting patient visits for the day. It took me at least 20 minutes to talk people down and get them calm before we could make a plan. The next several hours were spent working through various steps trying to get access to the secondary database to preserve patient safety. It was starting to look like a network switch might also have given up the ghost.

What surprised me the most was that they really didn’t have a disaster recovery plan. There were bits and pieces that had clearly been thought through, but other parts of the process were a blank canvas. Although there are plenty of clinical informatics professionals who are highly technical, it’s never a good sign when the physician consultant is calling the shots on your disaster recovery.

We engaged multiple vendors throughout the early morning as we continued troubleshooting issues. The IT director finally responded to our messages around 8:00 a.m. I realize it was Sunday morning, but he was supposed to be on call for issues due to the ICD code update and he frankly didn’t respond.

By 4:00 p.m. things were under control, with both the primary and recovery systems up and appearing healthy. My client created a fresh backup and decided to go ahead with the ICD code update. We weren’t sure how much of it had actually run given the aborted process from the night before. It appeared to be running OK initially, but after a while, it appeared that the process was hung. By this point, the team was stressed out and at the end of their proverbial ropes and there wasn’t any additional bench to draw from.

I finally persuaded them to contact the EHR vendor, thinking they would have had resources available since this was the prime weekend for ICD code updates even though my client was now more than a day late. It took several hours to get a resource to contact us back and then we had to work through the various tiers of support. Eventually midnight rolled around again and things still weren’t ready, increasing the anxiety as the team knew they’d have billing office users trying to access the system starting at 5:00 a.m.

Once we arrived at the correct vendor support tier (aka, someone who knew something), the team was run through checklist after checklist trying to figure out what was going on and whether we should continue to let it run or whether we should try to stop it.

The IT director finally made the decision at 6:00 a.m. that the practices should start the day on downtime procedures, and thank goodness they had a solid plan for that part of the disaster recovery game. The practices were given access to the secondary database in a read-only capacity for patient safety purposes and each site was said to have a “lockbox” with downtime forms. The group subscribes to a downtime solution that creates patient schedules, so they were quickly printed in the patient care locations along with key data for the patients who were already on the books for the day. Anyone who presented as a walk-in could be accessed through the secondary database.

At least on downtime procedures, users weren’t assigning any ICD codes to the patient charts since the utility hadn’t completed yet. It was restarted a couple of times and finally got its act together, completing around 4:00 p.m. Monday. After an hour or so of testing, we were able to let users back in the primary system to start catching up on critical data entry and billing.

Most of the day, though, was extremely stressful, not only for the IT team, but for everyone in the patient care trenches. It was also stressful for the patients since the group has a high level of patient portal adoption and there is no backup patient portal. Anyone who sent messages or refill requests or tried to pay their bills today was simply out of luck.

When an event like this hits your organization, all you want to do is just get through it. That’s not the hard part, though – the challenge is just beginning with the post-event review and attempts to determine the root cause of various breakdowns. It usually takes at least a couple of days to untangle everything and the work is not yet over. I’m happy to report that the analyst with the appendicitis did well in surgery and was discharged home before the EHR system was back online. I’m not sure having the primary analyst would have made a difference in this situation. I hope he continues to make a speedy recovery.

You never know when something like this is going to happen in your organization, and if you haven’t prepared for it or practiced you plan, you need to do so soon if not today. Similar to the practice of medicine, sometimes the most routine events can have significant complications.

Are you ready for a downtime? Is your disaster recovery plan solid? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/22/16

The Epic UGM was held this week and I was pleased to receive an invitation to LogicStream Health’s “Taste & Toast” event. Hosted at the Frank Lloyd Wright-designed Monona Terrace and lead by a certified sommelier, it sounded like a great event. I wasn’t able to make it to UGM this year due to conflicting priorities, but wanted to give them a particular mention for offering free Uber services upon request. The risk of driving under the influence is definitely reduced when you don’t drive yourself.

A recent study published in Annals of Internal Medicine looks at whether hospital employment of physicians improves the quality of hospital care. The study looked at readmission rates, mortality, length of stay, and patient satisfaction at hospitals between 2003 and 2012. There were 800 hospitals that had moved to a more employed physician model vs. 2,000 that had not. The authors noted no association between the presence of employed physicians and most of the scores, although there was a slight change in pneumonia readmissions. The study looked only at Medicare beneficiaries aged 65 and older, so it’s not clear how the data would apply to other populations. It also didn’t look at government-run facilities.

Another study that caught my eye this week looked at “The Effect of Wearable Technology Combined With Lifestyle Intervention on Long-term Weight Loss.” The authors compared a “technology-enhanced weight loss intervention” to standard behavioral modification techniques, looking at nearly 500 participants between 2010 and 2012. Everyone was treated with initial diet and counseling. At the six-month point, participants were split into a group who self-monitored and a group that used a wearable device. Weight was tracked every six months for a total of two years. Researchers also looked at fitness, physical activity, dietary intake, and body composition.

Nearly 75 percent of participants completed the study. Although both groups improved in fitness, activity, diet, and body composition, young adults with a body mass index (BMI) between 25 and 40 lost less weight if they were in the wearable group. Based on technology-related fitness behaviors I observe in the workplace, there’s a chance participants focused more on the technology than on their actions or personal responsibility. There’s also the chance that as they saw the activities racking up, they felt it was OK to eat a bit more since they were being active. The bottom line is that we still have a lot to learn about the effectiveness of technology interventions in solving complex health problems such as obesity.

If anyone questions the challenges facing healthcare, they only have to look as far as the recent FDA decision approving the drug eteplirsen. The FDA’s own advisory panel voted against recommending approval for the drug, based on a clinical trial that only involved 12 patients and didn’t have adequate placebo control. Critics accuse the FDA of setting a dangerous precedent for approving drugs based on patient and pharmaceutical company lobbying rather than on science. The FDA will require the manufacturer to conduct trials to confirm the clinical benefit, and depending on the outcomes may opt to withdraw approval of the drug.

In preparation for the October 1 update for ICD-10 codes, CMS is alerting providers to resources such as the 2017 ICD-10-CM and ICD-10-PCS code sets. I know a lot of providers that fail to understand that these need to be updated each year or are content to let their office staff or EHR vendor figure it out. Not having the correct codes installed after the cutoff can result in denied claims and a ton of extra work, so it’s worth a minute to make sure your practice has a plan.

AMIA is seeking submissions for the iHealth 2017 meeting. The event is focused a bit more towards the application of clinical informatics as opposed to research, and participants are encouraged to submit programs, pilots, and innovations in health informatics. Submissions are open through October 18 and this year’s conference topics are grouped under:

• Analytics and the Learning Health System
• Clinical Informatics
• Interoperability and Informatics Infrastructure
• Health Policy and Payment Reform

AMIA also announced that they’ll be offering licensed childcare during the AMIA 2016 Annual Symposium to be held November 12-16 in Chicago. The Women in AMIA task force led the efforts to make this a reality. Cerner and Epic were listed as sponsors on the email announcement.

I see several physicians at the local academic medical center. All of them are of the “once a year” variety, so I don’t expect a lot of communication from them. I had no recent appointments and nothing scheduled, so I was surprised to start receiving communications about my upcoming surgical appointment along with patient questionnaires and more. I called the help desk to figure out what was going on and they said they could see no appointments for me in the system, yet the messages kept on coming. Apparently I’m having a consultation for spinal surgery for my ongoing pain management problems, or at least that’s what the system thinks is going on.

I fully understand glitchy computer systems that do seemingly unexplainable things, but I’ve run into some attitude from help desk staffers that act like they don’t believe I’m actually seeing what I’m seeing. I’ve offered to forward the emails back to them along with screenshots of the portal, but they don’t seem keen on using that to troubleshoot. In this era of medical identify theft and big data, patients have the absolute right to have their documentation be correct and telling them to “just ignore the information if it doesn’t apply” is not the right answer.

Have you had success in correcting erroneous online records? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/19/16

A reader clued me in to this great piece in Forbes that discusses the 15-minute office visit. It ties the origin to Medicare’s RVU (relative value unit) formula and its attempts to standardize the calculation of physician fees. The RVU formula factors in geography, practice expenses, liability insurance, and a Medicare “conversion factor” in an attempt to level the playing field for physicians. Translating the average visit’s RVUs using the American Medical Association’s then-current coding guidelines resulted in an average 15-minute office visit.

The RVU formula came into being in 1992. We’ve been through some cyclic changes in healthcare with the rise of managed care, a frenzy of hospitals purchasing practices, the subsequent divestiture of the practices, then back to integrated delivery systems and hospital ownership of physician practices. The change has recently been fueled by the rise of Accountable Care Organizations and other risk-sharing programs as well as the regulatory pressures stemming from HITECH and resulting incentive (now penalty) programs.

Medicine has changed considerably in the last 24 years. Decision-making has gotten more complex. Many patients are more empowered and take an active role in their healthcare. These visits often require more time due to detailed discussions of the pros and cons of various treatment options or diagnostic maneuvers. Unless physicians are coding based on the face-to-face time spent in counseling or coordination of care, it’s hard to get insurance payers to adequately pay for the time spent on those visits. Payers often ask for loads of documentation to justify the visit code, which results in additional work and expense to the practice.

Payers have created lists of codes they won’t pay, regardless of the medical realities. Case in point: I recently diagnosed a patient with a skin infection, most likely from time spent in a hot tub with inadequate cleaning procedures. The patient required antibiotics and I had to take a detailed history to make sure I was selecting the correct drug based on the likely infectious agents. It probably lasted less than 15 minutes, but I was rewarded a week later with a denial because the insurance company refuses to pay for a diagnosis of folliculitis. My staff had to handle the request, then send it to me for potential re-coding, and then we had to submit the claim again. Knowing how much time had already been wasted, I slapped a couple of potential diagnoses on the chart in the hopes that I’d hit the jackpot with one of them and would actually be paid.

Why is that OK? The patient had an actual problem, it required thought to diagnose, antibiotics were needed, and the visit was legitimate. Counseling on hot tub hygiene was given. The problem wasn’t self-limited and was unlikely to resolve without medical attention. I see dozens of people who come in with issues that could be easily handled by a well-trained Scout with a first aid kit and I get paid for those, but this time the insurance decided they just weren’t going to pay for that particular diagnosis.

Whenever physicians complain about everything they’re trying to cram into the 15-minute office visit, the first answer is that maybe we don’t need physicians to provide the care. Nurse practitioners and physician assistants should be used as well as various care team members with a range of clinical training experiences. Regardless of who is delivering a given level of care, it still takes time to deliver it, document it, and make sure the patient understands the steps they need to take prior to the next episode of care.

In many states, nurse practitioners and physician assistants practice independently. We just had a mini-revolt in our practice when we tried to credential our physician assistants to work without a supervising physician. The maneuver was intended to lower the cost of care, but several PAs refused to take part, reminding our leadership that their title was “physician assistant” rather than physician and that they went into the field to assist physicians rather than to try to be interchangeable with them.

I often practice alone, without a second clinician to jump in if the office gets busy. Those 15-minute visits become shorter and shorter when we have six or more patients streaming into the waiting room every hour. Most come because either they can’t get after-hours care from their primary physician or because they don’t have a primary physician. Our mission is to address their issues as completely and compassionately as possible, and knowing that payers can just decide not to pay for our services really puts a shadow over the whole concept of what we’re trying to do.

The editorial mentions that of the typical 15-minute office visit, physicians may spend 37 percent of the time doing paperwork. I’m fortunate to work for an organization that values physician time and staffs the practice with scribes during peak periods so that physicians and our independently-practicing PAs can focus on patients and not paperwork. Most of the time my notes and orders are complete before I walk out of the exam room, which is truly a beautiful thing. Patients appreciate our focus, but having a qualified scribe doesn’t come cheap. A good number of our scribes are students and recent graduates who are applying to medical school and who are looking for experience. It continues to amaze me that people would still consider a career in medicine after what they see in the trenches.

Using a figure of 37 percent leaves eight minutes for the actual office visit. The piece breaks down the patient activities that must fit into that time slot: social constructs like saying hello, disrobing if you didn’t change already, explaining why you’re seeking medical attention, being examined, etc. It suggests that patients shouldn’t take more than two minutes to tell their story, likening the time slot to that of a commercial break during broadcast television. “If four companies can get you to buy things in two minutes, surely you can tell your whole story.” That works if patients have focused or prepared, which is a rarity. Usually when I ask how long something has been going on, patients have to work through a series of cues to figure out the timeline. “Well, it started when I went to Michigan for Dean’s wedding, that was in the spring, no maybe it was early summer…” and there you have it.

I don’t blame patients who haven’t prepared – they should expect more than assembly line care with physicians running on the hamster wheel. They’re seeking care, not auditioning for a play or interviewing for a job. However, as long as insurance companies (including government payers like Medicare and Medicaid) are intermediaries and patients aren’t able to understand the full cost of care, things aren’t going to change. Patients who are actually paying for the physician’s time are going to demand his or her full attention, not an overly-truncated excuse of an office visit.

Building a patient-physician relationship takes time and medicine isn’t something that’s practiced by following a cookbook approach. Technology can help,but it’s not the be-all, end-all solution for healthcare’s problems. However, it seems to get most of our focus. Patient-empowerment movements have helped raise awareness of the need for greater partnership and shared decision-making in healthcare, but no one wants to pay for it. Cost control will continue to be a downward pressure with clinical and emotional consequences for both patients and caregivers. Eventually something has to give.

When will we reach the boiling point? Have ideas on how to fix things? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/15/16

I was reminded today that this year marks the 20th anniversary of the Health Insurance Portability and Accountability Act of 1996, affectionately known as HIPAA (or HIPPA, as the case often is). As much as we lamented its beginning, most of us had no idea how much more regulation we would see in the healthcare space during the subsequent decades. Physicians and other healthcare providers are now more regulated than they have ever been, which has contributed significantly to physician burnout and early retirement in many communities.

Regulations are often nested within other policy and regulatory documents. A recent example of this is a requirement in the proposed 2017 Medicare fee schedule that would require surgeons and other procedural physicians to report a series of G codes during the postoperative period. The codes vary based on place of service, patient complexity, and time. They don’t match cleanly with existing bundled services. The fee schedule also proposes changes to the quality measures used for Accountable Care Organizations, which also met with resistance.

Sometimes CMS announces plans which benefit physicians, which feels like a rarity. The recent announcement of a “pick your pace” approach to MACRA implementation was welcomed due to the apparent flexibility of the approach. There are a few options for MIPS reporting in 2017:

• Providers can simply test their ability to report data, doing so at least once at some point during the year. Completion of testing allows providers to avoid penalties and ensures that systems are functioning prior to greater participation in subsequent years.
• Providers can also consider reporting for part of the calendar year. However, they must report performance in all three Composite Performance Score (CPS) categories. This approach could result in a small bonus in 2019.
• Providers can report the full calendar year (again in all three categories) to achieve what CMS describes as a “modest” bonus in 2019.
• Providers participating in certain Advanced Alternative Payment Models can qualify for a five percent bonus.

Selecting the third option will depend on the ability of vendors to quickly become compliant with the requirements of the final rule, which is expected to be released by early November. This means that they have very little time to achieve software readiness and upgrade thousands of providers. Depending on vendor resources and how much prep work has been done in anticipation of the release of the final rule, full-year reporting may be little more than a pipe dream.

For those of us who live and breathe this on a daily basis, having some flexibility in reporting seems refreshing. But for the large numbers of physicians and practices who have no idea what MACRA even is, let alone that these regulations are coming, the flexibility won’t be very comforting.

I recently received a blast letter from the Drug Enforcement Administration letting me know I would have to upgrade my browser in order to access DEA resources and renew my registration. That’s insignificant to many physicians, yet the DEA felt it was important enough to mail paper correspondence to every registered physician across the country. MACRA and the associated penalties and incentives are a big deal. Where is the letter to all Medicare providers? CMS is expecting physicians to follow blogs and tweets and webcasts that many physicians don’t even know exist.

I’m not absolving physicians from being responsible for what is going on in the world around them, but merely commenting on the reality of many physicians out there, which has also been reflected in various surveys and articles. Ultimately if a physician is going to contract with a payer, he or she is responsible for knowing the rules, but it certainly could be easier.

What’s also not easy is figuring out how to actually achieve savings under Alternative Payment Models. Recently CMS released performance data for 2015. The numbers show that of 404 Medicare ACOs, only 125 of them qualified for shared savings. Of the 392 Shared Savings Program ACOs, only 119 qualified for shared savings. Participation in Pioneer ACOs continues to shrink, with only 12 remaining.

I don’t think those statistics make Alternative Payment Models look appealing to the average physician. Of course the “appeal” is different for providers employed by hospitals and large health systems who are simply forced to participate. Those that weren’t successful based on the metrics are still doing the extra work required of ACO members but just not getting the shared savings payments at the end.

I do feel that CMS is listening and trying to respond. Recently they changed the rules for the Medicare Chronic Care Management services code to remove a requirement that providers have 24/7 access to patient records. The code allows providers to bill for coordination of care for patients who have chronic conditions. However, I’m not sure what kind of burden the 24/7 rule really was.

The bigger barrier in my experience is the fact that patients have to pay a portion of the charge, and many don’t see the benefit because the services performed on their behalf are often done behind the scenes – phone calls to consultants, review of personal health log data, etc. There’s also a process required to obtain patient consent for participation which adds to challenges in adopting the service. I find it funny that people who will pay for a maintenance/protection program for their phone will balk at paying for something similar to help safeguard their health.

I’m mentoring some medical students and several are out on ambulatory clinical clerkships, working with practicing community physicians. They always have questions about how regulations are going to impact them in practice. Sometimes I have answers and sometimes there are no good answers. What they see, however, is definitely driving them away from primary care, where it seems that providers feel a greater burden. We’re getting thousands of new Medicare beneficiaries each day, so the need for processes and policies is real in order to successfully manage the demands. I think many of us wish that there was just a better way.

What are you doing to celebrate the 20th anniversary of HIPAA? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/12/16

I wade through scores of emails each day, looking for items of interest for my columns. One recent email mentioned a new piece in the Journal of the American Medical Association titled, “The Ethics of Behavioral Health Information Technology: Frequent Flyer Icons and Implicit Bias.”

It caught my eye in particular because I’ve seen some pretty wacky icons in the dozen or so EHRs I’ve used during my career. One system’s demographic screen identified smokers with a little pack of cigarettes by their name, but this went away with the advent of Meaningful Use when smoking had to be further quantified based on the volume of cigarettes smoked and the number of days per week on which smoking occurred. It also had an American flag icon for veterans, which although I’m sure seemed like a good idea to some requirements writer or developer at the time, was problematic because the US isn’t the only country with a military, nor are American citizens the only individuals who serve in ours.

An EHR system I dearly loved (but which was unfortunately tied to a dysfunctional vendor, leading to de-installation) had an iconized chest x-ray that appeared when radiology results were available, and a smiling germ icon when a patient required isolation or contact precautions. There were many other icons that were not only intuitive, but served as shortcuts for the clinician, but I remember those two the best.

One icon that generated a lot of buzz at my health system when a new EHR was being installed was the one associated with expired patients. When that indicator was check-marked, a stylized angel icon complete with wings and halo appeared on the patient’s chart. Again, I’m sure someone thought it was a cute idea, but it was likely offensive to people from a variety of religious and spiritual traditions.

The JAMA article specifically addresses an EHR with an airplane icon that is used to identify “frequent flyer” patients. Unlike an airline frequent flyer whose high utilization is respected and encouraged, in healthcare jargon it tends to represent someone who seeks care frequently, and often for inappropriate reasons given the setting. Sometimes the term is associated with patients who are non-compliant, drug-seeking, or otherwise require additional clinician thought and creativity during the treatment process.

Although the article mentions that some emergency departments use lists or other methods to identify these patients, they take particular issue with the airplane icon, since “administrators may elect to configure so that clinicians can identify a patient as a high utilizer.” It goes on to explain that the plane may actually be color coded to identify the level of utilization.

Although I agree with the assertion that the icon “reinforces and encourages the use of disrespectful and stigmatizing terminology,” I have mixed feelings about their other reason for asserting that identifying high utilizers is “ethically and clinically inappropriate.” They claim that the icon “may frame the initial clinical interaction in a way that inhibits good diagnostic judgment” and may lead to poor patient outcomes. One of the key forces driving change in healthcare today is the idea that we need to identify and stratify patients who are the highest utilizers of health care and who are responsible for the largest portions of healthcare expenditures. We need to find those people who need extra resources to and supports to help keep them out of expensive care venues, such as the emergency department and the hospital.

Although the article specifically addresses psychiatric patients, physicians in all disciplines are being asked to identify these patients and care for them differently than everyone else. Health systems are investing large amounts of money in systems designed to do just this. Although the airplane icon is tacky, its function is no different than the red/yellow/green scoring that one of my current EHRs does when looking at patient risk for high utilization of services.

I do agree that flagging patients in this fashion creates potential risk for patients to be treated negatively. Although we’d all like to think that clinicians are going to be altruistic and make sure that they pull in a multidisciplinary team of social workers, therapists, behavioral health specialists, transportation services, etc. to handle these patients, the reality is that this population can be extremely difficult to treat and the supports needed are often scarce to non-existent. Especially in a risk-based reimbursement system, it’s often tempting for physicians to avoid these patients, leading to cherry-picking of the most healthy and compliant patients. The fact that they’re marked by an airplane rather than some other kind of icon doesn’t change the fact that these patients often receive different treatment than low utilizers. Sometimes the care may be negative, but identifying those at most risk can be beneficial for population management strategies.

The authors go on to mention the phenomenon of “diagnostic overshadowing,” where patients with mental health issues may be undertreated for medical conditions such as heart disease, diabetes, etc. There is more focus on the psychiatric illness, which may lead to overall poor outcomes and low quality care. This is a real phenomenon, often made worse by lack of resources. I worked at one emergency department where psychiatric patients in crisis were held over in the ED because the local psychiatric facility didn’t have physicians working on weekends so patients couldn’t be admitted. This creates an emotional (and sometimes physical) toll for those caring for these patients, which in itself leads to negative feelings about caring for similar patients in the future.

The authors make a brief foray into discussing social media platforms and patient engagement tools, calling out the need to include thoughtful development strategies that minimize problems like the airplane icon. They go on to state that, “Electronic medical record systems and behavioral health care applications should be built and tested in collaboration with patients, consumers, clinicians, social scientists, and ethicists who are sensitive to the broader ramifications of iconography and language.”

I’d like to point out that their continued use of the term “electronic medical record” throughout the piece may represent bias. It’s been a long time since we started calling them “health records” with a nod to the greater focus on health, wellness, and prevention and not just treating medical illnesses.

Regardless, I am skeptical that any of the current major vendors have social scientists and ethicists on staff, let alone iconographers. If they do leverage these folks, I’d be highly interested to hear about their work.

How does your system identify high utilizers of healthcare? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/8/16

I recently received two pieces of paper correspondence from the Drug Enforcement Administration. In following up on them, I was surprised to find that the DEA had become a bit more tech savvy than some of the other federal agencies I interact with.

The first piece of mail addressed a then-upcoming change to its websites, requiring browsers to support a particular level of Transport Layer Security starting August 31. The letter also contained a helpful link to test your browser to see if it was compliant. I was most impressed that the DEA sent the letter more than four months prior to the requirement, which is refreshing considering the number of federal agencies that either don’t give adequate notice or continue changing the requirements down to the wire or after the bell. (MU or MACRA anyone?)

The second piece of correspondence was the renewal notice for my DEA registration, which is required to prescribe controlled substances. The letter stated that most people renewing online are able to complete the renewal within six minutes and print their new certificate immediately. I decided to time myself and am happy to report that as long as you have the required paperwork ready (including state license data and state controlled substance data) that you can definitely do it within six minutes. The only issue was that the receipt didn’t clearly show that I paid my $731, which I’ll need for tax purposes. I’m not about to try to hunt it down with them, so I’ll likely just attach my credit card bill to the sketchy receipt, earning me an eye-roll from my accountant but saving untold time.

Oregon Health & Science University has received a grant from the Office of the National Coordinator for Health IT (ONC) to offer a free course for informatics clinicians and professionals. Update in Health Information Technology: Healthcare Data Analytics will be offered in two-month blocks from October 2016 through May 2017. The course includes 14 modules that will take approximately 18 hours to complete and is offered online. Registration is open and took about a minute to complete. Topics include extracting and working with healthcare data, population health, identifying risk and segmenting populations, big data, interoperability, privacy/security, and natural language processing. It also provides the Maintenance of Certification credits that many of us need to keep our Clinical Informatics certifications.

My virtual inbox contained an update from CMS on their State Innovation Model (SIM). The goal of the SIM initiative, which started in 2013, was to support states in being “catalysts for healthcare transformation and the value of CMS’ collaboration with states.” The strategy is to change healthcare “to have a preponderance of payments to providers from all payers in the state be in value-based purchasing and/or alternative payment models.” States are encouraged to “use their policy and regulatory levers to accelerate” the change from volume to value. It went on to discuss the usual transformation strategies, such as moving primary care practices towards patient-centered models, integrating primary care with behavioral and social programs, community-based population health, and of course “payment reforms.”

I’ve been following many of these projects for years. They all use some combination of bonuses or penalties or regulations to try to drive behavior. They all seem to rely on the practice to figure out how to deliver, despite physicians not traditionally being trained in how to do these things or in how to really run a business. Many are based on payments related to a per-member, per-month calculation that changes as patients enter and leave the practice, which makes it difficult to adjust staffing. This in turn drives physicians to look at third-party firms who provide the services based on a PMPM calculation. Although this shields the physician from risk, it introduces outsiders into patient care, which may not be well-received by patients.

I had my own private practice for several years and wish CMS and other well-meaning organizations would talk more to actual in-the-trenches providers and less to academics and large institutions. Know what would have increased my propensity to perform care coordination? A grant to cover the salary of a care coordinator, not some shifting PMPM payment amount that came long after the fact. Not busy enough to justify a care coordinator for your solo practice? Set up practice-share arrangements between groups to cover the split FTEs. How about a public health nurse that can be embedded in community practices to address the complex psychosocial needs that many physicians don’t have time to address in a six-minute visit?

There has to be an answer other than, a) providers selling out to large medical groups or to hospital systems; b) providers retiring or leaving to do non-patient-facing work; or c) providers opting out of Medicare prior to the biggest boom in its utilization.

The SIM models look at “engaging and supporting providers that have not typically been connected to health IT” through required system implementation/data reporting, interoperability, and analytics. In Round 1 of the program, six states participated – Arkansas, Massachusetts, Maine, Minnesota, Oregon, and Vermont. Findings from Year 2 of the program include:

• Increase in Medicaid primary care provider participation in patient-centered home models (Arkansas)
• Alternative Payment Model participation approaching 50 percent of the state’s total population in Minnesota and Vermont
• Alternative Payment Model participation approaching 80 percent of Medicaid population in Oregon and Vermont

Multi-payer efforts have been used to address payment and delivery system reforms, but I wonder how much of the provider participation has been because providers actually want to participate and feel it’s in the best interests of the patients, or because of de facto coercion by payers and regulators? What do the actual quality numbers show? Is this truly improving care or just changing the cost of care? Do patients have greater access to providers who are adequately addressing their needs or just shuffling them through in order to meet the numbers?

The CMS blog cheerleads its way into saying it is “too early to attribute specific quantitative results directly to the SIM Initiative,” although overall states are reducing emergency department visits and inpatient readmissions through other models that pre-date SIM.

In the reality in which I practice, I still can’t see basic health information for patients who turn up at my urgent care except for pharmacy fill history, which we receive from a pharmacy benefit manager. This of course doesn’t help patients who pay cash for their medications or who are surviving on samples from their doctors’ offices. I practice in a major metropolitan area, for which there is no functional health information exchange and in which several major health system players compete to keep patients in network and have no incentive to share data. None of them are willing to partner with my practice (the largest urgent care provider around by volume) to share data or reduce costs.

Of the last 100 patients I saw, the vast majority of them had concerns that would have been best addressed by a primary care physician. Many patients didn’t have a PCP, and those who do reported access issues. We constantly trim our PCP referral list because physicians are closed to new patients. It drives me crazy that I’m personally contributing to the healthcare mess in my clinical practice while I work to clean it up in my informatics practice.

For the clinical informaticists out there, do you see the same kind of fractured healthcare continuum? Email me.

Email Dr. Jayne.