EPtalk by Dr. Jayne 8/4/16

Even though we’re 10 months past the compliance date, CMS keeps sending me ICD-10 updates. They’re promoting “official coding resources that can help you maintain your ICD-10 progress.” I’m not sure exactly how one wouldn’t maintain their ICD-10 progress unless (a) they started seeing workers’ compensation patients that are still billed under ICD-9; (b) they started a cash practice; (c) they just came back to work after an extended sabbatical; or (d) some other extenuating circumstance.

The links direct back to the ICD-10 home page, which is topped by a February blog post by Andy Slavitt. Current events, indeed. The email did feature these funny icons and the first thing that popped into my head looking at the bottom one was “Sergeant Swaddle.” Between that and the baby bump one, I think they need a better graphic designer.

In other news, CMS announced the regions for its Comprehensive Primary Care Plus (CPC+) initiative and opened the application cycle for practices that would like to participate. CPC+ starts in January 2017 and is a five-year primary care medical home model. Up to 5,000 practices will be selected (2,500 in each of two tracks) to participate. Fourteen regions were announced including some full states. They were selected based on “payer alignment and market density to ensure that CPC+ practices have sufficient payer supports to make fundamental changes in their primary care delivery.” A list of payers that have been provisionally selected to partner is found within the FAQ document.

Practices can apply until September 15, and those applying to Track 2 must have a letter of support from their health IT vendors that outlines vendor commitment to supporting via “advanced health IT capabilities.” CPC+ counts as an Advanced Alternative Payment Model for MACRA purposes, so I suspect there will be a lot of interest. Selected regions are:

• Arkansas
• Colorado
• Hawaii
• Greater Kansas City area (KS and MO)
• Michigan
• Montana
• New Jersey
• North Hudson-Capital Region (NY)
• Ohio (and Northern KY)
• Oklahoma
• Oregon
• Greater Philadelphia area
• Rhode Island
• Tennessee

CMS has definitely been busy this week, also releasing a proposed rule that expands bundled payments into the realm of cardiac care. It also extends the current bundled payment model for hip replacements to include other hip surgeries. The cardiac elements aim to increase the utilization of cardiac rehabilitation services, which have been shown to lead to better patient outcomes.

CMS isn’t the only government agency that’s been busy, though. The US Department of Agriculture will fund distance learning and telemedicine projects in 32 states, helping rural communities to connect with medical and substance abuse experts. USDA will award more than $23 million in grants to support 45 distance learning projects and 36 telemedicine projects. Eligible applicants include: most state and local governmental entities; federally-recognized Tribes; non-profits; for-profit businesses; and “consortia of eligible entities.” Sounds like pretty much everyone is fair game.

A colleague forwarded me an article describing an observational study that appears to show “no overall negative association” of EHR implementation on short-term inpatient mortality, adverse safety events, or readmissions. It looked at the Medicare population across 17 hospitals that had go-live dates during the observation period compared to 399 control hospitals. It just came out this week so it only has one comment on it, which interestingly comes from a physician practicing in the United Arab Emirates.

Federal statistical agencies use the Standard Occupational Classification SOC) code system to classify workers into occupational categories. I learned from an AMIA blast this week that there’s finally a code for many of us: Health Information Technology, Health Information Management, and Health Informatics Specialists and Analysts. Right now it’s just a proposal which will hopefully be released for use beginning in 2018.

I had to make a last-minute trip this week to replace a subcontractor who flaked out on me. It was bad enough that my entire week was going to be disrupted, but even more, I wasn’t thrilled about the $1,000 airfare, nor was I thrilled about having a Monday morning flight. The TSA recommendation for my airport right now is to arrive at least two hours early. The travel gods must have been smiling on me at least a little bit because I arrived at the airport to find exactly no one in the TSA pre-check line. It was a beautiful thing, even though I ended up with a flight delay.

My client was cool about the last-minute substitution. It turns out that she only sees patients until 2 p.m. each day. After that, the office becomes a ghost town, so I’ve been able to keep up with other client engagements and even made it to the beach briefly. There’s something about having sand between your toes to rejuvenate you.

What gives you a little boost? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/1/16

I was recently hired to help a large health system migrate their ambulatory platform. They previously ran a best-of-breed system, with different vendors for their inpatient and ambulatory platforms. I’ve been working with them for some time now, although my previous engagements were around optimizing their outpatient workflows and helping them bring on new specialties and practices as the employed physician group expanded. Due to problems with their inpatient vendor, however, they decided to go for a single-vendor solution.

Their idea of a system selection process was pretty sad. They didn’t even really go to market. The decision had been made without much input from anyone except the CIO and the CFO. Of course, the employed physicians were upset, especially since they were happy using their current software and felt a bit like the health system had thrown the baby out with the bath water. It’s hard enough to do a migration when you have a legacy system that providers hate, but trying to do one with a legacy system that providers actually like and use efficiently is another challenge altogether.

My client’s parent organization doesn’t have a CMIO at the corporate level, although it has several medical directors who work together to fill that function across the different areas – ambulatory, inpatient, home care, hospice, etc. Although they’re a great group of physicians and dedicated to making systems work better for users, they’re unfortunately all part-time informaticists. Between their clinical practices and current EHR-related duties, none of them really have time to spearhead the migration efforts.

This led to an understandable amount of chaos as the IT department steamrolled ahead making decisions about architecture and setup. The IT department also made determinations on what clinical data should be migrated and what shouldn’t, without getting any kind of clinical approval. No one even knew it was going on until an analyst sent a conversion file to one of the physicians to ask a question about the data.

The physician informaticists demanded an immediate halt to any conversion or migration work until they were pulled into the loop. That’s how I was tapped to assist, since I’ve assisted with plenty of migrations off their soon-to-be legacy system. I haven’t done much work with this receiving vendor, however, and it’s been an eye-opening experience, especially since they’re one of the big three vendors that purports to have their act together. What I’ve seen behind the scenes has been concerning, with occasional episodes of being thoroughly horrified.

To start with, the vendor didn’t provide any recommendations on what kinds or how much clinical data should be brought into the new system. They left it completely up to the health system to define. The vendor’s front-line teams weren’t prepared to have any conversations around what similar clients have done or how things worked for them. They also didn’t make any recommendations on how to clean up the MPI for the most successful conversion of patients, which is a recipe for filling the new system with junk.

I’m not expecting a vendor to make detailed recommendations, but some basics, such as, “You may want to only consider bringing active patients in to the new system” might be helpful. I’m not sure if their lack of recommendations is truly systematic since I’ve only been working with a couple of vendor employees, but they’ve been less than helpful.

From the clinical side, the health system had decided to “bring everything over” on their patients regardless of data integrity or usefulness. Part of this was driven by the fact that they didn’t want to pursue an archive solution for the legacy patient records, which was in turn driven by cost concerns. I’m not sure those concerns are well founded, especially when you look at the potential risks of bringing across so-called “dirty data” due to an ineffective migration plan. Plus, do you really want to populate your new system with expired patients and those who have moved away? Do you really want to fill your brand new charts with 10 years’ of medication history?

I was brought in largely to help ask the hard questions around these topics, plus to help the client’s team of informaticists to learn what they don’t know so they can start to take on some of the migration tasks. I was able to help them focus their specifications on what they wanted to bring across. 

We started with medications, since those are typically straightforward given the preponderance of NDC and RxNorm codes in most systems. Although we had a couple of blips, we were able to finally get a good data set of medications which have been active in patient charts over the last 18 months. The entire medication history will be pulled as well, but it will be turned into a PDF document that will be stored in their scanning solution rather than inserting all that data into the prescribing module.

We are now working on the patient problem lists, immunizations, and diagnosis history data. The latter is unfortunately complicated by the recent migration to ICD-10, so there’s a fair amount of duplicative data that we’re still trying to figure out. At the same time, I’m lobbying the leadership to reconsider an archive solution for some of the other data, including all the patients who are never going to be seen in the new system.

I’m surprised by how difficult this fight has been, but I need to learn to not be surprised by anything from clients. Once you think you have them figured out, there’s always something that comes up to remind you that you haven’t thought of everything.

In parallel, there have been rapid design sessions going on where the physicians are supposed to be designing their future-state workflows. The build environment that was set up by the vendor included data from previous clients, which was easily identifiable (physician and facility order sets) and for the “vanilla” content from the vendor, I’m surprised by how rudimentary it was. With the availability of high-quality order sets and clinical decision support, I’m surprised they’re not incorporating more in their base installation.

The expertise of vendor reps in some of these design sessions has been lacking. They’re still working as if they’re bringing up new clients who have never been on EHR and haven’t been prepared to address the issues faced by organizations that have been live on a system for years. It’s as if their implementation process is stuck in 2002.

The project continues to suffer from scope creep, which is OK for me as a consultant since the client has asked to extend and expand my engagement. Job security in this economy is important and it will keep me busy for several months. Even better, it’s in a great location. I might just have to conduct more onsite visits than I might otherwise do for a project like this. Best of all, the client-side people I work with are not only helpful but fun, which is an asset for any consultant.

Where’s the most fun place you ever worked and why? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/28/16

I’ve said it before, but those of us that work in the healthcare IT realm have a skewed sense of reality when it comes to participation in federal incentive programs. We tend to think that “everyone’s doing it,” but the reality is that just over half the eligible providers in the US were reflected in the 2015 Meaningful Use attestation data.

With that in mind, I wasn’t surprised that only half of practicing physicians have even heard of MACRA. Based on conversations in various physician lounges, I’d argue that even those who have heard of MACRA see it as a fix to the SGR problem with physician payment rather than another quality and incentive program. The survey seems to confirm this, with 32 percent of respondents only recognizing the name.

Not surprisingly, employed physicians were less aware than independents. However, physicians with large Medicare panels weren’t any more aware than those with smaller panels. Also not surprisingly, 80 percent of physicians prefer traditional fee-for-service arrangements.

Often people jump on this as proof that rich and greedy doctors just want to preserve their cash flow. For many in the trenches, though, it’s no different than any other occupation wanting to be paid for the work that they do. We wouldn’t have many car mechanics if their pay was linked to how well people maintain and drive their cars, and sometimes I think the practice of medicine has become a lot like being a mechanic lately. If nurses were docked part of their shift pay because their patients died or were otherwise noncompliant, you would see an open revolt.

I’ve been doing some long-term work for a health system that requires me to use their laptop and VPN connection. It also requires me to use their desktop support team, which has been a struggle. We open tickets via email and often it takes days for anyone to respond. Once they do respond, it’s often apparent that the technicians haven’t even read the ticket. This is particularly irksome for someone like me who puts lots of screenshots and attachments with their tickets, so that the problem is clear in the hopes someone can resolve it more quickly.

I’ve had some difficulty getting some of their applications to run correctly, since apparently they aren’t supported across browsers. One requires that you use Chrome, another Firefox, an another will only run on Internet Explorer. Doesn’t seem very 21st century to me, but the rest of the organization seems to be OK with it.

I’m always interested to see how other nations handle various healthcare delivery problems, so this headline about Finland’s newborns sleeping in cardboard boxes caught my eye. Finland’s infant mortality rate is less than half the US rate. The box is provided to all pregnant women, with the condition that they have a medical exam during the early months of the pregnancy. It also contains various baby care and clothing items, including those needed for chilly winters. (I’ve never seen a baby balaclava, but apparently there is such a thing.)

Finland offers a lot of other benefits for parents, including a paid 10 month leave and a guarantee that full-time caregivers can return to their jobs within the first three years of the child’s life. At the urging of a non-profit organization that provides boxes in Minnesota, that state’s legislature considered a bill to provide them for low-income women. Seeing a baby asleep in a box reminds me of my grandmother’s story that she slept in a dresser drawer for the first few months of life, having been born early with no nursery preparations. Necessity is definitely the mother of invention, whether your baby sleeps in a box, a basket, or a drawer.

Medicare’s Hospital Compare “star ratings” are now live, and as expected, creating confusion. Now that we’ve had a chance to actually review the data, I agree with most detractors that it doesn’t really help consumers. I plugged in the three excellent hospitals in my area where I would actually have care or send a family member and couldn’t find any appreciable differences despite the fact that they received two, three, and four stars respectively. The two-star hospital is actually ranked top 10 in the nation for dozens of clinical programs, and if I ever had a serious medical problem, that’s where I’d want to be. Small community hospitals in my area scored highly despite the fact that they have no recognizable differentiators.

The star ratings do nothing to help patients evaluate quality of care for specific clinical programs, such as oncology or cardiovascular surgery, where volume and expertise really matter. I searched up quite a few specific hospitals, including every one where I’ve worked. Some that received four or five stars fall on the list of places I would never want a family member to go to for care – but not every family has a physician, so I feel for the patients who actually take the star ratings seriously.

The best part of the ratings is reading the reader comments in my local newspaper:

• This rating system is crap. (from a patient who goes on to explain the life-saving care, research protocol, and ultimately the organ transplant they underwent at a two-star hospital).
• This hospital rating system is misleading, especially when lives depend on it. My husband picked his hospital by ratings and it cost him his life.
• So according to this list, if I have a life-threatening illness, I should seek care at Tiny Community Hospital instead of at Big Medical Center which happens to be affiliated with one of the best medical schools in the world…. Seems legit.
• What does the government know about running and rating hospitals…. They run the worst hospitals in the country. #VA.
• The only government run hospital (VA) in the area didn’t get rated. The irony….
• Until Big Medical Center can get the uninsured patients that swamp their ED to follow up, they will continue to score low. The onus was put on the hospitals to manage their patients, but you can’t manage patients outside the hospital. The same people show up over and over for the same thing. Even with call centers making hundreds of calls a day trying to get patients to go get a test, get an exam, exercise, eat right, check on their mood and behaviors, it still comes down to the people on the other end to do what they’re asked.
• CMS couldn’t find its butt if its hands were glued to it.

That last comment gave me my smile for the day, so I’m going to sign off on that note.

What’s your favorite local comment about star ratings? Post it below, or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/25/16

The last couple of weeks have been a bit rough. Usually my personal life and work life have very little to do with each other, but a perfect storm of events has pushed them too close for comfort.

As a family physician and clinical informaticist, I’ve dedicated the better part of two decades to advocating for quality care. I’ve also spent a fair bit working on ways to leverage technology in order to deliver that care, as well as to help manage costs so that our healthcare system doesn’t topple under its own weight.

One of the hallmarks of trying to maintain that balance is the idea of evidence-based medicine. That approach is a data-driven way to try to comply with the physician’s prime directive of “do no harm;” it allows us as clinicians to try to make better decisions. Data that comes from research has a stronger impact than that arising from expert opinion or case reports. It doesn’t prevent us from taking the latter into consideration, but provides a framework for trying to make the best choices from the information available.

Evidence-based data is used to create clinical practice guidelines, which in turn helps physicians determine how to manage groups of patients. It’s the backbone of population-level health policy and has been a key component in US healthcare in that evidence is often used to determine whether Medicare or other payers will cover a particular treatment or service: whether it is considered to be medically necessary and/or clinically appropriate. To achieve the highest level of integrity in an evidence-based schema, data has to be peer-reviewed and reproducible.

This can be in sharp contrast to how most patients view the world. Often patients have heard about someone’s cousin, sister, or friend who had X condition and Y treatment, and stories about whether something worked or not travel at an amazing speed. The grocery store checkout lane is full of magazines talking about health-related issues and what various celebrities or other public personas have been through or done regarding a given condition. Walk into the average beauty shop in middle America and you will find a variety of armchair medical quarterbacks. The general public, especially when they are patients themselves, doesn’t care about evidence-based medicine, but rather about what is happening to them and the people around them.

When you have a patient — or family member, as in my case — who has had a bad outcome despite following the evidence, it makes things extremely difficult. That is where my worlds have been colliding, and it feels pretty disjointed. As someone who has taken more statistics classes than I ever cared to have taken, I know that there are always statistical outliers and the potential for chance alone to influence a given situation, especially when multifactorial disease processes are involved. We can only make recommendations based on population-based data and previous outcomes. Although the push towards precision medicine continues, using existing population-based data is going to be the reality for most of us for the foreseeable future.

We as physicians have to follow the best information we have, and sometimes it’s going to lead to poor outcomes. There’s no way to beat the statistics for every single patient. We use evidence to determine when it’s going to be cost-effective to do a particular screening service or treatment for a given population; we use it to determine when it is likely to be more harmful to do a procedure than not. In effect, this becomes a bit of a healthcare rationing mechanism, but with good intentions and well-reviewed evidence. The fact of the matter, though, is that it doesn’t make a bit of difference if your physicians followed the best evidence if you’re the statistical outlier.

What exactly should we tell the patient who didn’t have a screening service because it wasn’t indicated for her age group based on the evidence, but who developed cancer and doesn’t understand “why no one cared enough to make me have that test?” It’s not that no one cared, it’s that the risk / benefit / cost / value factors didn’t make the case to order the test.

On the flip side, what do you tell the patient for whom you performed a test based on clinical suspicion, but Medicare denied it because it didn’t meet criteria, and now the patient is calling you to apologize because she knows you can’t even balance bill for the services that you ordered based on the individual situation and shared decision-making? As physicians, how do we reconcile when we did all the right things, but bad outcomes still happened?

If we were to perform every test for every patient, the healthcare system would go bankrupt even faster than it already is. We’d also cause a fair amount of harm, because with increased testing comes increased anxiety, increased false positives, and increased follow-up testing. Treatments cause complications and sometimes disability and death. But what do we do with the patients who are ready to “fight like hell” –because that’s what our society says you should do whenever you are diagnosed with a disease — but as professionals. we know that such a fight is probably going to cause more suffering, disability, and expense than the patient is really prepared to endure? It takes a lot more courage to take the less-aggressive approach, but it’s often rejected as “throwing in the towel” or “giving up.”

When our own loved ones are in that situation, it’s incredibly difficult to reconcile the science with the reality of what real people are going through. It’s even worse when you have to preach the evidence every day but you know that even the best evidence will still have negative outcomes. Although it’s no one’s fault. it will still feel like it is.

Depending on age and other demographics, it’s doubly challenging dealing with this type of situation with patients who came of age when the US was considered a superpower. These patients watched us vanquish polio and smallpox. They see “modern medicine” as being just short of a miracle, and that we should be able to continue to cure and conquer the diseases around us.

Limitations on technology can be somewhat understood, but limitations due to cost and statistical improbability are nearly incomprehensible to many of our patients. This dilemma is one that many of us face all the time, but having to process it on a personal level is still difficult. It’s hard to educate physicians on the use of clinical decision support and clinical guidelines when you know first-hand that they’re going to leave patients behind. Those patients are going to be someone’s grandmother, father, sister, or mother. Or maybe your child or your brother.

There is a high level of pressure for physicians to be perfect, to never miss a diagnosis or fail to recommend a treatment. Many patients don’t understand the external forces that drive our decisions outside of the evidence – including whether a service will be covered, whether the patient can afford it, whether they can get a sitter so they can go have the procedure, etc. Those are all things that need to be taken into account as we move forward caring for populations rather than individuals.

We also need the best and brightest working on the psychology of our approach – how to help patients cope when they end up on the outside of the protocols’ intent, as well as how to help the healthcare providers whose decisions (whether shared or not) put those patients on the outside looking in.

What’s next for evidence-based medicine? How do we reconcile it against precision medicine and within our healthcare system? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/21/16

I’m always on the lookout for FDA alerts on drug recalls and other issues of interest to my clients. Usually those come as a “Dear Health Care Provider” letter and often involve contaminated biologicals, poorly compounded pharmaceuticals, or counterfeit prescription medications. This notice caught my eye, however, because it notified health care providers of hair loss, itching, and rash caused by a cosmetic product rather than a drug. Sometimes we forget that the FDA does more than approve prescription drugs, so this was a good reminder.

Although the majority of providers hanging around the typical physician lounge don’t have a working knowledge of MACRA or MIPS, those of us who are knee-deep in the transition to value-based care have some pretty detailed conversations. One of my colleagues has been in a discussion group about how Accountable Care Organizations submit their quality measures. I have to admit that I haven’t been deep into the ACO regulations, so I was surprised to learn that submission using the CMS Web Interface typically uses the first 284 Medicare patient encounters of the year. How do they even come up with a number like that?

The discussion group had been spurred by some kind of advertising piece targeting practices that see a lot of snowbirds, since those patients (who are often more physically and financially healthy than their peers) typically head south after the holidays. This could theoretically skew quality numbers in the less-temperate zones based on the demographics and clinical status of the remaining patients. Of course, depending on the size of the practice and the number of snowbirds, the skew could be negligible. But it makes one wonder about the rationale behind such an arbitrary number as well as taking the sample from the first encounters of the calendar year rather than as a random sampling. I’d be interested to hear opinions from those that know more about ACOs.

I’ve seen a definite shift in the scope of consulting requests that I’ve seen over the last couple of years. Where they used to be strongly flavored with the need to find an EHR, replace an EHR, or optimize an EHR, I’m not getting many of those these days. Most of my potential clients want help transforming their practices, either into a patient-centered medical home model or in helping with general office efficiency. One of the most common discussions I get into during these projects is the idea of panel size, or how many patients a primary care physician should have under their care.

When I first came into practice as a solo primary care physician, the hospital that sponsored me wanted to target a panel of 4,000 patients. That was partly based on the demographic of the area, knowing that many of my patients would be young and healthy and wouldn’t need more than one or two visits a year. However, since I was the only physician within a 10-mile radius taking new Medicaid patients, the ridiculousness of that panel size quickly became apparent as my schedule was loaded with patients who would come in 12 or more times per year. Helping clients determine what the right panel size for their providers is can be tricky, and I try to keep up with articles that address it.

One of the first things I look at the wait for a patient to get an appointment. Regardless of your panel size, if your patients can’t get in, you have too many patients (or not enough appointments – either way something isn’t right). I also look at provider scheduling habits and whether they run on time or double book and how they cope with that. If they’re getting through the day by double booking and praying for cancellations, it’s more likely to lead to burnout, employee dissatisfaction, and patient dissatisfaction. I also look at whether the practice is running using a care team model or whether they’re running as a more traditional physician-run practice.

Unfortunately, income goals tend to drive visit volume more often than other factors such as clinical quality or perceived workplace stress. I was recently wearing my EHR hat in a conversation with a practice management consultant whose opening comments to the physician asked how much she wanted to make per hour because that was going to drive patient volume and panel size. Although income is certainly a factor for most of us, I thought it was insulting to use that as the primary discussion point rather than asking the physician what kind of practice she wanted to have and how she saw herself and her team delivering care. My sense was that if this physician was about the money, she would have chosen something other than family medicine as a specialty, and leading with that aspect of practice management really put a damper on our ability to have a good discussion.

I came across an article this morning that addresses the concept of panel size as an issue in physician workforce planning. It addresses the idea that a panel size of 2,500 patients is often cited with little evidence to back it up. How far that is from my initial 4,000 patient target! The article goes on to look at practices that actively manage panel size (such as Kaiser Permanente and the VA) whose numbers are more in the 1,200 to 1,700 range. It also mentions that physicians in a “concierge or boutique” model care for between 900 and 1,000 patients, but my experience shows these to be even smaller – typically in the 500-600 range in the Midwest.

It’s no surprise that smaller panel sizes lead to reduced wait times and improved quality of care, as mentioned in the article. The trick is ensuring that primary care compensation allows smaller panel sizes so that physicians can truly get off the volume-driven hamster wheel. Compensation also has to allow for utilization of diverse clinical team members such as dieticians, social workers, care coordinators, and more, if that’s what our “value-based” system requires. I guarantee that if primary care physicians were compensated to the same degree that procedural subspecialists are (even if you adjust for years of training), you’d see people flocking to primary care.

We’re not there yet though – and we’re trying to use figures like $10 per member per month to drive change. It will be interesting to see what the next few years hold as we transition to new models of care and new models of payment.

What do you think about the transition to value-based care? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/18/16

I recently spent a week off the grid. I have to say that it was one of the best things I’ve done with my time this year. Six nights in a tent will definitely give one a new perspective on things, especially when you’re used to being connected 24×7.

Most of my work lately involves being barraged with a continuous stream of issues that my clients feel are critical, but that often turn out to be blips in the grand scheme of things. I spend a lot of time talking people out of high-stress situations and putting together plans to mitigate potential disasters. That kind of work takes its toll on you after a while, so I was looking forward to my trip.

During my week away, the biggest plans I had to put together revolved around keeping the area clean of bear-preferred smellables and helping newbie campers get through the week. While some of my colleagues elected to do some hard-core rock climbing, trail building, and even a trip to the summit of a neighboring peak, I spent a good chunk of time watching clouds reshape as they came around the mountain and listening to the aspens quaking in the breeze.

I hiked to a couple of overlooks and just sat, doing nothing, until I was done. There was no time-boxed agenda, no deliverables, and no follow-up meeting planned. I enjoyed responding to the question of, “What did you do today?” with, “Hiked over there, then sat, then came back.”

While sitting quiet and still, I had some wild turkeys come within feet of me, pronounce me uninteresting, and go on their way. That’s definitely something to think about for those of us in high-pressure jobs who are used to being in the thick of things. Guess what? The rest of the animal universe doesn’t care who we are, what we do, or how many deals we’re closed this quarter. Nor do they care about the number of email messages accumulating back home or the number of meetings we’re missing. And maybe for our own human sanity, it would be better if we stopped caring so much too.

For the first couple of days, we had a couple of people obsessively checking their phones and trying to get a signal, hiking here and there to see if they could pick something up. None of them were trying to catch up on anything truly critical like a sick family member. They generally just couldn’t disconnect from work enough to enjoy where they were and who they were with.

I’m fortunate to have coverage I can trust when I’m out, but it takes a lot of work to get ready to leave and there’s always a mountain of work waiting when I get back. Not everyone has that level of trust with their coverage, but still, most of us would be better off if we could get back to being able to put it aside at least for a short period while we are away.

Many of the clients I work with offer to call in to meetings when they are on vacation. They’re so afraid of missing something at work that they miss the point of getting away. I’ve been known to resend invites and drop those people off so that they don’t have an excuse to put their vacation on hold. There are rarely meetings that are truly critical enough to abandon your R&R. But it’s hard to make those determinations when you don’t have perspective on what happens outside your circle of work.

Over the past year, I’ve watched my friends be laid off, reorganized, repositioned, reclassified, and generally run through the corporate wringer. I don’t think any of them wishes they’d been more loyal to their employers or that they’d have attended more meetings while they were supposed to be on vacation. Most of them wish they had worked less and had better balance, because even their best efforts didn’t make a difference in how things ended up.

It’s increasingly rare for people to spend their entire careers with a single employer, or even with two or three. As corporations churn and our industry evolves, people are constantly forced to reassess where they stand and whether they still want to be doing what they’re doing in a year, or three years, or even in a month. Being away from civilization definitely helps with that introspection, especially if you’re willing to give yourself over to the moment and watch what is happening around you.

The place where we camped had been involved in a forest fire in 2013. Since the fire hopscotched across the property, it spared certain features while destroying others. Sitting under untouched pines and looking at devastation 20 yards away reminds you that life is truly unpredictable and that if we think we have everything under control, we’re kidding ourselves. Out of the ashes of the fire, new plants are coming that haven’t been seen in years due to the overgrowth of certain species that the fire took out. It’s gratifying to see the new growth and wonder what things will look like in a decade, or two, or three.

I can’t say that my entire week was stress free. This was my first time having to deal with bear precautions, and although I was confident in my preparations, I wasn’t sure the people camping in the tents next to me were as diligent with their own. I was also keeping an eye out for altitude sickness and trying not to get sunburned while also having fun. There was a brief interlude involving a camp-style cooking contest, but if that was the most major stressor I faced, I’m good with that. And as an aside, mixed berry cobbler cooked in cast iron over charcoal doesn’t need high-altitude modifications (although the sheer amount of butter used might just have made any baking problems irrelevant).

Although it’s good to be sleeping in an actual bed again, I miss having deer surprise me on the way to get water every morning. I also miss having hummingbirds buzz me while I contemplate the mysteries of the universe. It was a great trip. We didn’t have any wildlife problems and I might have even returned home with a cooking prize.

What’s your strategy for getting off the grid? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/14/16

HIMSS has started planning for National Health IT Week, to be held September 26-30. Events include a “Virtual March” to allow participants to reach out to their representatives to discuss the benefits of health IT in advancing medicine. The “Activities & Agenda” section of the website still lists the 2015 content, so we’ll have to wait to see exactly what is on tap for this year.

A good friend shared a link to Stop Meeting Like This. which has some eye-catching headlines. My favorite was the link to the flow chart that answers the perennial question, “Are you about to have a crappy meeting?” Although it’s largely tongue in cheek, it made me smile. The fact that other people think about how soul-sucking meetings can be reminds me that I’m not alone.

Other topics include strategies for making sure 24-hour access doesn’t interfere with work-life balance and the “dark side” of collaboration. I’ve got some colleagues who could definitely benefit from the latter piece. I love the last line of the piece: “Make sure that the collaboration in your organization isn’t just a smokescreen allowing many to coast on the efforts of others.”

Another friend clued me in to Athenahealth’s take on “If You Give a Mouse a Cookie,” which appeared just a couple of days after my own mention of the classic tale. They did a really good job with it, ultimately calling on CMS to “avoid ending this sordid tale exactly where we started” and saying “it may be too late at this point to take back the cookie from CMS, but it’s not too late to push back on the milk.”

The AMIA 2016 Annual Symposium “early bird” registration deadline is approaching. It’s closer to home for me this year, but I’m not sure I’m going to make it. It’s nearly back-to-back with another conference I’m already committed to attend and even the early bird registration rate is nearly $1,000. Add in hotel, meals, and travel and it’s a good chunk of change.

I do enjoy going, though, and getting together with colleagues who work in different spaces within the clinical informatics universe. It’s good to be able to commiserate about some of the things we see in the field, but now that I have more responsibility with my practice, it’s harder to get away.

I’m also interested in attending the NCQA Patient Centered Medical Home Congress in October (and also in Chicago). Moving forward with PCMH efforts will clearly benefit physicians and practices as we move towards value-based care. However, NCQA is planning to update its recognition program, “planning an ambitious full redesign.” Public comments on the proposed redesign close Friday, so I hope people have been able to submit their thoughts.

Recently I came across a physician who wants me to come up with a strategy to “de-spam” his Direct interoperability solution. He’s in a part of the country where secure communications between providers is really taking off, but he’s not happy that pharmacy benefits managers and other organizations have started sending patient-related communications. He wants to restrict use of messaging to only physicians, which flies in the face of the idea of team-based and collaborative care. He also wants to figure out a way to make his address “unlisted” so that people can only reach him when he wants them to reach him. I’m not sure what to tell him, but I’m betting my informatics colleagues will have some ideas.

It’s not health IT-related, but it did make my day. The Apollo Guidance Computer code is making the rounds on the internet. There’s some pretty humorous bits and also a little Shakespeare included for good measure. The article is worth the read if you’re looking for a little distraction.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/11/16

I read with interest the recent alternative certification proposal from John Halamka.

I have a couple of vendor friends who work on the certification process for their respective organizations. They both describe the process as cumbersome and tedious. One of them is a nurse and says she detests the entire process since it forces adherence to rigid scripts rather than testing the actual workflows users are going to need. Those of us who have spent a bit of time implementing systems know there is a significant difference between vendor QA testing (where vendors see if the code that was produced meets the build specifications) and true user acceptance testing, where we see if the code that was produced actually meets the needs of those using the system.

Whenever I assist with running user testing events, I make sure we test features and functionality using a dual approach. Some users will be given turn-by-turn test scripts that target a new workflow component in the context of the larger existing workflow, to ensure that the new pieces don’t adversely impact any other parts of the workflow. We all know about releases that fix one thing and break another, and this seems to be the best way for many clients to catch those kinds of issues.

Another group of users will be given test scripts that are a bit more nonspecific, such as, “Prescribe these three medications, then schedule an appointment for an office visit and send a referral for a mammogram through the portal.” This approach allows us to test new features against the way users actually use the system rather than against a rigid test script.

Users are generally creative. If there’s a work-around to be found or an alternate way to do something, they’ll unearth it. Sometimes those workflows are legitimate – the vendor offers three or four different ways to do something. However, some work-arounds may take advantage of unintended functionality or existing defects, so that that when those seemingly-unrelated defects are fixed, it causes issues with other workflows. You’re generally not going to find those with rigid test scripts since you may not have any way of knowing how creative your users have gotten or what workflows they have come up with.

Of course, testing those kinds of scenarios is far beyond certification, and with as tedious as certification already is, I’m certainly not advocating expanding it. It’s just a shame though that vendors are spending time certifying their products against criteria that have little impact on the actual use of their product.

At the same time, we seem to be lacking in actual usability testing. Although vendors are being pushed to include user-centric design principles in their processes, the outcomes still vary widely. The recent dust-up with Athenahealth’s Streamlined upgrade seems to illustrate this. Judging from the comments I’ve seen and heard, it feels like there may not have been enough user acceptance testing to identify workflow problems that are causing significant issues for a good number of their clients.

Although the comments should be taken with a grain of salt (since it’s difficult to know whether clients attended training, performed testing, whether they were following best-practice workflows previously, etc.) there is always a kernel of truth to be found. I’ve been on the receiving end of enough poorly-conceived or poorly-executed vendor “enhancements” to know that they seem to make it out the door more often than they should.

Sometimes they are the product of good ideas. but the technology doesn’t really make them executable. Sometimes they are enhancements that were created for a single client as a result of a contractual obligation even though they have zero utility for the rest of the vendor’s customer base. Other times they are enhancements that were created for sales purposes, to allow for a glitzy demo that looks good yet doesn’t meet the needs of actual physicians or clinical users. Not only are they unhelpful, but a couple I’ve seen recently are downright insulting to the good sense of the average doc.

In his comments, Dr. Halamka discusses how certification has negatively impacted the industry: “Overly zealous regulatory ambition resulted in a Rule that has basically stopped industry innovation for 24-36 months.” Clients who have waited patiently for their vendors to implement basic usability enhancements know exactly what he’s talking about. Rather than improving the user experience, scarce development dollars were spent meeting the letter of the law for requirements that may never be used. He closes with some profound thoughts that made my day:

If Brexit taught us anything, it’s that over regulation leads to a demand for relief.
Pythagoras’ Theorem has 24 words
Archimedes’ Principle has 67 words
The Ten Commandments has 179 words
The US Declaration of Independence has 1,300 words
The EU regulation on the sale of cabbages has 26,911 words.
As a comparison, the 2015 Certification Rule document has 166,733 words.

Good food for thought for the governmental bodies, agencies, payers, and others whose rules define how we deliver healthcare in the US.

What do you think about excessive rulemaking? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/7/16

The Independence Day holiday is understandably one of my favorites. It had a lot more meaning to me this year and I have my clients to thank for it.

During the last 12 months, I’ve had the privilege of performing consulting engagements in locations key to our nation’s history. I started in Boston, followed by Philadelphia, then Washington DC, and back to Philadelphia. For someone who is a bit of a National Parks junkie, it was like winning the lottery.

Fortunately, many of the monuments are open late. If you hit Independence Hall at the end of the day, there’s an “express” tour that doesn’t require tickets. You don’t get to see everything, but when you’re on site with a client and trying to squeeze in some sightseeing before your flight, you take what you can get.

Of all the monuments and memorials, my favorite is the National WWII Memorial in Washington, DC. During the day, you can often catch an Honor Flight group visiting. It’s certainly something to see the veterans reacting to their memorial. Sometimes I can’t turn off the physician side of my thought processes – not only did they survive the war, but they’ve experienced first-hand many of the medical advances of the past century. Things we completely take for granted were revolutionary during their lifetimes. At night, the Memorial takes on a supernatural quality. Each of the memorials has its own special quality, but for some reason, this one particularly resonates with me.

As much as many of us feel we are living in a word full of turmoil, thinking about what we’ve been through as a society during the last 200+ years puts it somewhat in perspective. Although we may be dealing with crises in healthcare delivery that consume us on a daily basis, we’re not dealing with smallpox, polio, or whooping cough. Many of the diseases we’re fighting are somewhat self-inflicted. We don’t need a so-called “moon shot” to cure them, but rather could make a huge difference with public health initiatives, preventive services, and individual lifestyle changes.

Population health has a lot of promise, if you can get through the hype. The ability to reach out electronically to hundreds of patients based on easy-to-access data points is huge. We can do in seconds what it would have taken days to do with paper charts. For most practices, though, the focus is on the sickest of patients because we’re targeting costs as a primary indicator. We’re trying to manage the top 10-15 percent but are losing sight of the rest of the population. For those organizations that have figured out how to expand their reach into the next quartile, the long-term returns on health promotion and disease prevention could be tremendous.

As a young physician, I used to rail at the fact that Medicare would pay for insulin but didn’t have adequate coverage for diabetic education. It felt like we were spending our money in the wrong place. We also weren’t paying for preventive services, but were happy to pay when people were sick. The Affordable Care Act has changed that for the better, as has the push to look at value rather than volume.

I’d like to see it go even farther, though. Rather than focusing primarily on diabetics with the worst control, how about we focus more on the pre-diabetics and newly-diagnosed individuals who we can truly impact? It may not bend the cost curve in the short term, but it certainly will in the long term. I think organizations are trying to move in that direction, but it’s hard to find the right mix of patients to target given the typical resource constraints in care management.

There are some solid programs to look at how we do this. I’ve been following the Comprehensive Primary Care Initiative (CPCI) and its evolution into the CPC Plus program. It’s been great to see the way they looked at the program and how it worked and are now creating two different paths moving forward. Hopefully we’ll have enough practices truly embrace the program that we will be able to see how effective the different approaches are in achieving health outcomes. I’m eager to see what regions will be chosen, what payers will participate, and whether any of my clients will decide to move forward with the programs. I’d love the opportunity to be hands-on with the next generation of comprehensive care.

One of the reasons I think programs like CPCI work is that they’re voluntary. Practices self-select if they want to be a part of it — they know from the beginning what they are getting into. They’re not doing it because they feel pressured or because they’re trying to avoid a penalty, and I think that’s the point we’ve collectively missed with Meaningful Use and now MACRA/MIPS/ACI etc. We all understand the psychology of the carrot and the stick, and even though we know some people will never get moving until the stick is approaching, the carrot is a more powerful motivator for many. Programs like CPC+ also speak to the reasons why physicians went into primary care in the first place.

As we all wait for the MACRA final rule, many organizations are trying to figure out their strategies for the next few years. Do we want to be the kind of practice that just aims to check the box, or do we want to try to do more? How can we get our nation’s best and brightest focused on solving these complex healthcare problems? Can we start to focus on the patients in front of us as much as we’re focusing on scores and numbers?

Unfortunately, these aren’t easy questions to answer. Eventually we will get through all of this, much as our forefathers have gotten through so many other challenges that were different and yet the same. Although it may not seem easy, we’re fortunate to live in a time and place where there are many opportunities to make things better for the people we serve.

Rather than focusing on the daily chaos that surrounds us, let’s remember to think about the promise that our technology holds. Who’s with me?

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/30/16

Lots of chatter in the physician lounge this week around the installation of the new president of the American Medical Association. Frankly, I haven’t heard physicians discuss the AMA this much in years. The consensus has been that the AMA doesn’t really represent physician interests. Front-line physicians think the AMA has sold them out in a variety of ways.

With that in mind, though, why is the AMA top of mind this week? It’s because new president Dr. Andrew Gurman doesn’t use an electronic health record and is proud to say so.

I think we’re all so subject to the EHR hype and the constant barrage of vendor messaging, that we’ve forgotten that there are a lot of physicians out there who either aren’t using EHRs or who have elected not to attest to Meaningful Use. According to CMS data, only 56 percent percent of office-based physicians had demonstrated Meaningful Use of certified EHR technology at the end of 2015. I couldn’t find all the detailed data for 2015, but looking at 2014 data, there were 17 percent of physicians who hadn’t adopted an EHR at all. Of those non-adopters, 48 percent practice either solo or in groups smaller than 10 physicians.

I’d have been a lot more impressed if the new president was a primary care physician who had opted out of EHR, but Dr. Gurman is a solo orthopedic surgeon who specializes in hand surgery. He admits his practice is just taking the 2 percent penalty at this point. If you’re just looking at a 2 percent penalty, the ROI on opting out is pretty clear, especially if Medicare isn’t responsible for the majority if your patient visits.

I don’t know what Dr. Gurman’s payer mix looks like, but the hand surgeons I know work mostly with younger patients who are likely to have commercial insurance coverage. The opt-out becomes harder as the practice’s population ages (more Medicare) or as economic forces shift (more Medicaid).

Those practices I work with that have yet to implement an EHR are generally concerned about costs. To implement an EHR well costs far more than the incentives that have been available to date, and the penalties are minor compared to the cost. Of course, when you look at the other costs that having an EHR can reduce (chart storage, supplies, staffing for inevitable “chart hunts,” inefficiency) one can make the case for an EHR. It’s when you start adding in provider time that the cost curve can start behaving unpredictably.

In an efficient practice with standardized processes and a commitment to fully support the EHR, the ROI can be tremendous. In a practice where physicians don’t have buy-in or the systems aren’t in place to make the EHR run well, the ROI can evaporate in an instant.

It’s possible to delivery high-quality, well-coordinated care without an EHR, but it’s definitely a lot of work. I’ve worked with a number of groups that have not only achieved Level 3 Patient-Centered Medical Home recognition using paper charts, but who also have been able to demonstrate higher-quality care than their peers. The reporting requirements for these initiatives can be significant and typically require using other IT systems to document outcomes even if the practice isn’t using an EHR. It’s certainly easier to use an EHR, especially if you have a robust one, but balancing the demands of the EHR with its benefits is a trick that many practices have yet to master.

I’m working with a practice right now that has only a few physicians and no dedicated resources to support their EHR. They are extremely demanding with their vendor, yet refuse to do even the simplest things to help themselves. For example, the physicians refuse to allocate time for staff to attend the complimentary webinars that their vendor offers for upgrade preparation. I suppose they think the staff will learn about the product changes through telepathy.

The managing partner refuses to work collaboratively with the EHR vendor. Today they copied me on an email to their lab vendor where they were completely out of line, making wild accusations about the EHR vendor. It doesn’t seem like they’ve ever heard the old adage about catching more flies with honey.

I’m particularly sensitive to the statistics about practices that have opted out of Meaningful Use since I’m part of one. We’re fortunate that our payer mix tips towards the commercial side, and that we’ve carefully cultivated other revenue opportunities that aren’t subject to the current regulatory environment. We provide comprehensive occupational health services for some local employers and limited services (such as pre-employment physicals and drug screens) for others. We do travel health and have some contracts for specialized medical clearance. We do use an EHR and initially participated in Meaningful Use, but stopped after it became more burdensome than it was worth.

Even though we’re robust EHR users, I wish there were better ways for us to share data with other practices. Since we provide mostly urgent care services, it would be great to be able to access patient records from primary care physicians or from other acute visits, but we really can’t get anything. We can send CCDAs like nobody’s business (and we do), but we rarely receive anything because patients generally don’t anticipate having to come in for pneumonia, bronchitis, or the flu. Our metropolitan area doesn’t have decent coverage by a health information exchange, so really the only information we can pull into the EHR is the medication history from the PBM.

The major health systems surrounding us have absolutely no desire to share information with our practice because we directly compete with their emergency departments, yet the vendors are the ones that get accused of information blocking.

Until the health systems are in some way incented to share data with the rest of us, it’s going to be hard to move forward and get the information we need to provide better care to our patients and our community. Although most hospitals have embraced EHRs, we all know how hard it is for patients to get their own records electronically. Until we start solving that problem, I don’t have a lot of hope for the hospitals sharing with anyone that’s not closely aligned with them.

We’ll have to see if there’s as much buzz around this AMA president at the end of his term as there is at the beginning. Will primary care physicians embrace him and his goals? Time will definitely tell.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/27/16

I’m having a little bit of professional déjà vu this week. I originally started working in healthcare informatics somewhat by coincidence. I was working for a group that wanted someone to test-drive an electronic health record for the practice, and since I was relatively new and didn’t have a large patient backlog, I volunteered. Little did I know that it would eventually grow into a full-time career in informatics.

After my time piloting the EHR (which turned out to be a total mess of a system), I was asked to participate in the search process for a replacement. When they selected a system and were looking for a medical director to oversee the EHR project from a clinical perspective, I threw my hat into the ring.

It started as a half-day a week, which was compatible with managing a full-time practice. As the project ramped up, it became a full day a week, which was still doable, but once they wanted me on the EHR project half time, I knew I would have to do something different about my office practice. I contracted with a nurse practitioner to help me co-manage my patient panel.

That worked for a while until the informatics work began to take even more of my time. Eventually I was only in the office one day a week, which created an unsatisfying situation for everyone. Patients weren’t happy that they couldn’t get in to see me. Since I had previously run an open access practice, they were used to same-day attention.

Some of the patients resented the involvement of the nurse practitioner since, in my part of the country, this was well before the concept of “team-based care” started taking root. Those patients felt that if they didn’t get to see the physician, they were somehow being shortchanged. It didn’t seem to matter whether it was an acute visit or whether it was a chronic condition that we were managing through a comprehensive plan of care. The bottom line was that they weren’t getting to see me, and eventually it reached a point where I felt like I was unable to give good care.

At that point, I went to informatics full time, cobbling together enough clinical work to keep the licensing folks convinced that I was in “continuous practice” as required in my state. It’s not entirely clear what happens when you have a lapse in practice, but I wasn’t willing to find out.

Sometimes I covered my former clinical partners in the office when someone was out, seeing acute visits or functioning in a locum tenens capacity. It was a little unpredictable, so I started doing more locum type work and working with some other groups, eventually working my way towards emergency and urgent care practice.

I’ve been in that space (with the occasional stint in a “traditional” primary care setting) for nearly a decade now. While staying on with the health system, I worked in their emergency departments both as an employee and as a contractor. After some changes in their clinical staffing, I bounced around a little until I wound up in my current clinical situation.

I’ve been working with this group for over a year and it’s been an interesting journey. The group is growing by leaps and bounds. The managing partners know that clinical informatics is my full-time gig, so they’re flexible with my work assignments, which is good.

I only had one near-miss with my consulting travel when I had a serious flight delay and wasn’t sure I’d be home to work my shift, but my colleagues were very understanding and were ready to back me up if I didn’t make it. It was a nice feeling since being a part-timer sometimes doesn’t lead to those kinds of relationships. Maybe it’s because they’re just nice people, or maybe it’s because I work a fair number of “undesirable” shifts (weekends and holidays) and they’re grateful. The rest of the physicians and staff know that I have a full-time job elsewhere and are always interested to hear my tales from the consulting trenches.

It’s been a little odd, though, because I have no real leadership or management role and I’m used to working in that capacity. They’ve tried to get me to move into a more permanent role a couple of times, but I haven’t been ready to just yet. Part of the reason is that I’ve been trying to build my consulting practice, but part of it is that I simply am not a fan of 12-hour clinical shifts and that was part of the role.

Recently, though, as the practice has grown, they’ve shown more interest in having someone with a solid informatics background take over that part of the administrative tasks. When they came to me recently with an ask to devote “just a half-day a week” to the EHR and its related operational and clinical impacts, I found myself unable to say no.

Although the pay is less than I’d typically make consulting, it’s nice to have 10 percent of your work hours accounted for without having to try too hard. Not having to write project proposals, do accounting and hours tracking, and deal with the payroll and task aspects balances out the relative loss of income. There’s also the intangible feeling of knowing that my work is making a difference in the grand scheme of things rather than just being an informaticist for hire. They’re willing to be flexible on the hours I spend with them given my travel schedule. Knowing the personalities of my employers, though, I can’t help but think that four hours a week is going to turn into something more.

One of my favorite books to read to my nephew involves a mouse who wants a cookie. When he gets it, he asks for a glass of milk. When he gets the milk, he’ll probably want a straw, and then a napkin, and so on. If you give a clinical informaticist four hours a week…. You never know what might happen. I do hope it involves cookies, though.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/23/16

Lots of readers have written with their favorite travel stories in response to my recent post. Long lines at security checkpoints continue to lead the tales, with at least two readers noting trips where the TSA PreCheck lines were longer than the regular ones. Lots of people are frustrated with the summer surge in travelers, many of whom aren’t used to packing their liquids appropriately or getting rid of their drinks before trying to go through the scanners.

I have one friend with a pilot’s license who flies himself to jobs. I went with him once and have to say there’s something to be said about boarding at the local general aviation terminal and heading on your way. His company pays for the trips as long as they’re equivalent to the cost of a commercial ticket, but they did have to get a special waiver for insurance reasons.

I’m still waiting for my red-light ticket, which I imagine will come in four to six weeks once it makes its way through the rental car company data trail. I have a little bit of a bet with my partner, who thinks it will come much faster. Considering the wager, I’m optimistic that he’ll be reconciling the travel expenses this quarter instead of me. There’s always a chance I’ll get stuck with it again as well as having to pay the ticket, but where’s the fun in not taking advantage of a friendly wager?

It’s been a fairly low-key week and I’ve been glad to be working from my home office. It’s nice to have a 20-foot commute and be able to work in shorts and flip flops for a change. It’s also probably been good from a career preservation perspective since I’ve been on a lot of calls where had I been there in person, my facial leakage would probably have gotten me fired. Sometimes it’s the little things that just make you smirk uncontrollably. One of my consulting offerings is around conducting effective meetings and I’ve not only identified some candidates for additional services, but added some examples to my teaching arsenal.

I’ve mentioned before that I typically schedule 25- or 55-minute meetings rather than 30- or 60-minute meetings. This allows people to reset and recharge before the next meeting as well as clear the room and get organized. Of course, not everyone subscribes to that strategy which often leads to overlapping conference calls. It’s always awkward to come on the line in the middle of a call in progress, especially when all you were trying to do was arrive early so you would be prepared.

On one call this week, I arrived to find the moderator saying that, “It sounds like a couple of people here have a hard stop, so we’ll have to go ahead and end the meeting.” Yes, when your meeting time is up, it’s a good idea to end it regardless of whether everyone has a hard stop or not. Just because some people are willing to stay over doesn’t make it acceptable.

I also had so many calls that didn’t start on time that I started keeping a tally. The worst was a call that actually started 22 minutes into its allotted time. Although I hate wasting people’s time and money, as a consultant sometimes it’s my job to stay on the call until the client dismisses me. This one was particularly painful because it was scheduled to allow a prospective vendor to present its solution to my client. I had been engaged to help the client evaluate the solution since they’re a small practice and don’t have a lot of experience in this particular area. I’m certainly not impressed by a vendor that shows up late and isn’t prepared. I understand that sometimes inevitable things happen, but those are situations where one wants to call or text or do something to let people know you’re not just standing them up.

My other favorite is when people feel the need to make sure they say that the group is pausing for a “bio break” or a “coffee dump” or some other description of bodily functions. When did it stop being OK to simply say, “Let’s take a 10-minute break?” Do we have to discuss exactly what people are going to do during the intermission?

One of my calls this week was an all-day strategy meeting, which had several examples of restroom-related euphemisms. I was grateful, though, that it had a formal lunch break rather than a working lunch. Although my headset has enough range to get to the kitchen and make a sandwich or reheat some leftovers, I always worry that I will forget to put myself on mute. I was jealous though of the outstanding Texas barbecue that I knew was being eaten on the other end of the conference call. I had to be content with my chicken salad sandwich, but that’s how it goes.

I spent all day Tuesday creating recorded training materials for a client. They’re getting ready to migrate to a different EHR and ran out of steam in getting ready to train their end users. I long ago made my peace with Adobe Captivate and don’t mind doing the recordings, especially when it means not having to travel. They can be tedious at times, but fortunately the client realized that it’s still more efficient to hire someone to do it who has done hundreds of them rather than struggling trying to create them on their own. Fortunately, they had created most of the scripts and I just had to do some minimal polishing before digging in.

I also had the chance to attend a couple of educational webinars, which is a rare treat. They’re nice because I don’t have to present and can actually absorb information. Sometimes if I’m lucky and can plan enough in advance, I’ll hit the treadmill while I tune in, but that’s a rarity. This week I was able to catch up on some laundry folding and pack my suitcase while reinforcing my knowledge of MACRA and MIPS.

I’m back on the road in the morning for a quick proposal presentation to a prospective client, and as long as the travel gods are smiling, I’ll be home by dinner time. I hope they end up accepting it because they seem to be a really cool medical group that is already moving in the right direction but just needs a little boost. Those are my favorite kinds of clients, and the fact that they’re in a cool city doesn’t hurt.

What are your thoughts about the summer travel season? Where is your next great trip? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/20/16

CMS sent an email notifying people that it will be making updates to the portion of the CMS website covering HIPAA administrative simplification. Although users might be looking forward to “streamlined content and easier navigation,” nothing says “administrative simplification” quite like creating a new URL and making tens of thousands of users across the country update their bookmarks.

Unfortunately, this is just the tip of the iceberg with CMS and all the other federal bodies that have a say in regulating how we practice medicine and how our EHR vendors should support us.

A physician friend of mine works for a vendor. We had the opportunity to get together over the weekend and commiserate about what medicine has become and what MIPS/MACRA is going to do to our respective customers. He’s completely frustrated by some of the clinical quality measures that he is expected to bake into his application. Some of them aren’t really ambulatory measures and would require a lot of manual abstracting of hospital data into the ambulatory chart. There are another group of measures that impact few patients unless you’re in a narrow subspecialty, which makes it difficult for EHR vendors that are trying to support all possible specialties.

Others require use of screening tools that his company doesn’t already have rights to use. This process can take months (plus a fair amount of cash) to get legal agreements in place allowing software vendors to use proprietary screening tools. In the spirit of interoperability, shouldn’t our federal and regulatory “partners” be selecting the open-source equivalent for the content they are specifying? I know there may not always be a non-proprietary option, but if there isn’t, maybe they can use their development dollars to create initiatives and competitions to create that content so everyone can use it.

Every time we get into a regulatory update cycle, vendors’ attention is diverted from providing the content that their users want and need to providing what they are required to provide, regardless of whether their users plan to use it or not. My consulting firm is involved in a fairly deep way with three vendors, all of which are in the same pinch whether they’re privately owned or publicly traded. Of course some vendors are more nimble than others and they have it a bit easier as far as creating content and distributing it to their respective client bases. Like physicians, though, they’re all having to focus on checking the box. This means that they’re not necessarily as focused on innovation as they otherwise could be.

Vendors are not entirely without blame in this game, though. One that I work with frequently recently made a decision that defied logic: they changed the provider home page to remove the instant messaging portion that had previously been embedded at the top of the screen. Now, physicians have to go to a separate screen to address their messages, which not only adds clicks, but increases the possibility that something will be missed.

Since they didn’t use the real estate for anything else, it boggles the mind why they would have thought this was a good idea. I can’t imagine they did usability testing on this before releasing it to the client base, and if they did, I’d be interested to talk to the people who thought it was a good idea so they can explain it to me because I’m missing it.

As with so many things in healthcare today, it feels like we’re focusing on the wrong things. Case in point: precision medicine. Don’t get me wrong, I think technology is sexy. The idea of being able to look at someone’s genetic makeup and use that information to diagnose disease before it happens is extremely sexy. But it’s expensive. Given the need for research, development, etc. it has a long lead time, so that makes it feel a bit like we’re pouring money into something that’s not going to provide benefit to everyone, and not for a long time. That’s my perception from the trenches and I’m sure the perception from academia or industry is likely to be different.

It might feel different it we were also pouring money into proven but un-sexy solutions like public health. Obesity prevention, anyone? Getting the number of obese people in our country down under 20 percent again is going to save more lives and provide more quality of life in the intermediate to short term than precision medicine will. But it’s not sexy.

I was on a webinar the other day for family physicians where the speaker was telling us we’re supposed to be referring our patients to community gardens and organic food pantries as ways to combat obesity and food insecurity. Yet another thing for primary care physicians to do while they’re trying to keep all the plates spinning and coordinate care in an increasingly fragmented environment.

Where’s the funding to promote these solutions? Can I get an embedded care coordinator to reach out to those patients and have the conversation about community gardens? Can I get someone to pay for the custom reporting I’ll need to identify eligible patients by diagnosis and ZIP code? Guess what, there’s no funding for that. And even if you have an EHR that can do it and a population health system that can do the outreach, there’s no recognition of the fact that it’s additional work on the practice.

Of course if the dreams of advanced payment models and whatnot come true and we start to see additional reimbursement for this additional work, it might all balance out. But that’s not the reality that most of my primary care clients are living in today. I’m watching my colleagues retire or move to non-continuity practices like urgent care or cosmetic medicine in droves.

Although I find issues like this to be exasperating, it’s a good reminder of why I’m in consulting. Many of my clients are small practices that can’t navigate this world on their own and rely on my partner and me to get it done. We’re their first line of education and sometimes the last line of defense at keeping their practices afloat. They trust us to help them, and by extension, their patients. When it all works out, it can be very satisfying. But most days it just feels like a grind.

What do you think about the tension between high-tech and public health fieldwork? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/16/16

It’s weeks like this that make me want to hang up my consulting shoes for sure. Storms have intermittently snarled air traffic in the Midwest, making it hard for my partner and me to get to clients. Fortunately, since we work for ourselves, we have the ultimate authority as far as rebooking and rerouting and can decide whether we want to absorb the cost of a new ticket or stick it out.

On Monday, I was surrounded by business travelers who weren’t as lucky as I overheard several frantically calling travel agencies or seeking management approval to reroute their flights. As the week progressed, I did my fair share of sitting on the tarmac and also had one round of going back to the gate. Early summer travel is always dicey (especially if you have to go through Chicago) and my plans to avoid it never seem to actually happen.

I was optimistic yesterday morning, as I found a seat on an evening flight that would allow me to avoid leaving my hotel at 4 a.m. to catch a 6 a.m. flight to the next client. The only wrinkle was that I had to arrive at a different airport than originally planned, but that seemed OK since the client is halfway between two major airports and the drive time from each is about the same. I could arrive at my destination airport at 10 p.m., hop in my rental, drive for an hour and a half, and still get a good night’s sleep. My friends at my favorite hotel chain were happy to waive any early check-out penalty because I was booking the night at another hotel in the chain.

Little did I know that the travel gods were going to make up for my seemingly good decision in a multitude of ways. I arrived at the rental car vendor to find that there were no cars. Seriously, none. The staff was kind and offered bottled water while we waited for vehicles to be brought around. There were six of us who had come off the shuttle bus from my flight, all of us had reservations, and our flight was on time, so I’m not sure why it was a problem. Since I wanted to get to my hotel to crash, I took the first car available and headed for the exit.

All was smooth until exited the airport proper and immediately got nabbed running a red light. It was a large intersection and the light turned yellow right as I entered it, but it went red while I was in the middle of it. I’d chalk it up to bad luck, but there were three other cars that also got caught so I think it’s a timing issue on the lights. Regardless, I’ll be looking forward to a ticket in the mail in a couple of weeks and really didn’t need to add that to my to-do list.

I finally made it to the highway and settled in. I knew that I was going to have to be on toll roads, so I came prepared with cash. What I didn’t know is that the toll roads were coin-only, unattended. At the first one, I didn’t have the right change but made note of the website where I can supposedly go online and pay later. At the second booth, there was an attendant, but I was so flustered by the previous incidents that I forgot to get a receipt. Depending on who you work for, there’s no reimbursement without a receipt. I’m not going to quibble about a couple of dollars, but was just annoyed at forgetting it. At the third booth, I remembered to get a receipt, so thought victory was just around the corner. Sure enough, a fourth booth (again, unattended and coin-only) loomed.

I had planned ahead at the previous attended toll booths by making sure I got my change in quarters, so I was ready. There was a car in front of me whose driver was clearly digging through the console for change. He’d come up with a coin, throw it in the basket, and start digging again. I had my window down ready to throw my quarters in when it was my turn and could hear when he started cursing and yelling. Apparently he had thrown in enough change and it still wasn’t changing his status from “Stop!” to “Thank You” and he was getting agitated. He was reaching out and punching the toll basket. The yelling was getting louder and at one point half his body was out the window. His car was shaking from side to side because he was a big guy and he was getting really, really agitated. Needless to say I put my window up – there’s nothing quite like being trapped in a line of cars with someone acting strangely near you and you know you can’t get away. Given our current times, I wasn’t sure if he was going to end up shooting the toll station or what. He finally drove through.

I confidently tossed my coins in the basket and waited for my “Thank You” and never got it either. By now it was well past midnight, I was tired and agitated, and I just drove through, thinking I’ll sort it out on the website later. Clearly the booth wasn’t functioning correctly, but what can you do at that point? I thought back to my exit from the rental car lot –  they didn’t even offer the magic toll pass option, but I promise if I ever have to rent a car in this city again, I’m definitely asking for one.

I arrived at my hotel well after midnight, but luckily check-in was uneventful. The travel gods did finally reward me, though, with the best hotel water pressure I’ve had in a long time. People without long hair don’t always appreciate the value of ridiculously high shower water pressure, and people who aren’t on the road day in and day out may not understand the value of the little things when you’re away from home. When I got to my room, I found dozens of emails waiting for me and am now addressing them intermittently while I eat breakfast and get dressed.

For those organizations who work with consultants, it’s good to understand what your hired help might have been through to get there. If they look less than rested, there’s a reasonable likelihood that they had a hard day of travel rather than staying up watching Netflix and surfing the net. (Of course I’ve had the latter kind of days too, but they’re extremely rare.) So offer them a cup of coffee and a comfortable chair (my current one at the hotel doesn’t adjust up enough to reach the desk correctly, so I’m getting tingly nerves as I type this) and let them get to work. Don’t assume their travel has been glamorous and ask them to tell you about it. You might just get more than you bargained for.

What’s your worst travel day story? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/26/16

My hospital’s “chasing the quality numbers” work is in full swing. This morning I received a five-page packet on how to appropriately document our new tobacco cessation Core Measure.

I’m not sure why it takes that many pages to explain that a) everyone needs to quit using tobacco; and b) we are required to help them do it. What’s worse, the packet didn’t even include instructions on how to do the documentation in the EHR – it was strictly around the philosophy of the core measure.

I pinged the physician who replaced me when I left my leadership position and asked whether they had built the workflow into the EHR. Unfortunately, they haven’t. They didn’t add tobacco cessation medications to the admission orders, nor did they include an easy way to document when you’re not ordering them due to a medical issue. This would seem to be an area that is ripe for order sets and clinical decision support. It wasn’t clear whether timeline or capabilities were the barrier, but either way, it’s a sad commentary on missed opportunities.

Other than that, my visit to the hospital was uneventful. I stopped by the physician lounge to grab a bagel to go. There was some conversation about the pending “star ratings” for hospitals and a recent Washington Post article was being cited. One of the health systems interviewed noted that smaller hospitals that treat less complex patients earned higher ratings than tertiary care centers. According to the article, the preliminary calculations for the stars would result in awarding five stars to only 100 hospitals nationwide. There’s no firm date on when the ratings will be released (it’s been postponed from its July date).

I understand the desire to have some kind of composite rating system for patients to use, but the lack of granularity makes it difficult to truly assess how well a hospital is performing. If I were advising my relatives, I’d recommend they look at specific data for the procedure they were having or the condition for which they were being treated, not an overall “feel good” rating. I’d rather go to a hospital with fewer stars but the top rating for my disease, if I have that choice. When this rating scheme is rolled out at the provider level, as is planned, it will get even more interesting. More to come.

The last couple of weeks, I’ve had an increase in unwanted email volume. It’s not truly spam, but a combination of things that have to be dealt with, even if it’s just by deleting it. The folks who do the email blasts for the Annals of Internal Medicine apparently sent out a test blast of what looked like an online journal notification. It was followed up by an email saying it was a technical error on a test, and that it included “online journal content that was not valid.” Sure, they may take seconds to read, but it adds up throughout the day. I’m also seeing a deluge of LinkedIn requests. Pro tip: If you don’t have a last name, I’m deleting the email without opening it.

Furthering the email overload, this week AMIA migrated to a new online community platform and asked the Clinical Informatics Community of Practice to confirm receipt of the migration by replying to an individual. This resulted in dozens of “reply all” emails and even a request to be removed from the group. Those were pretty easy to sift out, but the last category of unwanted emails is more insidious. I receive quite a few emails each week from different vendors and organizations wanting to partner with me, often on the recommendation of someone I know. They start along the lines of, “I was talking to X the other day and they said we should consider working together” and then range from a general assessment of interest to a, “We’d like to talk to you on Thursday at 2.”

When I think I have colleagues or vendors who might be a good fit, I say something along the lines of, “I work with someone who does X. Would you be interested in seeing if there could be some collaboration?” If they’re interested, I then talk to the other party to see if THEY are interested and if both are amenable, I do an introduction. I don’t ever give out people’s direct contact information and would be horrified if I connected someone who reached out to my contacts and demanded a meeting at a certain time.

I had one of these situations this week and the vendor (which is actually a competitor) emailed me daily asking for meetings at specific times. Apparently they didn’t get the message that when someone ignores a cold-call email, they’re not interested. I’m usually pretty good at taming the email beast, but lately it’s just gotten out of control.

My HIStalk email has also been fairly full of people asking for advice, career coaching, and more. I try to incorporate as much of the advice and coaching into my posts as possible because the topics in question are usually of interest to a broad segment of readers. I’ve had several recent requests, however, where readers want me to review books or papers they’re writing or give advice about specific situations they’re encountering. I’ve had a couple of people get pretty demanding when I said I wasn’t able to accommodate their requests.

I think people forget that HIStalk isn’t my full-time job. I run a consulting company and also see patients I usually write Curbside Consult and EPtalk while I’m on a plane or sitting in an airport. If I’m at home, I’m usually writing it well after midnight. I still enjoy writing it, but some weeks its harder than others to find the time.

How do you keep your email under control? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/23/16

I’m working with a client who hired my partner and me to do a complete review of their practice operations and both financial and clinical workflows. Initially, they had requested us for a system selection engagement since they were ready to jettison their vendor and look for greener pastures.

Since I’ve worked with this particular vendor multiple times, I strongly suspected that the problem wasn’t with the system at all, but with how it had been implemented and was being used. The client has been on the system for a long time and I suspected they hadn’t been keeping up with newer releases, or if they had, that they hadn’t been adopting new features and incorporating them in their workflows.

They understood that paying us for a thorough review and potentially executing a remediation plan would definitely be more economical than completely throwing out the system. My partner started digging through their financial workflows a couple of weeks ago and we didn’t find anything too surprising there.

The practice is a group of procedure-driven subspecialists. In our experience, those groups tend to be fairly strong at maximizing their financial returns. We found some opportunities as far as them not using some of the automation available in their system. Although it may save them a couple of staffing FTEs, in a group their size, it wasn’t truly earth-shaking. If we had to give them a grade on how well they’re using the system and keeping up with the times, we’d give them a solid B+.

The clinical team’s use of the system was something else entirely. As we worked through their clinical workflows, it was apparent that they hadn’t taken advantage of many of the system upgrades that had occurred since their initial go-live more than five years ago. Once we review the user workflows, we typically meet with the physician champion or super users to determine whether they are aware of new workflows and made a conscious decision not to use them or whether they were not aware of the best practices. We try to avoid having these conversations with end users because they become frustrated when they learn that there were enhancements that could have helped them and their practice didn’t implement them for one reason or another.

The group has had a fair amount of turnover with regard to EHR super users, although the same EHR lead has been present since system selection. With every feature we discussed, her answer was, “Nobody told me about this” despite the vendor offering free Web-based training every time a system upgrade was available.

The physician champion just wanted to argue about how poor the system was and how they were going to replace it anyway rather than wanting to learn about the features that would eliminate their pain points. He clearly was not on board with the practice’s executive committee decision to bring us in to try to fix the current system rather than chuck it.

We also found that essentially they had been doing what needed to be done to get their Meaningful Use incentive payments, but hadn’t at all embraced the clinical realities of the metrics they met. For example, they made sure that every patient had an entry on his or her problem list, but the lists were not up to date; nor was there any policy or procedure in place to cover how often they should be updated or by whom. As far as they were concerned, since their vendor provided documentation that the problem list was “in use,” that’s all they needed.

One of the providers I interviewed told me that he didn’t put any problems on the patient’s list that he didn’t personally treat. This is the classic view of the problem list as “the physician’s problem list” rather than “the patient’s problem list.” I tried to have a conversation with him about the goals of Meaningful Use in providing more comprehensive records for patients, making it easier for practices to integrate data, the evolution of patient-driven medicine, etc. but he was having none of it.

He mentioned that his job was to take care of patients and made statements that sounded an awful lot like he felt he was above making sure he was aware of all the different problems impacting the patient. I tried to use logic with him, noting that although he doesn’t manage a patient’s hypertension or diabetes, they’re certainly important factors to consider prior to putting the patient on an operating table.

I also demonstrated his system’s functionality to filter the problem list by sorting the problems that are attributed to him to the top of the list, but he continued to push back. Although he seemed to agree in principle, he wouldn’t arrive at the point where he admitted that he (or his staff) should be keeping an updated problem list.

Having tried the “it’s good clinical care” angle and failed, I decided to press a little more on the MU aspect. I asked how he felt about the fact that he accepted federal incentive payments for doing something that he clearly wasn’t doing.

Mind you, I had no problems pressing this guy because he’s taking home more than half a million dollars a year. He’s also pontificating about being there to care for the patient, but refusing to do the basics. I tend to get a little aggravated with people like this, having come from the primary care trenches where many of my peers were working long hours updating charts to provide complete and accurate data for their patients (simply because it is the right thing to do) while making 70 percent less money than this guy.

He rationalized his actions (or lack thereof) by saying that the EHR vendor provided documentation that he met the performance threshold. I explained that the reports deal with the fact that the problem list contains data, not that anyone is actually working with it or keeping it current. Ultimately the physician is responsible when someone attests on his behalf that he has done something that he clearly hasn’t.

Although this guy may be a technically brilliant surgeon, I’m not impressed with his professional ethics. When I told this story to a friend, he assumed the surgeon in question was older and had been trained in a more paternalistic model. This physician finished his training within the last decade, so I’m not buying that excuse.

Medical schools are doing a lot of work trying to shift physician culture and educate in the benefits of patient-centric care. Regardless of whether you use an EHR to document your work or not, we need to be doing things differently and this guy clearly doesn’t get it.

Still, as one of the highest-compensated physicians in his region, he’s being rewarded because we still value procedures over cognitive skills. Ultimately the drive towards value-based care should help with some of this, but I don’t think I’m going to see the change in my career lifetime.

Is it just me, or are there still a lot of physicians like this out there? Do you have to deal with them? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/19/16

The week has been chock full of stories that unfortunately I can’t even remotely write about. Although some of my experiences are universal and could happen almost anywhere, sometimes I run into situations that I can’t imagine happen more than once. I’m pretty good about writing them down, though, in the hopes that I can change them up a little bit and use them in the future.

If nothing else, this week I have gotten a lot of practice in trying to maintain my composure when I literally wanted to laugh out loud. I’ve also made good use of my skills in talking executives off the proverbial ledge when they’re ready to jettison staffers, building hope that with hard work and thorough follow-up, we can turn things around and prevent further casualties.

One thing I can talk about is my work with customers who want to work on population health projects. The first thing I do is a run a working session called “What is Population Health” that forces the organization’s leaders to come to terms with the fact that it’s often ill-defined, and even more so given the fact that everyone around their table has a different idea of what they think they need.

Plenty of people still think they’re going to be able to buy a single technology solution that’s going to deploy itself with minimal input. These are the folks that also think that these are IT projects rather than clinical and operational ones, and who are generally surprised when I explain that it’s going to take a village to get them done and that no one is going to be allowed to abdicate their responsibilities.

My clients often complain about their software vendors, demanding more bells and whistles than what exists in current general release versions. In my experience, many customers are using only a fraction of the tools they’ve already got, and sometimes the continued banter about future content is just an excuse to avoid dealing with current-state problems.

One of my clients had been fighting with a vendor about their ability to create complex reports to identify certain sub-populations of patients. In reality, the client wasn’t ready to handle even the simplest of population health work flows and refused to admit it. They need to spend a lot more time looking at their staffing and deciding who they want to be as a practice before they start outreach and disease management programs. For starters, they have to deal with their six-month appointment backlog and their insane phone volumes. Until they address those issues, they can’t handle more patient visit volume or consider offering non-face-to-face visits.

I love a good challenge, and the groups I’m working with right now are unlikely to disappoint. Although they require the kind of long-term consulting that’s going to need not only my partner and me but some contractors to execute, some of the help they need is of a more routine nature. I’m never surprised by how many organizations lack the basics, such as communication plans, service level expectation agreements, and other types of policy and procedure documentation.

There are different ways to approach dysfunctional organizations. Sometimes it needs to be done from the top down, sometimes from the bottom up, and sometimes you just want to implode the whole thing and start from scratch. Figuring out the best way to approach it given an organization’s culture and leadership is sometimes more of an art than a science and sometimes it’s frankly voodoo.

The week has also been full of non-work laughs, with the best occurring at my home airport, recently made infamous by a viral video about their TSA lines. Fortunately, I had TSA PreCheck, so I was in a shorter (yet still long) line when my companion and I observed a woman with a hula hoop trying to cut the line. She started all the way at the back of the regular line and just kept working her way past passengers until she got to the first airport employee who was sorting the PreCheck passengers from those with regular clearance. She was slurring her speech, explaining that she was going to miss her flight and that she needed to get to the front of the line with her friends. Although the agent stalled her for a bit, eventually she was let through.

By now plenty of people were watching the spectacle from all four or five lines that were snaking their way towards the actual TSA agents. She was just shoving past people by this point, with no one stopping her. Whether they were worried about getting into a confrontation with someone who was possibly impaired or disturbed or something else, most of them stepped aside as she pushed past, thumping passenger after passenger with her hula hoop slung over her shoulder. Most of us in the PreCheck line were waiting for TSA to send her packing, but were surprised that they let her through.

This circus was a stark contrast to my experience at another airport recently, where my friend was forced to check her bag because it was slightly non-rectangular, having been crushed on an earlier flight to the point where it exceeded the bag-sizer’s dimensions by half an inch due to its skewed shape. At that airport, they were examining bags before people were allowed in the security line, vs. my recent experience where the hula hoop was allowed through. I’m pretty sure a hula hoop fits neither in the overhead compartment nor under the seat in front of you, so I wonder what they did with it on the flight.

Regardless, it was good to have some diversion before I boarded a flight where I knew I’d be immersed in the exciting world of QRUR reports, which require a 20-page document to explain their contents. I envy the travelers that board with a stack of magazines or their headphones and eye mask. Those magical minutes during takeoff, taxi, and landing before I can fire up my laptop and get to work are always good times to reflect on the week ahead or behind, depending on which way I’m heading.

I chuckled to myself as I thought of one client leader who still can’t figure out how to pronounce my name despite multiple onsite visits. One of his colleagues told me they play a behind-the-scenes game to see how he’ll mangle it next. Someday I’m going to write a book, and it’s going to center around the fact that you can’t make this stuff up.

What are the craziest things you encounter during your work day? Email me.

Email Dr. Jayne.