Curbside Consult with Dr. Jayne 11/30/15

I wrote last week about open enrollment for health insurance and other benefits. A reader sent me this screenshot of his company’s enrollment management system, giving it an “F” for usability. Although the rolling hills are probably supposed to calm employees before they see what their premiums will be this year, the fact that they obscure half of the labels is likely to increase anxiety. Not to mention, can you trust a company that doesn’t care if you can read the password requirements or not?

Another reader wrote about the expanding list of employee-paid options his company offers. In addition to medical, dental, and vision insurance and flexible spending accounts, employees also had the option of choosing pet insurance and a legal services PPO.

I admit that I don’t know anything about contract legal services, but found it kind of funny that lawyers would start down the slippery slope that got physicians to where we are today. We’ve seen what having third-party payers has done to the healthcare system and are still trying to cope with payments that are spiraling down while insurance company profits continue to climb. If anyone has inside knowledge on this trend, I’d be happy to run comments.

Nearly everyone I’ve talked to about open enrollment and health care coverage has mentioned that they get either a premium discount or a penalty (whichever way you look at it) depending on the presence or absence of certain health-related behaviors. Anecdotally, the most common are discounts for being a non-smoker or participating in a smoking cessation program.

Close behind are discounts for having certain lab screenings done, although the results aren’t taken into account. My former employer required lab screening for all employees to get the lowest rate, regardless of whether the labs were evidence-based or indicated. Although I’m sure they got a volume discount for having the lab work done, the concept of coercing people into having screening tests isn’t exactly driving down the cost of healthcare.

Looking at my former team (which was fairly young), only 20 percent of them were in an age bracket where the blood work was actually indicated. I’ve had plenty of conversations with Medicare patients who want a specific test regardless of whether it’s indicated simply because “Medicare covers it and I’ve earned it,” which is no way to practice medicine. Seeing this type of behavior reinforced by private payers is disappointing.

The other troubling thing about the whole business is the aspect of coercion. Those of us who believe in evidence-based medical care have spent our careers trying to order the right tests for the right patients at the right time, not just doing things because they’ve always been one way or another. Even simple laboratory tests are not without risk. There is a chance that they will uncover an “abnormal” but irrelevant value that will lead to patient distress or to further unnecessary testing. There is also the loss of the patient’s time in going to have the test and jumping through related biometric screening hoops.

Additionally, I’m not aware of a significant amount of high-quality research that shows that these programs actually work as far as driving healthy behavior or reducing overall healthcare expenditures. There are a handful of papers but the design and execution are somewhat variable. I’m not sure how I feel about employees being part of an experiment – when I was in academics, I would have to get approval from the Institutional Review Board to do something like that with my staff. Employers, however, have carte blanche to do whatever they want.

Everyone is awfully keen on these “wellness” programs, but they’re of varying quality. I saw a patient at the office last week who just needed documentation that he had a “physical” so he can get a discount on his insurance. There was no description of what exactly was to be included in the physical. The general “physical” has not been shown to reduce morbidity or mortality. Age-appropriate preventive and wellness visits can have an impact, but they’re best performed by a primary care physician who knows the patient and his or her history.

Unfortunately he showed up at our urgent care, where in the absence of specific criteria (such as pre-participation sports physical or a pre-employment physical), the content can be somewhat variable. Half our physicians are Emergency Medicine certified and they’re not that into continuity of care. He also presented to the office the day after Thanksgiving, which is historically one of the top three busiest days of the year at our practice and probably not the best choice for a preventive medicine visit unless you want to catch influenza or an upper respiratory infection in the waiting room.

I picked him up rather than one of the ED docs, so he did receive a full age-appropriate preventive medicine visit with preventive health counseling and notes on what screenings he should start having and when. I’m not sure how much he actually absorbed, though, and since we’re a walk-in urgent care, there’s not likely to be much continuity.

Another spin on this is the employer-owned health practice, where employees actually see on-site physicians for wellness visits, chronic disease management, and associated services. A friend of mine started working in one of these practices last year and found it to be much harder than she anticipated. She finds a tremendous conflict of interest with patients tending to want to conceal certain information that they wouldn’t want their employers to know. Although there are supposed to be safeguards in place, patients don’t always trust them.

Another negative aspect of open enrollment is the annual churn of patients having to change physicians when their coverage changes. Often this means starting over in the middle of treatment or having delays in care due to the need to obtain new referrals and authorizations. When I was in a traditional primary care practice, January always brought a flood of requests to transfer medical records, often with notes from the patient apologizing for leaving and asking us to let them know if we ever decide to start taking XYZ insurance plan.

For someone who became a family physician because I hoped to care for people longer than a year or two at a time, it was just sad. I’m personally averaging five primary care physicians in the last 15 years, which isn’t ideal as a patient.

I’m not sure what the answer is, but I hope it involves the ability of patients to choose physicians based on quality and cost and without network restrictions or burdensome processes. Somehow I think that’s just too much to ask, though.

What do you think the answer might be? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/23/15

I’m still tunneling out after having been at the AMIA conference and then on site with a client who scheduled an emergency board meeting to discuss pulling the plug on their EHR. They’re a mid-sized multispecialty group that is physician-owned, so the entire board is made of physicians. The board meetings can be extremely contentious.

Apparently this one was in response to some agitation among doctors who recently joined the group and are not happy with having to give up their previous EHR, so they’ve united with some other unhappy doctors to push the idea that the entire group should change platforms.

My role was largely to support the IT department and the rational members of the physician leadership who don’t want to throw the baby out with the bath water. They’ve had some bumpy upgrades in the last year, but the group is also experiencing growing pains courtesy of some physician acquisitions as well as general growth in their geographic market. They’re also experiencing some Meaningful Use-related challenges with workflow (which is how they came to be my client). 

With all of that swirling around, it’s hard to lay blame on the vendor. Unfortunately, the vendor hasn’t had good communication through all of this and hasn’t been as participatory in troubleshooting some of the issues, so they already have a black eye.

Although the board meeting ran nearly three hours, we were able to achieve a reasonable resolution. I’m going back in a few weeks to do not only a workflow assessment, but also some stakeholder interviews to try to get to the root of what is going on as well as to try to uncover any other factors that haven’t fully bubbled up yet. Once we have the full picture from all the physicians (including those who are happy and therefore weren’t at the meeting screaming), we’ll be able to put together an action plan and make some interventions to improve things.

I did a follow-up call with the vendor on Friday. I don’t think they know what to make of a consultant who is not only a physician, but also knows her way around infrastructure. I left them with a to-do list of troubleshooting that they hadn’t even looked at yet, so I’m sure we have additional amusing (for me) and/or uncomfortable (for them) conversations in our collective future.

Also on Friday I listened to the Athenahealth Leadership Institute webinar, “An Interview with Dr. John Halamka and Jonathan Bush.” Although they had some audio troubles at the beginning, it was a good interview. I enjoyed John Halamka’s comments on information blocking and the perception that vendors, hospitals, and health systems are charging too much for interfaces. Halamka cited one survey that said physicians would be willing to pay $5 per month for information exchange, which is a far cry from the hundreds to thousands it may cost to implement an interface. Having seen it from both sides myself, it’s a great topic that needs further exploration.

They also discussed Halamka’s genome since it’s been sequenced and available, and how knowing his genetic status makes a difference in the screening services he should receive. I’m not sure if it’s recorded or available, but if it is, it might be worth a look.

I spent most of Saturday doing a community service project, which was a great way to reset after being gone for the week. I’m a mentor for a local youth organization and it’s particularly nice to see teenagers out serving the community, even if it means being in the snow and slush when they could be home watching TV and texting each other. This is my tenth year doing this particular project and some of the kids I started with are now old enough to drive, which is a bit of a scary thought. It does give me hope for the future, though.

As most of you know, I left my CMIO position some time ago. My hospital, however, still has not removed me from the email distribution lists, a fact which continues to provide ongoing entertainment. This week’s email gem (sent on November 19) outlined all the changes that took place in the system on November 17. I know I wasn’t perfect, but at least I got the change notices out before they happened. I know they’re in the middle of a system replacement and whoever is responsible for the communications now is probably distracted, but I still feel for the physicians and end users.

I also feel for all the employees who are going through open enrollment right now. Several of my friends have been cursing the rising premiums and shrinking benefits even with self-insured employers. I’m eligible for benefits through my clinical position, which thank goodness has no change in medical premiums and only 1 percent change in dental with the same level of benefits for both. I don’t know what kind of good karma we’re riding, but I know it’s making our employees very happy.

Looking at the open enrollment statistics for the federal marketplace, the happiest callers might be the Spanish speakers, who averaged an 11-second wait for a representative vs. the average four and a half minute call center wait time. That’s still a lot better than I get with either my Internet provider or my cellular carrier. Looking at the data, there are a lot of window shoppers out there as well.

In other CMS news, I’ve seen several headlines about the Affordable Care Act leading to $2.4 billion in consumer rebates on health insurance premiums. This sounds like a lot of money until you realize how many patients it is divided among. My clinical employer was a recipient of one of those rebate checks, which ended up dividing out to $0.48 per employee – not even enough to cover a stamp. I’m sure our administrative staff spent a lot more than $0.48 per person dealing with questions and helping people understand how tiny it was. Personally I was in favor of taking the refund and donating it to a local food pantry, but they did go ahead and post the amount to each person’s paycheck. The CMS press release claimed $470 million in rebates for 2014 alone, averaging to $129 per family. Based on the math, some people might have gotten some nice rebate checks.

How’s your open enrollment process going? Email me.

Email Dr. Jayne.

Dr. Jayne Goes to AMIA-Wednesday

Today marked the closing of AMIA, with presentations in the morning and a final keynote by Robert Wachter, MD, one of the founders of the hospitalist movement. I had been looking forward to the keynote, but due to an unforeseen crisis at one of my clients, I had to leave earlier than planned. That’s the hazard of being a workforce of one. At least I have enough clean clothes in my bag to pull off an urgently-scheduled board meeting. Unfortunately, my flight was delayed, so I’m now camped out at the San Francisco airport catching up on work.

I mentioned the other day my disappointment at not being able to attend Monday’s ONC Listening Session. ONC Chief Health Information Officer Michael McCoy, MD graciously emailed me to apologize because they did indeed have room for more attendees. I sorted out the problem and the miscommunication was on my end, with my new (and very part-time) assistant confusing the ONC session with another meeting next week that I was also trying to register for. I haven’t had an assistant since I left the health system and I am reminded that “what’s the status on that meeting for Monday” is an ambiguous question. I truly appreciate his reaching out and I apologize for the confusion. I heard in passing that the session went well. I’d be interested to hear specific comments from anyone who attended.

My absolute favorite panel of the conference was on Tuesday and was titled “What Could Go Wrong? Migrating From One EHR to Another.” Since I have done quite a bit of work in the migration and conversion space, I was interested to hear how my experiences stack up against those of others. I was hoping to have the slide deck before I wrote about it, but it doesn’t look like it has been posted yet. Luckily for this session I joined the legions of people snapping pictures of the slides, since not only was it content rich, but had some outstanding clip art ideas.

The session was heavily attended. After some excessive microphone checking “check check, hey hey, check check” it was off to a great start. Richard Schreiber, MD, CMIO of Holy Spirit Hospital (a Geisinger affiliate) talked about the published research literature to date looking at system migrations. It’s scanty at best, with only five peer-reviewed studies and a few surveys. Not surprisingly, there are numerous blogs and anecdotal stories, however. One study looked at a hospital one year after migration and found heavy access of the legacy system. The hospital’s legal team consulted with AHIMA and recommended that even with a data conversion, they may need to have the legacy system live for up to 10 years in a read-only status.

Data conversions were a hot topic, specifically the fact that customers might not get what they asked for or paid for. There was discussion around the need to manage expectations around a system transition, as some sites have noted lower satisfaction due to high expectations that were unrealized. There was some interesting data in some of the studies: that 40 percent of providers are on their second, third, or even more EHRs. As practices and hospitals continue to consolidate, this will only continue. My former employer is on its second ambulatory EHR headed for its third and is consolidating multiple hospital systems into one. Schreiber noted that EHR changes often accompany cultural and political shifts in addition to ownership changes.

He went on to talk about the “think freeze” that occurs around EHR upgrades. Because of code cut-offs and system and environment freezes there is less consideration of what the end users need. With a migration, this is even worse, with that freeze occurring for potentially years rather than months or weeks as the organization prepares for the transition. Community hospitals are particularly challenged by a lack of resources, training, and support. Physicians experience “large efforts with small teams” that mean “army swarms and then retreats.” For providers who aren’t in the hospital consistently, they may have limited support after a go-live.

Sociologist Ross Koppel, PhD of the University of Pennsylvania then took the podium. I got a kick out of the fact that his bio in the AMIA app lists him as, “Among most hated by some vendors, but appreciated by clinicians.” He talked about the fact that the average hospital has between 150 and 400 separate IT systems that link with the clinical system, not counting outside systems such as reference laboratories. “Each one is an opportunity for a screw-up” also known as a “vulnerability.” He talked about how “hospitals are unique fiefdoms” and the fact that new systems bring a loss of institutional memory, such as the work-around done by a unit secretary to actually get things done for patient care.

He discussed the problems that customization can cause with system migrations. Looking at two different Epic systems in neighboring hospitals revealed that the systems were related “like Spanish and Italian” but that “data and interfaces differed enough that assumptions of similarities could be treacherous.” Having gone live on Epic at two community hospitals in the same summer several years ago, I can agree with that assertion. Koppel also discussed issues with calculating return on investment and the difficulties with hospital bookkeeping on some projects. ROI research is also commonly done by vendors, confounding the issue. He discussed the $1.7 billion implementation at Harvard as being $400 million in software, $700 million for Deloitte, and the rest internal.

The next presenter was John McGreevey III, MD of the University of Pennsylvania, talking about the PennChart project. With six hospitals, 2,524 beds, and 84,000 admissions a year, this is a massive project. He talked about their lessons learned:

• Not enough operational leaders. He felt they needed three to four times what they had.
• No health system budget for clinical subject matter experts to design note templates, order set content, etc. EHR tasks were added on to their regular responsibilities. Doing a project like this without SMEs and adequate human infrastructure is like a fire department that tries to fight a house fire by hiring firefighters after it’s already started and paying them zero.
• Not enough “internal housekeeping” prior to the project. He stated that after signing a contract, vendors should tell the hospital “thanks for your check – call us in a year” after you’ve done your housekeeping.
• Vendor liaisons were relatively green – most had only one or two implementations under their belts. They could not cite definitive best practices from other academic medical centers or make good recommendations about decisions. He did note, though, that other customers were very gracious with their time despite being heads-down in their own implementations. This might be a future role for AMIA, as a clearinghouse for best practices.
• Build decisions may have created barriers to interoperability. Standardized approaches to naming, organizing data, etc. are needed. This results in “big data we can’t use and can’t share.” Vendor guidance often oversimplified complex decisions, leading to rework.
• Siloed project teams led to lack of understanding, fragmented work, and wasted time.
• They got a late start on changed management, leading to lack of shared urgency or mission. He recommends “bathing the organization” in change management before any work starts, not just before go-live.

Catherine Craven, MLS, MA of the University of Missouri closed out the panel talking about system migrations among Critical Access Hospitals. There is even less data on these hospitals, because as of 2010, fewer than 3 percent had EHRs. A good number of facilities (300) haven’t attested for MU Stage 1 yet, although 150 did receive Adopt/Implement/Upgrade funding. She completed her doctoral dissertation last year and studied four hospitals. The statistics are shocking: many CAHs have less than 30 days’ cash on hand and often the cost of an EHR is between 75 percent and 100 percent of total cash assets. In other words, these hospitals have to bet the farm on their EHR project. Craven did an excellent Peggy Lee impersonation.

She went on to note that the CAHs she visited did only basic installations without workflow transformation. They often relied wholly on vendors because there was no budget for consultants. They were also rushing to implement, with one hospital having less than five months from contract signing to its go-live.

Tuesday afternoon I ran into a friend from the VA and attended a session on human factors. The room was packed as presenters shared their work. Topics included observational studies of user workflow while accessing both the EHR and a RHIO, cognitive demands of EHR via task analysis, and cognitive support for ICU data. I noticed Brian Dixon in the front row with his jacket from The Walking Gallery, but wasn’t fast enough to get a picture.

Throughout the conference, there were a couple of things nagging at me, although they are decidedly first-world problems compared to the plight of the many homeless in San Francisco:

• The use of “MD” as a substitute for physician, not only in presentations, but in the official printed publications. There are plenty of DO informaticists and international physicians with slightly different degrees.
• Interchangeable use of the terms “sex” and “gender.” Especially among people who are talking regularly about coded data and the need for specificity and interoperability, it’s time to learn the difference between the two.
• Continued references to Epic, even if they’re veiled. We know it’s the predominant system among academic medical centers, but it’s not the only system out there. I got a kick out of two physician users of a less-prominent EHR vendor who looked at each other and said, “Ours does that” when the speaker lamented a particular lack of Epic functionality.
• Late arrivals. The conference encourages people to drop in and out of sessions to “follow the conference buzz,” but that doesn’t mean you need to enter the room like a herd of elephants or climb over and disrupt those that area already there.
• Seating arrangements included excessively close chairs that nearly prevented people from sitting next to each other unless they were both less than 14 inches wide. This led to a lot of empty chairs between people, but that made it a little easier for those with large bags that they’re using as a mobile office. Also the rows were close front to back, making it difficult for people to slip in and out without tripping over legs, feet, and bags.

On the flip side, I was happy to see one of the presenter’s children at the conference, complete with badge and ribbons. I’m sure the conference was a highlight for both of them. I also saw a couple of dogs at the conference, which made me chuckle. They didn’t appear to be service or support dogs, but they were well behaved.

I was considering attending AMIA’s iHealth conference in May since its more focused on clinical and operational informatics. I may already have something on the docket for that week, but would be interested to hear people’s impressions on that conference’s usefulness to CMIOs vs. the annual symposium. I want to make the most of my conference budget, and considering that this one set me back almost $3,500, I want to choose wisely. For those of you in the MOC trenches, that’s nearly $175/hour for the sessions I attended.

What’s your favorite conference? Email me.

Email Dr. Jayne.

Dr. Jayne Goes to AMIA–Tuesday

Another busy day at AMIA today. I started the morning with a panel, “Looking Back and Moving Forward: A Review of Public Health Informatics.” Neither of these disciplines is something I do in my daily work, but I’ve always been interested in public health, so I thought I’d check it out.

I admit that global health is entirely outside my comfort zone, but was interested in learning more. I appreciated that the presenters spelled out how the articles and events were selected for review as well as their admission that they slides weren’t quite ready to share with the world yet. I’ve been hunting for presentation slides all week without much luck. They shared a URL link to a Google drive, but said it may be a few days before everything is available. I’m looking forward to getting them.

Presenter Brian Dixon shared a couple of interesting vignettes:

• In one study looking at provider prompts for immunizations, there was no difference between the control and the intervention. The clinical decision support intervention didn’t use data from the immunization information system, only from the local EHR. The authors believe this may be part of the problem. I was surprised that there was no difference, but that’s why we do research.
• Another study looked at direct to consumer portals for self-testing regarding sexually transmitted infections. Essentially patients could go online anonymously and request a testing kit, which was to be mailed to the lab. They could receive their results securely, and if they tested positive, receive a prescription via eRx or telephone. They didn’t have to actually present to a healthcare provider. Out of the thousands of patients eligible, only a few hundred followed through. I would have thought the uptake would be higher since testing in the privacy of one’s home is less embarrassing than going to the office.
• Another study looking at healthcare-acquired infections concluded that most research is done in academic medical centers or the VA, institutions with “considerable financial resources” and technical skills not widely available. Dixon noted that although people in those settings likely feel they never have enough resources, they’re relatively wealthy compared to some public health settings.
• The Biosense surveillance system was rebranded this year to the National Syndromic Surveillance Program and moved to the cloud. The goal is to have it be more about disease surveillance and less about bioterrorism detection, but how well that is achieved remains to be seen.
• Public health applications aren’t just about MU anymore. This year there was a rise in use of mobile solutions, patient portals, and social media. The research base for public health informatics is increasing.

The presentation shifted to global health informatics with presenter Jamie Pina, who explained that typically these are resource-constrained environments and are defined as “low- and middle-income countries” based on the World Bank definitions. Often there is external or donor funding, such as philanthropies or other countries. There is generally a weak market for global health informatics products, so organizations typically use open source or homegrown tools. There were many articles on mHealth and telehealth found in their review.

There are data quality challenges and other limitations, including the fact that traditional medicine doesn’t fall into the same paradigm or concepts that we have in what we consider modern medicine. One study from Bangladesh looked at linking local traditional medicine practitioners with trained physicians through a call center. Another study found (no surprise here) “cultural misalignment between IT and healthcare providers” in Botswana. At least something is consistent globally. Other notable facts: 80 percent of users in rural Africa are computer illiterate or beginners, but more than 95 percent have a positive attitude towards computers. He did also mention the end of the current Ebola crisis as a notable event that solidified the need for attention to global health issues. Programs are starting to focus on implementing the lessons learned from that crisis.

There was also some buzz today about changes to the clinical pathway for board certification in Clinical Informatics. I had a couple of people ask me if I heard anything, but I admit I didn’t. Hopefully someone in the know will see this and provide an update if there really is going to be a change.

I’m going to save writing about my favorite presentation of the day until the slides are available. Some of the ideas put forth are just too good not to share. Of note, today’s multitasking included some impressive knitting by one attendee who was using nearly microscopic needles. I never figured out what she was making, but it was fun to watch.

I ducked out for lunch at the Ferry Building Marketplace with the always-entertaining Matthew Holt. He had just returned from a whirlwind trip including Japan, Finland, the UK, Seattle, and finally San Francisco. There were many stories of lost baggage and adventures including the most polite people in the universe (Japan) and time in the sauna (Finland). Our conversation ranged all over the place and included startups, conferences, HIMSS preparations, and the exorbitant cost of Epic projects. My adventures are not nearly so interesting, but he humored me in listening to stories about my current practice situation (which I dearly love) and my ongoing consulting road show. Next stop, Des Moines!

I hustled back to the conference and caught a panel on “Needs of the Digital Native: Adolescents and Access to PHRs.” It was one of the more compelling panels I attended, with speaker Pam Charney talking about her own experience as a parent of a child with medically complex issues. In her state, patients can’t have access to personal health records or patient portals after age 13 to when they turn 18, which created a lot of complexity due to the loss of online scheduling, secure messaging, and test results. Rather than being able to manage her daughter’s health online, she became trapped in an ongoing maze of phone calls, faxes, and lost test results.

Speaker Fabienne Bourgeois has it a little easier in Massachusetts, where there can be graduated changes in access for adolescents. They initially had a parental consent requirement for portal access, but dropped it after a large number of obviously forged consent forms were returned. She provided an excellent discussion on the various needs of flagging data by category (HIV diagnoses and labs) vs. by patient or provider tagging. Catherine Arnott Smith noted that there have been only 13 studies on PHR use in adolescents and young adults since 1991, which is pretty thin. She gave an excellent discussion of academic accommodations for young adults after they leave the K-12 education system. These patients go from a system where their family is involved in advocating for them to one where they have to advocate for themselves, often without a full understanding of their medical history.

Consider the scenario of a child who turns 18 while away at college and whose parents no longer have access to health information. He or she is expected to manage on his or her own, and if there hasn’t been enough education or transition prior, it can be disastrous. Apparently the process for seeking academic accommodations resembles that for Social Security Disability. Having helped patients through the latter, I can’t imagine trying to manage the reams of data required while adjusting to life as a college freshman. Healthcare entities are often not helpful because they send reams of patient notes and data which may not be relevant or useful to the college in determining a valid disability requiring accommodation. My favorite comment of the day was from an audience member who highlighted the need for “a curated record vs. a raw sewage record.”

There were additional questions and comments on the fact that EHR data is much like the proverbial “permanent record” many of us feared in school – that it persists and can follow adolescents into adulthood, potentially creating difficulties when behavioral health diagnoses may be present. Attendee Adam Davis stated, “EHR is forever, but paper dies.” It’s definitely something to think about in the digital age.

On the fashion and social front, I’m happy to report that overall, bowties are leading standard neckties by a factor of six to one, although I feel I should give double credit to the attendee who paired his traditional tie with a snappy vest. After hitting another panel and a corporate member focus group, I headed out to dinner with some industry movers and shakers. On the way back I breezed by the Dance Party social event, which had several attendees cutting a rug and others continuing to network. By this time, though, my toes were tired and my brain was lagging, so I decided to call it a night.

Tune in tomorrow when I’ll cover the rest of Tuesday’s sessions and wrap up my overall thoughts of the conference.

Email Dr. Jayne.

Dr. Jayne Goes to AMIA–Monday

After having seen the long lines for breakfast in the hotel over the weekend, I stocked in some provisions and enjoyed sleeping a few minutes later. I’m glad I did since the line to just get coffee was well over 60 people long when I passed by. The meeting has felt significantly more crowded today, although the conference center’s slightly wacky multi-level, multi-building layout helps spread things out. I’m also very pleased that there is plenty of seating throughout the common areas for those of us who want to get to know new friends, catch up with colleagues, or just take a break.

My morning session was a panel on “Harmonization of ICD-11 and SNOMED CT.” Yes, ICD-11. Experts have been working on it for years and particularly in how they plan to address some of the challenges in mapping between the two systems. Since mapping can lead to errors, they’re leaning towards a common framework of sorts that will make things better for those of us who have to use both systems.

This is going to require some changes in how both systems are currently structured. However, it will reduce the need for crosswalks and therefore errors. It took owners of the two systems nearly three years to agree to a memorandum on collaboration and I’m sure it will take years to work it all out. I personally hope to be retired before it hits.

Looking around the room, at least 10 percent of the people were using their phones or tablets to take pictures of the slides at one point or another. This really underscores the need to have the slides available to participants. At another conference I attended earlier this month, the presentations were linked to the entries in the conference application, which made it nice to follow along and to magnify slides that were difficult to read. So far, the didactic panels I have attended have featured 5-6 speakers giving mini-presentations on a main topic and that would help sort out who said what.

I spent a little time in the exhibit hall, which was significantly less crowded today. Although there are a few vendor booths, there many booths representing various informatics training programs and graduate schools. I had a good conversation with IMO about their work not only in the US but with health systems in other countries. We’re all facing the same issues, but it sounds like there are many approaches to solutions. Having been a user of their tools embedded in several different vendors’ EHRs, I’m looking forward to their next generation of solutions to make physicians’ lives easier.

Break service was again offered in the aisles of the exhibit hall, which made it crowded and difficult to move, especially with people stopping randomly to check their phones regardless of the people flowing behind them.

My next session was a very-well attended one about the “Clinical Quality Framework Initiative to Harmonize Decision Support and Quality Measurement Standards.” Presentations (again in the multiple mini-talk format) included some of the federal initiatives via HHS to align various measurements and reporting systems.

There was quite a bit of laughter when a slide was shown asserting a government mandate for “full interoperability” by 12/31/2018. In addition to aligning existing systems, though, the US government is also adding new metrics, such as the appropriate use criteria for advanced diagnostic imaging studies. Providers are going to be asked to document whether they’re using clinical decision support to avoid ordering expensive tests. Although this is a good thing at face value, I’d like to also see it coupled with a patient-facing program to educate patients on the fact that they don’t need these tests.

Front-line physicians in the United States are constantly barraged by patients wanting the most high-tech (and often expensive) tests whether they need them or not. There is a cultural “need to know for sure” that something is or is not OK and patients see technical studies as the means to reach that end. In many cases, patients don’t want to play the odds or listen to statistics — they just want a test. If physicians don’t order the test and are insufficiently able to talk the patient away from it, our patient satisfaction scores suffer. We’ve seen this phenomenon with antibiotic use as well. I’m a huge fan of how England’s NHS does it. They have many direct-to-consumer campaigns about how healthcare should work. I’ve included my favorite above.

I attended a corporate member roundtable over the lunch hour. I’m not going to name the vendor because there were very few women in attendance and my cover might be blown. It was interesting to see where various participants were in their journey with informatics in general with specific kinds of technology. There was a nice mix of participants from research, training programs, large health systems, third-party firms, and end users.

I tried to attend the ONC listening session that also occurred over the lunch hour but wasn’t able to register. Space was limited to 65 seats but the session was to include Chief Medical Information Officer Andrew Gettinger, Chief Health Information Officer Michel McCoy, and Chief Nursing Officer Rebecca Freeman. They were seeking specific feedback regarding the federal IT strategic plan, interoperability roadmap, precision medicine initiative, and other key initiatives. I’d be interested to hear from anyone that made the short list of cool kids attending.

I spent some time after lunch cruising the poster presentations in the exhibit hall. My favorite was one from a group in Japan, who created a “Smart Snack Box” system to record snacking behavior. They’re looking at the timing of meals on metabolism and how it impacts health and disease. Using Raspberry Pi technology and Python, they created a box that records how many times it is opened as a method of tracking snacking without patient self-reporting. Currently they’re limited because it only tracks the opening of the box, not the amount of snacks that were consumed or if the patient was only window shopping. I have a pre-teen nephew who is all about Python, so I sent it his way. Maybe there’s a future for him in biomedical research.

The AMIA format lends itself well to session hopping and I did that a fair amount today. Topics included social media within consumer health informatics, natural language processing, precision medicine, patient portal use in safety net healthcare systems, and care team communication. Although intellectually stimulating, it is truly exhausting trying to attend all the presentations that grab my interest.

There were a couple of social events tonight: the “Top of the World” Meet-up and Tweet-up and a movie premier for “No Matter Where,” which is a documentary following the journey of some of our field’s pioneers as well as how health information has impacted patients, providers, and other interested parties. I ended up opting instead for dinner with an old friend and former colleague who helped me stand up my first HIE way back when. Usually we only run into each other in the whirlwind that is HIMSS, so it was good to catch up in a lower key setting. We wound our way through Chinatown to the Marina District and various points in between and I’m grateful for him not making fun of my white knuckles on the near-vertical streets.

Email Dr. Jayne.

Dr. Jayne Goes to AMIA – Sunday

This morning was the last of my pre-symposium sessions. I attended a talk on clinical decision support led by some heavy hitters in the field: Jerry Osheroff, Robert Jenders, Jonathan Teich, Robert Murphy, and Dean Sittig. I was pleased to see that they provided clear objectives and a time-boxed agenda up front. Although a lot of the content may have been review for those of us who have been championing clinical decision support projects, I managed to pick up a couple of useful tidbits including a new term “ehrophilia,” which is your positive disposition towards EHRs.

I appreciated learning “Murphy’s Rule of CDS” which is that everyone wants the alert to fire to someone else. I’ve found that to be true and most egregious when operational people want to put physician-facing alerts on patient charts. We lost a fair number of people at the coffee break, but those that returned took part in small group discussions moderated by the presenters. It had been a bit rainy this morning (much needed here, but I don’t think it made the AMIA Fun Run very fun), so I took advantage of today’s longer lunch break to hit the streets and get some fresh air.

The afternoon started with an opening session. AMIA Board Chair Blackford Middleton highlighted the presence of 2,100 attendees as well as some member perks, including the fact that the Journal of Applied Clinical Informatics is now an official AMIA journal with online access. AMIA has over 5,000 members and it looks like a good chunk of them are here. Also during the opening remarks, the Morris F. Collen Award of Excellence was presented to Jan van Bemmel, one of the pioneers of medical informatics.

Keynote speaker and security specialist Avi Rubin thoroughly entertained the crowd with some great stories about “security researchers – some people call them hackers.” Interesting tidbits included that the Nest thermostat has roughly 10 million lines of code, which is comparable with a 1995-era operating system. Since the number of bugs is a function of the number of lines of code, complexity of development is leading to more points of exploitation for those intending mayhem.

He also schooled the crowd on buffer overflow attacks. You could tell from the ears that perked up in the seating areas which attendees were more or less techy than others. I did spot a couple of people multitasking including Facebook and Sudoku. For those of you who weren’t playing along, the USB Banana was a hoax. Rubin closed with a great quote: “Just because you can connect something to the Internet does not mean you should.”

The opening session was slightly marred by people in front of me who could not stop talking despite multiple shushing and meaningful stares. Finally, someone walked up from the back of the room and told them to be quiet and they generally complied.

Following the keynote, I attended a panel on “Wearable Health Data and the Quantified Self.” It featured five panelists speaking on different mini-topics. I’ve not been to a session like this and have to say I liked it, although I missed the more formal opening we usually see with continuing education sessions, where presenters list their objectives.

I hope the slide deck gets posted because it was a great presentation. I would like to have had it in advance so I could annotate on it, but didn’t find it on the conference website. I got some interesting examples of the Quantified Self movement to use with some of my peers, including an anecdotal story about one patient who tracked his sneezes for two years to discover how allergies were actually affecting his day-to-day life. I also was not aware of the Open Humans Project, which allows research participants to receive their own data and helps match people with future studies.

The final speaker of the panel was patient Craig Braquet, a self-described “gadget geek” who began to use wearables to analyze his symptoms of fibromyalgia, degenerative disc disease, and chronic fatigue syndrome. It was great to hear from the patient’s point of view. It sounds like having his own data has made a difference in how he manages some of his conditions.

The evening was chock full of social activities, starting with a welcome reception in the exhibit hall. The exhibit hall was extremely crowded during the reception with appetizer stations set up in some of the aisles, which made navigating difficult. I did happen to run into a medical school classmate that I haven’t seen since graduation. There are several of us from my class and the class following who have landed in the field of informatics. Even though it was a very quick catch-up it was good to see him.

I breezed by the Clinical Informatics Diplomate reception on the way to dinner with a colleague, hitting the NavigateAMIA reception on the way back. It is targeted to new members and first time symposium attendees and featured desserts in addition to networking opportunities.

I didn’t stay long because I wanted to head up to the Women in Informatics Networking Event (WINE) at the Cityscape restaurant on the 46th floor. It was a great way to cap the evening with lovely views of the city in all directions. I chatted with a doctoral student doing work in predictive modeling for ICU patients and a couple of other students in nursing informatics programs. It was fairly crowded, but I didn’t see any other CMIOs there so I headed back to my room for some much-needed rest. Tomorrow is definitely going to be a day for (sigh) flat shoes.

Are you attending AMIA? What’s your take on the meeting? Email me.

Email Dr. Jayne.

Dr. Jayne Goes to AMIA–Saturday

Since I live in a city with multiple academic medical centers, I expected to run into a friend or two on the way to the conference. I was surprised, however, to see two other physicians on my parking shuttle. Although one was headed to AMIA, the other was headed to The Liver Meeting 2015, which is also being held in San Francisco.

Given my crazy frequent flyer status, I was one of the first on the plane and watched at least a dozen other physicians and health informatics professionals pass by. I was relieved that if the question was to be asked whether there was a doctor on the plane, I would have backup (although as an emergency department doc, I’d likely be a better choice than the pediatric hepatologist for most in-flight issues).

I had the chance to catch up on the flight with a friend of mine who works for my former health system. They’re on a journey to a massive rip-and-replace. There is no shortage of informatics work to be done as they retire dozens of major systems in the name of single-database efficiency.

There was another informaticist seated near me and it was interesting to eavesdrop on his chat with his seat mate. He was explaining what he does. There was a brief discussion about data sharing and the difficulties of doing it not only technically, but also about the nervousness of physicians in sharing some of the more sensitive health information that is out there.

We’ve gotten to a point where the incidents of hacks and breaches are too numerous to count. I get the sense that physicians are at the tipping point of being more worried about unauthorized access to medical data than they are about patients having the data. In some ways, that’s a good thing because my peers are getting over their resistance to patient ownership of their own health information. It’s been a long time coming.

The Hilton Union Square was also hosting a nursing convention, where I spotted several people wearing this tee shirt. I’m going to have to seriously think about ordering a few for some of the people I’m working with right now.

I was able to check in to my room a couple of hours early, which was much appreciated and allowed me to head to Union Square. I got a kick out of watching the ice skaters, most of whom didn’t have much experience, but were giving it a good try. Several were watching one man who was there teaching his son and who clearly had spent some time on the ice. I was tempted to rent skates and show off my winter sports skills, but decided to head to the cable car line instead. No less than 30 minutes after I left Union Square, there was a horrific crash of two double-decker tour buses. I wish a speedy recovery for all those injured.

After a couple of hours roaming the city, I returned to the hotel to register for the conference. I loved the Wall of Ribbons and picked up a couple of gems to wear during the week. The conference program guide had a lot of helpful information such as “remove your lanyard when you leave the hotel so you’re not immediately recognized as a tourist,” but it didn’t include a warning that apparently in San Francisco, you’re expected to bring your own bag for carry-out restaurants. Oherwise, there is a bag charge. I’m pretty good at the reduce/reuse/recycle game, but got caught off guard when picking up lunch earlier in the day. That kind of local color information might be helpful in future programs. I appreciated the adjustability of the AMIA lanyards, which allows those of us on the shorter side to hang our badges somewhere north of our navels.

Fast forward to Saturday, when the pre-symposia sessions began. I attended one on “Health Information Exchange Challenges and Methods.” There was a lot of good information covering the different models of HIE and the evolution from early systems to where we are today. There are still quite a few barriers to effective data exchange, including lack of a unique patient identifier or universal physician directory. I learned about a couple of new approaches to bridging between centralized and federated models, but based on the amount of multitasking going, on I’m not sure everyone in the room was as interested.

Maybe they were distracted by the “Data Mining for Medical Informatics – Predictive Analytics” session being held in the next room that must have been pretty exciting judging by the seven rounds of applause heard through the wall in the first 90 minutes of the presentation. For the people who were multitasking, though, may I recommend 3M’s lovely line of privacy screens to keep your neighbors from seeing everything you are doing if you choose to multitask? Surfing Facebook doesn’t make you look like a serious informaticist, although debugging code does. I felt for the gentleman who was doing the latter.

At the break, I ran into HIStalk songwriter extraordinaire Ross Martin, who happened to be seated next to a friend from my customer days at a shared EHR vendor. It’s the first AMIA meeting for both of us and neither of us had dinner plans, so I appreciated the serendipity of running into her.

During the afternoon, I attended a session on “Practical Modeling Issues: Representing Coded and Structured Patient Data in EHR Systems.” Presented by Intermountain Healthcare’s CMIO Stan Huff, it definitely earned its stripes for Maintenance of Certification credit. The session was highly detailed and I got a lot out of it, but I’m sure it was overwhelming for some. I hadn’t heard about the Clinical Information Modeling Initiative becoming one of the HL7 workgroups, but it sounds like it has a lot of potential.

One of the interesting points Stan brought up was the challenge of handling data from a subject who might not be the patient. For example, information on fetal characteristics documented when treating a pregnant woman, or information on tissue donor characteristics for the recipient’s chart. It’s not something I’ve had to do much of in the ambulatory space, but it grabbed my attention. I also enjoyed watching a physician at the next table doing origami with dollar bills. It just goes to show that informatics professionals are a talented bunch.

Do you multitask during conferences? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/12/15

I’m headed to San Francisco for the AMIA meeting and will be reporting from there for the next several days. I haven’t been to a conference that is this academic in a long time and I have to say that planning for it has been more rigorous than I expected.

From everything I hear as well as from the pre-symposium orientation webinar, there is going to be more to do, see, and learn than one person could possibly do. There are more than 2,000 pages of content available already, plus a few hundred pages of questions and answers for Maintenance of Certification (MOC).

There are also Twitter feeds and an event app for managing your schedule. I’ve enjoyed going through everything and flagging the sessions I plan to attend or that I want to keep on my list as a backup. For someone like me who dabbles in many different areas of informatics, it’s a bit like being a kid in a candy store.

I’ll be attending some of the pre-symposium sessions as well. Dealing with them has been the only negative part of my experience so far.

When I signed up for AMIA several months ago, the list of sessions that are available for MOC credit for clinical informatics wasn’t available. Even though they’re no charge, the pre-symposium sessions required advance registration. Once the list of MOC-approved sessions was available and I had time to go back through them and see whether they matched what I had registered for, those that I wanted to switch to were full.

Attending conferences is expensive. Given the status of MOC for Clinical Informatics, I want to maximize the amount of credit I bring home. Although I’m not choosing sessions strictly by whether they are approved or not, given two sessions at the same time that I’m equally interested in, I’m going to lean towards the one that will give me credit.

I suspect AMIA is seeing a spike in registrations due to being one of the few providers of relevant and approved continuing education credit for our subspecialty. It will be interesting to see how it shakes out. In the mean time, I’m going to continue refining my battle plan to get the most out of the conference.

Whenever I head out for an extended trip, I gather up any hard-copy publications that can be read during taxi, takeoff, and landing so I can read and recycle them on the way. I saw this Healthcare IT News headline and it just struck me as somewhat offensive. Although IT is a key player in most industries, to say that a hospital would be “nothing” without its IT department is obnoxious. It would still be a hospital, it would still provide patient care, and it most certainly wouldn’t crumble to the ground.

The associated article is about best hospital IT departments, so I don’t expect it to address the fact that there are worse things than having no IT department – namely, having a bad IT department that creates chaos. Or one that behaves aggressively towards clinicians and doesn’t respect the input of various stakeholders. Or one that’s flat-out incompetent.

As a culture, we’ve become obsessed with these “best of” lists. I always think about one of my good friends that continued to make the “best doctors” list in my city despite having moved away several years prior.

The loss of any department — whether clinical, administrative, support, or other disciplines — would negatively impact any hospital. Headlines like this don’t help bring people together. I’d love to drop this in the physician lounge and see what kind of responses it gets. Maybe that’s an idea for a reality show – kind of a candid camera for healthcare IT users. I know some people who would watch.

What’s your idea of good entertainment? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/9/15

My parents are quite the travelers. Although they’ve avoided most illnesses on the road, they did wind up recently at a walk-in clinic in rural Australia. The facility is staffed by a rotating slate of physicians who fly in periodically. They were eager to be seen before the doctor flew out.

Given my career with electronic health records, my father thought I’d get a kick out of his visit note. It’s a grand total of four pages (two which really matter) and features such complex notations as “unwell” and “sinusitis.”

The physician note is the haiku of clinical documentation and made me wonder what kind of job satisfaction this physician has related to topics such as “administrative simplification” and “regulatory documentation.” I think it’s pretty good since he doesn’t appear to have too concerned with gathering bullet points or capturing all the screenings that we’re required to document on patients in the US regardless of their presenting problem.

I’m betting the form was captured electronically since he was discharged with the original document. Talk about OpenNotes and transparency for patients. It reminded me of a note I saw in a chart when I first went into practice. We had purchased a retiring physician’s charts and it said simply: “Sore throat – PCN – $10.” You can bet the patient paid at the checkout desk and that the note was complete before the patient left the room. It may not be interoperable, but it certainly is elegant in its simplicity.

My mother also had a visit. Both were treated appropriately for their conditions and with low-cost generic medications. It’s interesting to hear about healthcare delivery in its purest form. Although their situations were low complexity and low risk, not every visit needs to have a full-court documentation press. There may be times where minimalist documentation is appropriate, but unfortunately our systems don’t support that. Even with the push for value-based care, I don’t see any payers loosening their documentation requirements.

It was with that situation in mind that I headed out this morning to work with a practice on a population health initiative. They’re a mid-sized primary care group that’s already running pretty lean, but they want to try to figure out how to better reach patients who need preventive services or who may have missed follow up steps on their chronic conditions.

Although it’s really a productivity and optimization project that doesn’t necessarily need clinical oversight, practices like to hire me because I’m an actual doctor. They feel like I have a better understanding of their needs because I’ve been a practice owner myself and have been in their position. Sometimes it makes things difficult, though, because I see clinical issues that are outside the scope of my current role but still need to be addressed.

Today was one of those days. While I was shadowing the triage nurse to get an idea of her workload and the flow of her day, she was interrupted by a call from a patient’s family member. Apparently the 87-year-old patient has been having low blood sugars after recently being placed on diabetes medication. Her sugar has been less than 50 several times in the last few weeks, which typically isn’t compatible with good brain function and puts her at risk of falls and other serious complications. As she was talking to the family and later the patient, I was watching over her shoulder to see the patient’s lab values.

Hemoglobin A1c is a marker of longer-term blood sugar control. Hers was barely elevated even before she was started on medications. She immediately had low sugars when starting drug therapy, so the physician had changed her dosing to three days a week and she was still having issues. I started wondering why in the world this doc had her on medication to begin with. With many diabetic patients, if you can keep them at a reasonable level with just diet and exercise, you try to avoid medications. Her near-normal value was certainly reasonable by most physician’s standards.

The whole goal of keeping people’s sugars in the normal range is to prevent the long-term complications of diabetes. I didn’t see any complicating diagnoses on the patient’s chart – no kidney disease, nerve damage, eye problems, etc. There’s plenty of literature that shows that especially in older patients, it’s more risky to try to keep blood sugar control too tight. Once the patient was scheduled for an appointment, I gently queried the nurse about the physician’s typical treatment of these kinds of patients.

She mentioned that he is “obsessed” with his performance scores and this isn’t the first time she’s dealt with this issue. Apparently he’s worried about “being dinged” in reporting and “losing his star” with a payer. It made me immediately remember the old adage from medical school about needing to “treat the patient and not the numbers,” which means to consider the person in front of you and not just their labs or the data. I asked her if they knew how to exclude these kinds of patients from clinical reporting if there were good reasons that they shouldn’t be treated in a certain way or managed to a certain level.

She hadn’t heard of the ability to do this in their EHR, so we asked a couple of other nurses and none of them knew it either. Excluding the patient from reporting on this particular parameter would prevent the physician from being penalized for less-tight blood sugar control in this patient who clearly should not be managed so aggressively. By lunch time, we were able to grab a few minutes with the physician in question and he didn’t know about the ability to exclude, either.

Although he was initially offended and felt that I was questioning his care, he realized that I was not only trying to help the patient, but to help him be able to practice in a more rational patient-centric manner without running afoul of the scorecards that we’re all slaves to now. Excluding patients such as this one may take a few more clicks, but they’re well worth it. Although Big Data can provide impressive insights and help us change how we practice, we need to make sure we’re changing in the right way and for the right reasons.

How has Big Data impacted your care delivery system? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/5/15

A shout-out to representative Steve King of Iowa for attempting to inject some Midwestern common sense into the Meaningful Use chaos. His “Putting Patients and Providers Ahead of Compressed Regulatory Timelines Act of 2015” would sunset meaningful use penalties and rebate 2015 penalties back to providers and hospitals. It doesn’t have a realistic chance of passing, but I applaud him for trying.

I mentioned last week that I’ll be attending the AMIA meeting. During my email cleanup, I happened to come across an invitation to a pre-symposium educational session and registered for it. It was lucky that I did my cleanup when I did because the session was the following morning. The late registration caused a couple of hitches in accessing the session, but the team at AMIA still got me connected in time.

I’ve attended a lot of conferences, but appreciated the ability to get some solid recommendations for first-time attendees. One of the pieces of advice that surprised me was their openness with attendees dropping in and out of sessions and following the “buzz” on social media.

One conference I attended last year required attendees to declare their intentions weeks in advance under the pretense of predicting room sizes. In reality, they were using the attendee information for target marketing in advance of the conference. They also had some pretty aggressive door-checkers who scolded attendees for leaving sessions or trying to enter ones already in progress. I understand minimizing disruptions, but I would rather people move to another session where they may learn something than to sit in a session where they don’t find value.

Now that I have more information on the meeting, I can spend my free time putting together my social schedule. There are several networking events planned, including one called WINE (Women in Informatics Networking Event). How can you go wrong with a draw like that? Unfortunately, a couple of my favorite San Francisco-area colleagues will be out of town while I’m there, but that gives me an excuse to look for new and exciting things to do in my free time.

Also in the email clean-up, I found a direct marketing piece from Pfizer about October being Gaucher Awareness Month. Although Gaucher disease only affects 50,000 – 100,000 people worldwide, it has a disproportionate impact on people of Ashkenazi Jewish heritage (one in 600) and medications are available for treatment that can make a dramatic difference for patients. Unfortunately, it’s extremely expensive (cost was $150,000 per patient per year when it first launched in 2012) despite its obvious benefit. I’ve never actually seen a patient with Gaucher Disease (treated or otherwise) as compared to other more prevalent conditions, so it seems an odd choice for a direct marketing piece.

I also found yet another email from Doximity asking me to review the residency program where I trained. I’ve been deleting these for several months. When it first launched in 2011, Doximity tried to brand itself as the LinkedIn for doctors. I’m not sure how successful they’ve been, but I suspect they’re somewhat struggling for relevancy.  I laughed, though, when I read the body of the most recent email, where they asked me to review the program because “choosing a residency program is one of the biggest decisions new physicians face in their careers” and “reviews help medical students find the right training program.” Thankfully, the program where I trained bears no resemblance to what it looked like when I was there. There have been tremendous changes to graduate medical education in the last decade and frankly anything I write would be wholly irrelevant to anyone considering the program today. I’d think that a company that is supposed to understand physicians would have a better handle on this.

A reader contacted me about how hospitals handle Daylight Saving Time. “Our hospital claims that every hospital in the US that deals with Daylight Saving Time turns off their EHR from 1:00 to 2:00 a.m. so there are not duplicate orders, meds, notes out of order, etc. For 15 minutes prior and 15 minutes after — a total of 90 minutes — we have “Zombie Hour” every year for DST. No medical care happens in the system for one hour. Is this your experience? That if you are an unlucky soul that hits the ED from 1:00 a.m. to 2:00 a.m. on November 1 that you do not exist for 90 minutes? Isn’t there a better way? Use UTC or GMT time for meds and timestamps? I cannot imagine that EHR vendors and ONC did not think of this when it has come up before. Help me understand this.”

I was a bit puzzled by this because it hasn’t been a factor in any hospitals where I’ve worked. I double checked with one of my former hospital colleagues and our system handles timestamps in UTC but uses an adjustment for the display, whether regional standard time or regional daylight time. I polled a couple of colleagues at other systems, though, and several of them have Zombie Hour. The reader named a specific vendor in his email, which surprised me that they would not have a better solution than dropping to paper. I’d be interested to hear from vendors how they handle this issue. In the meantime, I found this NIST document on DST rules.

How does your facility handle DST? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/2/15

I attended a continuing education seminar the other day. It was a rare treat since I’m usually on the speaking side of continuing education engagements. I get most of my continuing education from online sources, reading my specialty society’s journal, and answering continuing ed quiz questions.

The seminar I attended was put on by one of the local hospitals. It targeted physicians who have been using their EHR for some time, but who need tips and tricks to make documentation faster.

A friend of mine was teaching the class and invited me to attend. She is relatively new to being a clinical informatics administrator, although she’s been an end user for a very long time. This was her first time teaching a “techy” class and she was looking for feedback on her delivery. She also wanted my opinion on whether she had prepared a good blend of clinically relevant information and technical suggestions.

I’m not on staff at her hospital, but wanted to help her out. Not to mention it was an easy way to get CME while getting a sneak peek at their state of the art (aka “hundreds of millions of dollars”) system and hear feedback from users of a system I don’t usually work with.

Physicians tend to think the grass is always greener on the other side of the fence. Being able to peek under the hood of another system usually shows that although the grass may be different, it’s not always greener. Many of the physician comments made during this class were the same ones I hear when working with users of other systems: not enough user-level configurability, alert fatigue, too many clicks, etc. Half the physicians in the room might love a particular features while the other half hate it.

This group was no different. Some of the lines of disagreement split as anticipated, whether specialists vs. generalists or procedural specialties vs. cognitive specialties.

My friend did a great job covering some of the nuances of the EHR. Whenever she covered an area where physicians were particularly struggling, she was not only able to show the best practice workflows, but often provided commentary on why the system was set up in a particular way or why a feature might or might not be enabled. Many of the attendees were in agreement that understanding the “why” behind a given feature can make it seem less clunky if it’s clear the benefits outweigh the annoyances of the workflow.

This allowed for a lot of dialogue among the end users, the IT department, and the administrators. Usually I don’t see IT or administration attending sessions like this and it went a long way towards convincing the providers that their organization really does care what they think about the EHR and that they are committed to making the workflows as good as they can possibly be. It also allowed them to hear directly from the physicians without the help desk or a physician services liaison trying to translate or summarize the concerns.

My friend did a fantastic job with her training. After the initial lecture portion of the class (which granted continuing education hours), there was a 45-minute lab time where trainers were available to work with attendees on particular workflows or sticking points. That way, any outstanding questions could be addressed immediately and the learners could also practice and solidify the new workflows they had used in class. She also incorporated hot button clinical issues into her examples, leading several of the providers to go in and update their order sets or modify their preferences accordingly.

Having immediate lab time after the formal lecture is something that many workflow classes lack. Attendees are often excited about learning, but then have to go back to their department or patient care area and have difficulty finding the time needed to try new workflows in a protected environment or to update system configuration. It was also great having trainers to work one on one with attendees so that those who might have been struggling or had more questions knew that they would be able to get help and didn’t derail the rest of the class with questions.

I met with my friend after and gave her a couple of ideas for changes to her presentation style as well as a heads-up about some speech habits that might be distracting to learners. As a clinician who was thrown into the administrative and training realm without a lot of formal support, I know that kind of feedback can be valuable. I have a mentor who sits in on some of my presentations from time to time and does the same thing for me and the advice I’ve received has been extremely valuable.

Depending on the medical school and residency training program a physician attends, there may be solid presentation skills training or none at all. I remember my first presentation as a student, using overhead projector transparencies and a carousel projector. I may be dating myself, but that required a lot more advanced preparation to get slides organized and transparencies created. I definitely appreciate being able to throw together a presentation on the fly, but sometimes we lose the formality we had when we were lower tech.

Hospitals that don’t offer this kind of ongoing EHR training and optimization sessions are short-changing their end users. They don’t always have to be this formal and with this many resources involved, but having them available to users on an ongoing basis (whether live or recorded) is critical to long-term success and user satisfaction.

Does your hospital offer ongoing EHR training? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/29/15

October is finally coming to an end, and with it, Breast Cancer Awareness Month. Several of my clients did population health outreach campaigns around mammograms and breast cancer screening. It’s rewarding to see that so many patients were reminded of the need to stay on top of preventive health care.

I literally ran across one of these pink carts on my morning jog, with its “Kick Cancer to the Curb” slogan. Definitely an interesting campaign, but I’m wondering how long it will be until a veritable rainbow of carts for other diseases starts to appear. They could probably get some traction with medical offices and shredding services, replacing the standard boring carts with disease-awareness ones.

I’m a big fan of focused population health outreach campaigns, which we used to refer to as “disease of the month” at my practice. With the advent of unquestionably powerful population health applications, it can be overwhelming to start robo-calling or texting patients who are overdue for multiple screening and interventions.

I recommend that my clients gradually work their way into full-scale reminders, selecting first a disease or condition that is either of high prevalence in the community or of key importance to the practice. Once the staff is familiar with managing patients who respond to the outreach messages and can handle the volumes it may bring in, it becomes easier to incrementally add additional outreach campaigns.

I also recommend they put signage in the offices and provide relevant patient education material as well as educating the staff through in-services. That way everyone in the office can assist as patients respond. It’s tempting to fire up multiple campaigns at the same time, but unless your system is sophisticated enough to combine reminders, it can quickly become annoying. Even if the reminders are combined, I’m not sure I would want to be a patient on the receiving end of a laundry list of preventive services being read to me by a disembodied computer voice.

I’ve spent a fair amount of time over the last decade helping practices redesign their offices, not only from a workflow perspective, but also architecturally. Transitioning to an EHR works best with appropriate exam room layouts. Getting rid of the chart room usually frees up space that can be used either for employee engagement or revenue generation.

I’ve worked with quite a few office designers and am always interested in looking at computer carts and other equipment at HIMSS. One of my designer friends shared information on the Beam Virtual Playground, which is a ceiling-mounted projector that creates a “touch screen” on the floor for games. I like the idea, and the fact that it’s germ free is a big plus. I’m always astounded when I see well-chewed books and slobbery toys in medical waiting rooms.

‘Tis the season for vendor user groups, and apparently I’m attending all the wrong ones. This week’s IBM Insight conference featured an exclusive performance by Maroon 5, sponsored by Rocket Software. Talk about a client appreciation event. And for those working the show from the vendor side, not a bad day at the office.

I had a couple of days off this week and spent most of them trying to tame the email monster and complete long-overdue tasks. Thank goodness for being able to work anywhere. As I was hanging out at the car dealer having my oil changed, I got a glimpse behind the scenes at something that resembled a medical chart room. I was surprised since this is a high-tech dealer who appears to do everything electronically from checking you in with the electronic code on your car key to sending email reminders. Apparently they have a dark secret, however. I’m glad that the people who make chart tabs and other filing accessories found another line of business since we don’t need them very much any more in medicine.

I’ve got two conferences to attend in the next three weeks, so it will be good to get things squared away before I go back on the road. The only thing left to do is purchase candy for Saturday night. Thanks to Travel+Leisure magazine for providing these wine pairings for Halloween candy. I’m not sure I agree with some of their selections (Hot Tamales and Riesling, anyone?) but I can definitely get on board with Raisinets and Merlot.

What’s your favorite candy and beverage combination? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/26/15

With the goal of expanding the number of meetings and conferences we report on, Mr. H is sending me to the AMIA Annual Symposium this year. I’ll be reporting on the activities each day. I’m looking forward to it as I haven’t attended previously. I’m also eager to log some hours towards Maintenance of Certification (MOC) for my Clinical Informatics board certification.

I’m not the only one looking forward to getting the continuing education credits. The AMIA listserv for the Clinical Informatics Community of Practice (CICOP) has been hopping with quite a few complaints about the whole MOC process for those of us in this new specialty. With the first cohort passing their exams in the fall of 2013, we’re decently into the first part of our 10-year recertification cycle. Those of us certified through the American Board of Preventive Medicine (the American Board of Pathology also certifies) are required to obtain a certain number of ABPM Lifelong Learning and Self-Assessment (LLSA) hours every three years in addition to regular continuing education hours.

Most of the current LLSA-approved continuing education offerings are within ABPM’s longer-standing subspecialties such as Aerospace Medicine, Occupational Medicine, General Preventive Medicine, and Undersea/Hyperbaric Medicine. The number of courses for clinical informatics are few and far between and typically involve on-site courses. AMIA has completed the process to offer LLSA hours for the fall meeting, and for those of us unable to get hours over the previous two years, it’s a huge help.

When I initially decided to try to become part of the first class of board certified clinical informaticists, I really didn’t think about what it would be like to maintain certification with two different board organizations. The American Board of Family Medicine already requires me to do 150 hours of CME each year, of which a certain percentage has to meet specified criteria. Certification by the AMA or the American Academy of Family Physicians are two of the criteria that count. Finding AMA- or AAFP-approved CME is easy. It’s everywhere, and can be earned not only through face-to-face symposia but also by reading journal articles and taking CME quizzes or doing online coursework.

We’re one of the first specialties that required Maintenance of Certification. Although the policies are a little tedious, they’re well documented and pretty straightforward. With Clinical Informatics being relatively new (coupled with the fact that many of us in the first two certification cohorts are, shall we say, fairly Type-A personalities) there’s a lot of tension around MOC. In addition to the LLSA credit, we’re also supposed to complete a “patient safety module” which is somewhat ill-defined (although ABPM did offer a link to a discounted course from the National Patient Safety Foundation that they’ll accept). A friend of mine got his university course approved as well, but the rest of us may not have that option.

I’m grateful that the Board has agreed to recognize some of the MOC (called Part IV) activities that physicians are already performing for their primary board certification. The current Clinical Informatics subspecialty certification requires physicians to maintain full certification in another American Board of Medical Specialties sanctioned discipline so it seems only fair, especially considering that the Board has yet to come out with a recognized clinical informatics module. I have to admit that the process to have my Family Medicine credits recognized was fairly straightforward, although it did require printing and completing a paper form and emailing it to the Board.

One of the respondents on the AMIA email thread mentioned that as a specialty deeply involved in computer-based projects, we should be at the forefront for virtual and online courses. Unfortunately one of the major challenges is completing the paperwork from the board to have your course recognized, which I hear is not exactly straightforward. I don’t know if there are fees involved with submitting a course offering, but that could be a de-motivator for some providers of continuing education credit.

There aren’t any well-known online providers for the kind of credit we need. Although some of our colleagues in academic settings are going to try to get their local courses certified, that doesn’t help those of us who are in parts of the country where we’re thinly populated. I’m one of two certified informaticists in my metropolitan area of over three million people, and I’m sure there are others even more sparsely arranged than we are.

One of the AMIA representatives mentioned being in contact with the Board and that we’re going to get an extension on some of the initial deadlines, but as a diplomate of the Board, I haven’t received that communication directly from them nor has it been posted on their website or in any other print media that I’m aware of. It’s understandably frustrating then for those of us who don’t want to fall behind but are somewhat stuck about what we need to do to be successful.

We’ll gather at AMIA, though, and see what kind of credits we can rack up and whether they’ll be enough to get us through the first checkpoint at the end of Year Three of our certifications. Hopefully some virtual offerings will be approved soon, or at least some recordings for those of us who aren’t willing or able to spend several thousand dollars (not to mention the time out of practice) to attend a conference in person.

It’s exhilarating to be on the cutting edge of things, but like being in the health information technology industry, it can also be frustrating and at times downright exhausting. I’m hoping that attending AMIA and networking with others in the field will help recharge some of my depleted energy and give me ideas for future projects. If nothing else it’s an excuse to visit San Francisco, which I’ve never done in the fall.

Will I see you at AMIA? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/22/15

This week is one of those “you can’t make this stuff up” kind of weeks. It’s been filled with plenty of hard work, a fair amount of organizational dysfunction, and some pretty cliché observations.

Despite the challenges, I’m working with some genuinely nice people who seem to want to be successful and that makes all the difference. I’d rather work with people who know they have issues and want to try to be better than with people that think that everything is just fine when it’s not.

The practice I’m working with provides a fair amount of cash-based services (mostly cosmetic) and we dealt with some complaints about the lack of support for those workflows by their EHR vendor. It’s been interesting trying to explain why vendors have been spending all their time and energy on MU-related features and functions when the providers don’t care about being meaningfully used.

We did get some quick documentation templates done for a couple of their most common procedures, so that was a big win. One of the partners was so happy with the new workflow that he offered to give me some complimentary services. I wasn’t sure whether I should be excited about that or offended that he obviously thinks I need some work.

The physicians also have traditional primary care patient panels, but it feels more like a sideline rather than their focus. They’re trying to get in step with current primary care trends, but it’s a hard sell when you can make more money smoothing wrinkles, lightening dark spots, and making irksome leg veins go away.

Since they’re in a building on the hospital campus, several of the physicians hit the physician lounge for lunch every day even though they don’t admit their own patients. They’ve been taking me with them and it’s been enlightening to see what some of their peers think about the state of healthcare IT since I haven’t done much work in this part of the country.

I almost spit my sweet tea across the table when one physician said that since he was going to switch EHR vendors in the spring, he was going to go ahead and apply for a MU hardship exemption. He’s got connectivity issues with his current “lousy” system and has decided to just stop charting electronically. I’m not sure that qualifies as an extreme and/or uncontrollable circumstance, but he’s welcome to try. The vendor in question has tens of thousands of physicians who have successfully attested, so it’s an interesting position to take.

The practice is one of the first I’ve been in recently that still has pharmaceutical representatives call on the physicians. Most of the reps I’ve encountered over the years are hard-working and spend a lot of time dealing with cranky physicians as they haul samples from their company cars (used to be a lot of Ford Taurus-equivalent sedans, but now I’m seeing a fair number of minivans). The highlight of the week was the sales rep that pulled up in a new Maserati that cost more than my first house. He turned out to be EHR vendor’s regional sales exec. I guess he’s not hurting for business.

While I was fielding agenda changes from the client (who apparently thought of 20 other projects for me to work on during the time I was en route), I got a couple of emails from family members. My grandfather had a bone marrow biopsy last week and was told the results would be available in eight days. He dutifully called the office at the end of the eighth day after hearing nothing, only to be told that the physician would be out of town until October 29 and no one else in the office could give him results.

He sent his primary care doc a message through his patient portal trying to get the results, but was asking me for advice (as were his wife and my aunt). I thought it would be better to try to get in touch with the hematologist’s partners, who would presumably have access to his chart and would know what question the bone marrow biopsy was to answer or what condition was to be confirmed or ruled out. Even if he could see the results in the hospital system, I didn’t think this particular primary care physician would be likely to give them since he wasn’t the ordering physician.

I suggested that they call the hematologist’s office again and ask what the physician’s coverage arrangements are while he is out of town, and if they were told there aren’t any, that they mention the words “patient abandonment” and see what happens. This isn’t a question of a patient misunderstanding how he was to get the results – his discharge instructions clearly said to call for results in eight days. As a physician, I’m horrified at this kind of a process failure and the stress and worry it’s causing the patient and his entire family.

A couple of hours, later the PCP responded, basically saying he doesn’t know much about interpreting bone marrow results but that it “doesn’t look that bad.” That’s not exactly a vote of confidence for a worried patient. I saw the screenshot of the secure message and he definitely could benefit from a little coaching on how he explains things to patients. We’re still waiting to hear back from the hematologist’s office, who said their office manager would be calling to explain the cross coverage arrangements. Like I said, you can’t make this stuff up.

Turning my attention back to the client’s workflow issues, we identified several more commonly-seen conditions where the EHR didn’t fully meet their needs. I headed back to the hotel to get some additional custom templates built before selecting my next dining adventure. Several readers have commented or emailed about their BBQ preferences. The Carolinas are leading Texas two to one and I’ve received some suggestions I can’t wait to try. Tomorrow I’m finishing the day with a tour of the local Bass Pro, which promises to be something to behold.

Where do you get your local color? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/20/15

I wrote last week about interoperability, mentioning that attempting to connect through Direct has added confusion for providers like me who have multiple practice situations or multiple locations. A reader commented, “vs. how many fax numbers to create an out-of-paper trail with?”

That’s a very good question. It points to a larger problem with EHRs – one that most if not all providers complain about – which is the shifting of work from staff to providers.

Sometimes this is in the name of efficiency. Why have the patient wait for the referral to be entered when the provider can just do it at the point of care? Why have the provider have to tell a staffer when he or she can do it real time?

In many cases, this is a misguided attempt at efficiency. Although we can reduce the number of steps in a process, that’s not everything we look at when we map workflows. We also need to look at the cost of various people doing various tasks. It often doesn’t make sense for providers to do certain steps that EHR workflows are trying to force them to do.

Other times this is in the name of patient safety. In its purest form, this makes sense. Having providers enter medication and laboratory and diagnostic orders can prevent transcription errors and allow them to acknowledge warnings and alerts. It’s a good use of some of the most expensive employee hours in the office. Unfortunately, that thinking has driven a lot of work upstream that organizations haven’t yet redistributed to where it is most appropriate.

In the paper world, my referral process involved a single page flow sheet where I marked what to send in the referral bundle and who to send it to, along with a diagnosis. My medical assistant knew the short list of common referrals and where to send the packet. They managed that list of fax numbers and locations, not me. They knew whether to send the packet to the West Office for a Thursday appointment or to the South Office for anything else.

Now that the referral workflow has been embedded into the provider workflow in my EHR, I’m supposed to manage those facts while I’m sitting in the room with the patient, because they system wants me to complete it before I move on.

Of course, I could simply send an electronic task to my staff and ask them to do it, but that takes me out of my standard workflow as well. Don’t get me wrong, I’m excited about the ability to exchange secure messages with consultants and colleagues and have a copy added to the chart automatically, preventing phone tag and manual note-writing. But if it’s too complicated to find my key providers, I’m going to struggle.

Two of the three systems I use on a regular basis have no way for the physician user to create their own address book or contacts list outside of the practice. One has a robust partial search where I can search a metropolitan area for a given physician. The other requires me to know the specific postal city associated with my target’s ZIP code. Honestly, I need to just search for Dr. X who is a cardiologist in the Chicago area. I have no idea whether they’re in Oak Park or Oak Brook and neither does my patient.

These are usability issues as well as workflow issues. I can’t help but think that if vendors did more trialing of product with real-world physicians they would be better able to identify these things up front. We know from recent publications that vendors vary widely in how they perform usability testing (if at all) and how valid the results might be.

I’ve been on some usability focus groups as a participant and it’s hard to manage bias and dominant behavior by some members. I’ve also supported usability testing for vendors and know that it’s hard to find knowledgeable participants who are willing to take time out of their busy schedules to participate in a usability study unless you throw ridiculous amounts of money at them. Even then the output varies widely.

There are also physician psychology issues at play when work gets redistributed. Physicians realize how lean their offices run and can be reluctant to shift work to staff members that are struggling to get out of the office on time to pick up their children or tend to other obligations. Employers may be unwilling to pay overtime or to approve the hours needed to actually do the work, so someone has to take care of it and often that is the provider. There is also a perception that it’s quicker to just do the work yourself rather than ask someone else to do it. Couple this with a lack of time and energy to do the actual process improvement work needed to fix the underlying workflow issues and it’s a recipe for dissatisfaction all around.

I’m working with a practice this week that has engaged me to do some workflow re-engineering, so this is in the center of my thoughts. I’ve worked with them before and the issues are complex. They only took about 20 percent of my advice last time, and although they initially made progress, ICD-10 and two software upgrades have caused some chaos.

They’re one of the last independent practices in their community and does a mix of traditional primary care and somewhat fringe (read: cash only) services. The owner doesn’t really have a head for where primary care has been going in the last few years and I’m not sure he’s committed to doing what needs to be done to be successful. Frankly they’d be better off transitioning to a retainer or concierge-type practice, but they don’t want to do that either.

It’s shaping up to be an interesting week and I can guarantee no boredom or downtime as I dig in with these folks. Not to mention they’re in one of the best cities in the US for barbecue, so I have nothing to complain about for dining choices this week.

What’s your favorite BBQ locale? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/15/15

Both the American Hospital Association and the American Academy of Family Physicians have publicly weighed in on ONC’s revised Interoperability Roadmap. Both organizations believe it doesn’t go far enough or fast enough.

Although quite a few stakeholders accuse the EHR vendors of being the villains with regards to data blocking, my personal experience has been that health systems and hospital-controlled physician networks are really behind it. Not to mention that ACOs naturally create barriers to interoperability as they encourage physicians to keep patients within a well-defined (often narrowly so) network.

I had the adventure of standing up a private HIE seven or eight years ago. The sponsoring health system’s express purpose was to share data only within our referral network. Providers affiliated with other hospitals were not invited to join.

At least in my metropolitan area, I haven’t seen that philosophy change across the years. While the AAFP calls for “increased accountability on industry and decreased accountability on those who are using their inadequate products,” I think we need to focus the microscope on some of the other interested parties.

Let’s hold health systems accountable. When their vendors provide interoperable products, they need to be using them in an interoperable fashion. They need to force their owned hospitals and employed physicians to accept and integrate electronic health data brought by patients. And they need to release the data electronically when patients request it. Mr. H’s story of his inability to get his records electronically is just one of thousands out there.

Let’s also bring the non-provider technology stakeholders into the business of being regulated in the same way that providers and hospitals are. For example, reference laboratories. The fact that there are still numerous laboratories who cannot (or will not) send LOINC codes with their results is appalling.

Let’s also start regulating the pharmacies, getting their information systems under control. One of my local pharmacies sends scads of duplicate prescription refill requests all the time. This leads our practice to have to spend time determining if they’re really duplicates or not. When we call the pharmacy to complain, we’re told that it happens due to limitations in their computer systems and the inability to match refill responses to the original requests in an accurate manner.

Since all patients and physicians depend on pharmacies and labs, why shouldn’t this be part of the solution? What about standardizing all the other systems we have to interact with, such as home health systems and those used by nursing homes and other extended care facilities? Many patients that we used to hospitalize for care are instead receiving services through home health agencies. It doesn’t do me much good to interoperate with the hospital if the patients aren’t in it.

I started reading the Roadmap essentially to have a break from reading the Meaningful Use final rules. I’ve been jumping around in it rather than reading it through, however. I was pleased that they called out “Authentication and Identity Proofing” early in the paper (page 11 if you’re interested). They admit that lack of standard approaches has hampered information sharing. They mention that Direct was intended to “work much like email and lower the barrier to exchange for providers and hospitals.”

In my market, however, Direct has added all kinds of confusion, especially for providers like me who have multiple practice situations. I have different addresses for the different urgent care groups I work with on different EHR platforms. If a PCP is looking for me to send a follow-up, how do they know where to send it? Other health organizations have created additional complexity. One organization created separate addresses for each location for each provider, so a cardiologist who sees patients at six physical locations has six addresses. Although I understand their original reasoning for doing it, it’s untenable in reality.

Page 36 addresses individual data matching. They point out that although HIPAA required creation of national identifiers for patients in 1996 and Congress blocked appropriations, there is no prohibition against private or non-HHS governmental agencies creating their own. They note that the Department of Veterans Affairs and the Department of Defense assign unique identifiers for service members. Although I understand the arguments against it, I’d volunteer to test drive a national ID myself even if it’s private and voluntary.

I’ve had too many bad experiences with using existing primary data elements (name, DOB, sex, phone number), both personally and professionally. Even existing non-healthcare governmental systems don’t always handle the data in the same manner.

Here’s an example. Due to my southern roots, my actual legal name has a compound first name. My legal middle name is actually a family name, which looks like a last name to most people. Then I have my actual last name. Let’s work with “Peggy Sue Herrington Mitchell” as our example. My original birth certificate was completed on a typewriter, with “Sue” landing squarely on the line between the caption for “first” and “middle” names.

When I was in medical school, I had to get a certified copy of my birth certificate to prove identity for licensure. My birth county had computerized, and the person keying the data had made “Peggy” my first name and “Sue Herrington” as my middle name. It also truncated the “Herrington” by a few letters since there weren’t enough characters in the middle name field. With the layout and truncation issues, the computerized copy didn’t match my college transcript or my medical school transcript or my passport, which had my legal name listed correctly. The authorities refused to accept my identity proofing. I had to petition the county to pull a microfiche copy of the original and certify it.

When I complained about the truncation issue as the reason for needing the original, they said that they were limited by their systems. I pointed out that it was good that George Herbert Walker Bush wasn’t born in my county because his middle names wouldn’t have fit either. The county clerk didn’t find that amusing.

Fast forward a number of years to last year when I applied for TSA PreCheck status. Guess what? TSA in 2014 had surprising character issues. I was told that if I wanted to continue through the application process, I needed to formally shift Sue into my middle name or they couldn’t process my application since “space” was considered a special character and wasn’t allowable in the first name field and they couldn’t run PeggySue all together because it wouldn’t match my passport. This meant changing my name on all my frequent flyer profiles.

Additionally I’ve had hundreds of issues with patient matching during system migrations and data cleanups, not to mention the HIE project. How many people with either longer names or those that are more complex than mine will look like different people depending on how the data was entered? Of course there will be other matching criteria, but it’s going to take a lot of work to meet their stated goals of reducing system duplicate record rates from 2 percent in 2017 to 0.5 percent in 2020 and 0.01 percent in 2024. It should be interesting to see where already strapped (or cheap, as the case may be) organizations find the resources to get it all done.

I still have more to read, but at least it’s more interesting than MU rules. What’s your take on the Interoperability Roadmap? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/12/15

All’s still relatively quiet on the ICD-10 front, so I’m catching up on other projects that have been pushed to the side during the transition. Most of my clients are seeing some sporadic claims issues, but nothing that is going to cause a major cash flow disruption. As long as practices have processes in place to monitor the revenue cycle and take action as soon as they see patterns forming, they should be fine, although it will take a good month to see how things are really working.

Some practices still haven’t sent a large volume of claims. I continue to be surprised when I see practices that don’t bill every night or don’t have requirements for their providers to complete charts in a timely manner. I don’t have a lot of visibility into how ICD-10 is going on the hospital space, so I look forward to hearing from readers.

I’m working on a lab project for a client. It’s the kind of project I enjoy – extremely detail-oriented, beneficial to end users and patients, but something that practices don’t seem to have time to deal with. Essentially it’s an analysis of their lab ordering patterns with an eye towards redoing their primary ordering screen and some order sets. The practice set up their orders when they went live on EHR in 2010 and haven’t touched it since. A lot has changed in the last five years. They’ve added vendors. Vendors have changed test codes. The community standard of care has changed. Professional organization recommendations have changed.

I’ve pulled all their ordering data and can manipulate it by provider, specialty, location, and time. Right now I’m working on the tedious (yet oddly satisfying) task of updating the vendor order codes to make sure they’re all correct. Luckily they’re using two national reference labs that were happy to provide me digital versions of their orders master. Unluckily, they’re also using a hospital lab where all the knowledgeable lab staff seem to be out of the office on an ongoing basis. They won’t give me their order master (citing “intellectual property”), so I’m at a bit of a disadvantage. I’m not sure how having a copy of the orders master is going to cause them harm since they have an online directory for providers to reference.

Their level of cooperation may also explain why the practice sends such a small portion of its business to the hospital lab. If their day-to-day service is anything like what I’ve experienced, I’d steer clear. One would think it was in their best interest to assist customers in cleaning up their orders, because every time they receive an invalid one, they have to call the office for a clarification. But I guess it’s like everything else with being short staffed. Additionally, I’m sure it didn’t occur to them to plan for the eventuality that if all their customers go to EHR, eventually they’re all going to have to update their orders masters. Interoperability seems like a great idea until you realize you don’t have the resources to support it.

Keeping vendor codes in sync can be a full-time job. Some of the national reference labs change codes as often as weekly. Some are better than others at telling you what codes have been retired or replaced. Others leave you guessing somewhat. I’m seeing some challenges, though, with the various vendors coming up with proprietary tests which can make it hard on the end users. Say a user wants to order a serum porcelain level (a common med school/residency joke). In many cases, the physician doesn’t care whether the test is run via liquid chromatography or liquid chromatography and mass spectrometry – they just want the value. For a large number of tests, the methodology doesn’t make that much of a difference.

Of course there are tests where it makes a tremendous difference and I would expect to see the methodology specified in the name of the test to make it clear. Labs, however, seem to be trademarking various methodologies – perhaps one calls it “PorcelainPure” and the other calls it “TruPorcelain.” It’s impossible for the end user to figure out what they’re ordering without going to websites and comparing. This becomes more of an issue when patients are switching insurance or employers (and therefore lab providers) and end up having serial tests done at different facilities. It’s also a problem when the tests really are equivalent but the labs have trademarked them as a marketing strategy. It’s getting to the point where we almost need generic and branded labs like we have for drugs. I’ve seen it become more complex even over the last two to three years, so I can’t imagine what the next decade will bring.

Once I get all the codes up to speed, I’ll provide them with a program to help keep the codes up to date. Usually I suggest monthly, but a lot of organizations aren’t staffed to keep up with that. They may elect to do it quarterly or twice a year. I stress that it should at least be done every six months or more often if the lab provides clear information on the nature of changes to its orders master. After that, I’ll start reviewing the data based on ordering patterns and we’ll really start doing some clinical transformation.

In midsize practices, it’s interesting to see how different providers order even when they share a specialty. I see a lot of variation in ordering of metabolic test panels. Some habitually order more comprehensive panels whether they’re indicated or not. There is also a lot of variation in cholesterol testing and pap testing. These are conditions where the indications are well identified in national recommendations and guidelines, so you can imagine what it looks like when we analyze ordering on less-common conditions and diagnostic workups.

There can be emotional minefields associated with analyzing ordering patterns. What do you do with your senior partner who is ordering tests based on outdated recommendations? Many groups are unwilling to deal with those kinds of issues head-on, so I end up creating educational programs where everyone in the group gets re-educated as to the current standard of care. Although it’s good to make sure everyone is following guidelines, it’s a tremendous waste of resources when everyone else is already in line and you could just deal with an individual directly.

There are a lot of people out there who never want to ruffle anyone’s feathers, which makes it easy to see why they’re having challenges delivering the kind of care they want to deliver and that patients expect. As the old saying goes, sometimes you have to break some eggs to make an omelet.

Once we analyze the ordering patterns, I’ll make suggestions on updates to the main orders screen and the order sets. We want to get the most commonly ordered tests in prime position for ease and speed of selection. There’s an art to it, though, because if you make too dramatic of changes, it can cause issues with muscle memory and the staff getting back up to speed.

We also have to figure out the timing and how we’ll train users, etc. There’s a lot more to it than just updating templates, and often my role is to help an IT team understand that. We need to give the users time to practice so they’re not hunting around when they’re patient-facing.

I’ll be working on this for a while, so I’m interested to hear how readers approach similar projects. Do you like your eggs over easy or sunny side up? Email me.

Email Dr. Jayne.