Curbside Consult with Dr. Jayne 9/19/16

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/15/16

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/12/16

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/8/16

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/1/16

I completed my HIMSS registration this week. This year’s registration has a space for attendees to list their Twitter handles so that they appear on registration badges. I don’t remember seeing that last year. I was sorely tempted to appropriate someone else’s handle just to see if anyone noticed, or to see if hilarity ensued. But alas, I went the conservative route and just signed up as myself.

HIMSS isn’t cheap for “regular” attendees. Even the early bird rate is $785, not to mention the mandatory $199 renewal of your HIMSS membership. I can’t complain too much, though, since it’s one of a handful of places that those of us that are board certified in clinical informatics can get our required continuing education credits.

As I went through the registration process, a couple of things struck me. The first was the addition of the “HIMSS Star Service” option for $149. It’s basically a concierge service offering assistance with booking at the hotels (on a space-available basis, so good luck with that) as well as coat check at the convention center and restaurant reservations. It also offers “help to design your tailored conference agenda, including social events and exhibitor appointments” and “exclusive tours on the exhibit floor based on interest.”

The show floor is already crowded enough with people standing in the aisles oblivious to those around them. I envision a Disney-style guide with a pennant leading a tour group around the hall. Maybe I should put out my shingle and offer “Dr. Jayne’s Tour of Cool Booths.” I already give party planning tips for social events, so it might be a natural next step.

Speaking of party planning, I recently had a negative email from a vendor rep who took issue with the fact that I didn’t mention their company’s upcoming user meeting when I mentioned the events of multiple other vendors. I write for HIStalk on top of my day job of running my own consulting business and my night job of seeing patients. Although I’m pretty good at keeping up with the industry, I don’t keep track of every possible vendor event. The best way to make sure that I know about your event is to tell me – and not with a mass email, but something personalized that shares interesting tidbits about it or helps me understand why it’s noteworthy. For HIMSS, actually inviting me to events exponentially increases the chances that I’ll swing by to visit.

The list of HIMSS events also includes multiple woman-focused events. I’m not sure how I feel about that. Although women are under-represented in many science, technology, engineering, and math fields, organizing events strictly around status as a man or woman seems problematic. Rather than seeing the Women in Health IT Networking Reception, I’d rather see other professional minorities addressed, such as an Ambulatory Informatics Networking Reception or Independent Physician Practice Networking Reception events. The latter is definitely a minority, for sure. There’s also the Most Influential Woman in Health IT Awards Dinner as well as the Disruptive Women Luncheon.

I’m not a fan of the naming of the Disruptive Women Luncheon and would think that its sponsor (a public affairs company that specializes in “creative communication”) could have come up with something better. Disruptive how? In the innovation context? In the grandstanding Jonathan Bush context? In the snapping-your-gum teenage context? In the context I saw this morning, where a disruptive man held an entire meeting hostage and prevented the rest of us from getting through the agenda? “Disruption” is an overused buzzword that needs to go and the whole idea of special women’s events needs to be rethought.

I’ve often joked about putting together a “Textbook of Organizational Pathology” with case studies based on my work life. I’m sure I have enough stories from my time at Big Hospital System to fill at least a dozen chapters, and then there’s the physicians and hospitals I’ve worked with since I started consulting. If I ever write it, there will definitely be a chapter on “The Art of Work Shirking.”

I had a prime example this week when working with a practice support representative at a large health system. The practice support team is charged with fielding questions about EHR use and associated technology that originate from the practices that the health system has gobbled up over the last decade. I’m supposed to be backstopping the department, identifying areas for additional education and assisting in putting together a training program for the new hires.

Due to the group’s growth, some of them are very green, but others are just lazy. I had just done a presentation on HIPAA and the need for appropriate use of secure messaging vs. text vs. email vs. voice mail for the team when I received an email from one of the support reps. She went overboard with praise about my recent talk and then dropped this gem: “I think I’m clear on how to answer the client question below, but wanted to know if you had any additional feedback.”

To be able to provide any “additional” feedback, I might need to know what she planned on advising. However, I suspected her of hoping that I’d just answer the question my own and save her the trouble of formulating a response, so I asked her what her advice was going to be. She responded immediately saying, “I don’t want to bias you with my response, I was just curious what you would advise.” Looking logically at this, I just taught the class on this, which her employers hired me to teach because of my expertise. Yet she thinks my response to a question might be biased by her ideas? It doesn’t even make sense.

I’m happy to help people who genuinely don’t know the answer to a question, who want me to critique their potential response, or who just need help. But then let’s call it what it is, and not try to be coy, using flattery and evasion to cover the fact that either you don’t know the material that was just covered in a class, that you spaced out during said class, or that you’re just lazy. I suspect she was also naïve enough to think I wouldn’t forward the exchange to her supervisor, who was appropriately irritated by her staffer’s actions. I’m continually amazed by the antics people try to pull using email, that I doubt they would try in a face-to-face conversation. They also forget that email is forever and easily forwarded.

What’s the worst example of work shirking you’ve seen lately? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/29/16

Many of us who work in the informatics space full time are attached to academic medical centers, large hospitals, large physician groups, or vendors. We’ve been working with electronic health records, billing systems, and interfaces a long time.

In my case, I was fortunate to work with a large health system that saw the value of electronic health records and data exchange long before Meaningful Use or any kind of payer incentive programs. We decided to move forward with technology because it was the right thing for us, allowing better data capture and the ability to track towards better outcomes.

Although I worked for a large health system, many of our employed physicians ran offices that looked a lot more like private practices than anything else. When I went into consulting, that was naturally one of my sweet spots, working with small to mid-sized practices that might not know much about informatics or the forces changing healthcare.

I still do work for large health systems as well, but my partner and I are fielding more requests from independent practices than we can handle. Quite a few of the requests involve things that most of us take for granted, such as lab interfaces. My most recent client has three physicians and six support staff. They outsource their billing functions and revenue cycle and use a major vendor’s EHR and practice management software on a hosted platform. Their installation is pretty vanilla, with very few customizations. They haven’t participated in the Meaningful Use program in the past, but with the increasing penalties for failure to do so, they have decided to start increasing their use of the system. They’re still not sold on MU, but want to be closer to ready in case they decide to take the plunge.

I’m not sure why they didn’t implement a lab interface when they went live. They are an internal medicine group and order a large volume of labs. I’m guessing that at the time they installed their system, they had been managing well with their paper orders workflow and basically just automated it. They do order their labs in the EHR, but print a paper requisition and either send it with the patient to the lab, or send it in the pouch with blood drawn in the office. The laboratory vendor delivers results through a Web portal, which they had been using pre-EHR and were comfortable with it. They print the labs, scan them into the EHR, and then the physicians manage them either through a telephone messaging template or by sending a letter to the patient.

It’s fairly efficient, although you can’t graph or track or trend the results. You also can’t mine them for outreach purposes, which is the key driver of their interest in having a lab interface.

Working with someone who knows why they want a particular feature and what they hope to achieve by implementing it is always a pleasure. There are plenty of groups who embark upon technology projects due to penalties or fear of penalties, and that makes it more difficult because the team may not have a sense of buy-in or understand why the extra work needed is valuable or important. This group wants to be able to easily identify patients whose lab values show that the patients need extra attention or need to be brought back into care. Most of us take this functionality for granted, so it’s been refreshing to work with someone who is seeing it through new eyes.

Although at times there has been a sense of wonder, there has also been significant frustration. The EHR vendor hasn’t been terribly helpful. The EHR vendor supports multiple lab vendors, but didn’t make it clear that some of the lab vendors have multiple business units with different lab compendia, so my client downloaded the wrong one. The client doesn’t have any dedicated IT resources and the vendor didn’t require the client to attend any training prior to attempting to install a lab interface, so they immediately wound up off track.

They hadn’t talked to their lab vendor about installing an interface prior to starting work with the EHR vendor, either. They got in touch with their lab account rep to figure out which business unit they were using, and the lab sent the required test plan as they normally would during an interface project. When the practice saw it, the project ground to a screeching halt because they didn’t feel they had the resources to take on a testing effort while doing their regular work.

The project stalled for several months until one of the partners decided to push it again, and obtained some referrals for consultants. There are at least a dozen consulting companies that work closely with the EHR vendor, so I’m surprised that no one on the vendor side had suggested that the practice go that route to get the project moving. They ended up contacting me because I was local, which ended up not really mattering since I’m not doing anything for them in person. All they really needed was someone to run interference with the vendors and help execute the test plan. Since they were already ordering and managing tests in the EHR, there was maybe 30 minutes of training to do for the staff.

I put together a bid and they were surprised at how small the effort really was. I quoted them 15 hours to complete the project from their side and it ended up only taking 12 hours over less than two weeks to get them live. However, when you don’t know what you’re getting into or how to accomplish what needs to be done, that 12 hours is a mountain. It stood in their way for months because they didn’t know how to get over it. Guides were available, but they didn’t know how to find them and their vendors didn’t suggest ways to get help.

I’m glad I was able to help them, but it’s sad that it took so long to get a simple interface live. There are hundreds of practices facing similar issues every day, and unfortunately they’re choosing to sell out to big hospitals or health systems because they don’t know where else to turn and are weary of trying to figure it out.

It’s like the Benjamin Franklin quote about the kingdom being lost for want of a nail. Having come from private practice roots, I don’t like to see physicians give up and sell because they feel there isn’t another option. They are struggling with things that many of us find routine, and that’s sad since the knowledge is out there it’s just not in the right place at the right time. Some feel it’s better that we move into larger organizations and the Accountable Care movement certainly supports that. But we’re losing a little bit of our identity as physicians along the way.

What do you think is the answer for small practices to keep up with technology? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/25/16

I missed the opportunity to write up the Greenway Health User Group Conference, held earlier this month in Atlanta. I was looking to find information on it when I stumbled upon the 2017 website, which is already live. In case you’re wondering, you have 377 days left to register.

Optum Health held their user group this week, featuring keynote speaker Michael J. Fox. I’m always interested to see what kind of client events are cooked up at these events. Wednesday’s client block party was set to feature a band called Hairball performing “the greatest hits from the most popular hair bands of 80s rock.” If you have pictures, send them along and I’ll share. Some year I’d like to take the fall off and attend all the user groups that I’ve heard about for years but never made it to. Most of us only make it to a couple of vendors’ meetings in the course of a career, so it would be interesting to do the comparison. Kind of like baseball fans that spend the summer on pilgrimage to ballparks across the country, I could be a user group vagabond.

Like millions of other people, I carry an EpiPen. I have a food allergy and thank goodness I’m an adult and can avoid eating things that might be suspect. It’s tougher on children with severe allergic reactions. I had heard a couple of months ago about dramatic price increases, but today my inbox exploded with client questions about the situation. Now that Congress is involved and calling for an investigation, the price hikes are mainstream news. My clients were mostly asking for assistance with reports to identify how many patients have been prescribed EpiPens so that they can reach out proactively to discuss the situation and make sure patients who need them are getting them. Another client asked if I could help them automate a process to generate prescription orders to substitute a similar product on affected patients. Even though the manufacturer is seemingly responding to a free market economy, it feels sleazy. I’m glad I was able to help my clients out from an IT perspective, but the situation is just sad.

CMS posted vendor global support letters for the Comprehensive Primary Care Plus initiative. I found the formatting of the letters odd, with all vendors strung together into a single PDF. Although they are in alphabetical order, the best way to find a particular vendor is to use your browser to search. There are a couple major vendors missing – hopefully their letters are just delayed.

It’s no secret that I’m skeptical about precision medicine and its ability to make a difference for large populations. I was pleased to see this JAMA editorial that tackles the issue. It calls out a number of important points: the presence (or absence) of disease is driven by not as much by genetics as by behavioral and social factors; the difficulty in identifying disease predictors for complex conditions; and the assumption that large groups of patients will change their behavior to modify their risk profile, when faced with the information.

We have clear and direct evidence on how to prevent many diseases and injuries (stop smoking, eat less, move more, wear your seat belt) yet it’s still difficult to move that needle. Our societal reliance on technology makes it easy to want to take a pill or use a laser or have robotic surgery, but not to do the basic preventive maintenance that the human body requires (sleep, exercise, healthy foods, etc.) The piece also mentions that the United States is lagging behind other nations in life expectancy and infant mortality, which are best addressed by broad-based rather than individual efforts. The funding of precision medicine initiatives corresponds with a decline in funding for public health efforts.

The authors go on to mention reasons why precision medicine might just be the answer: helping target resources to those who are most at risk; the economic and societal benefits of previous precision medicine initiatives (such as newborn screening for metabolic diseases); and the ability to use genomics to target infectious diseases, which have long been a part of public health efforts. The editorial concludes that although there are “clear tensions at the intersection of precision medicine and public health” there are ways to move forward. However, we might still find that old-school interventions on nutrition, poverty, healthcare access, and education may have more benefit than personalized medicine.

Although I’ve been generally skeptical, I’ve recently found myself in a place where personalized medicine may be relevant to my individual health. Although I’m waiting for results of genetic testing of affected family members, I’ve been combing through the literature trying to figure out what my options are depending on whether testing is positive or negative. Even as an educated, science-literate person, the evidence isn’t as clear as we’d like it to be and the process is frustrating. Depending on the results, I’ll likely have a consultation with someone other than the Internet, but for now that’s my approach. We’re also waiting on some copies of pathology reports from more than 20 years ago. It will be interesting if they actually show up in a timely fashion. The hospital doesn’t have anything in their electronic data repository before 1998, but hopefully we can track it down since it might make a difference.

What do you think of personalized medicine? Has it impacted your family? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/22/16

I wrote last week about preparations for a go-live I’m supporting. My client is a hospital that has had a stalled implementation of their inpatient EHR and decided to address it by completely re-implementing the systems rather than trying to tackle adoption system by system or provider by provider. Our official go-live started at midnight, although one could argue that we’ve had a soft live that’s been going on for several years.

Monday morning can be very busy at hospitals for a variety of reasons. Often major surgeries are scheduled on Mondays so that patients can recuperate and be discharged either to home or to another facility before the end of the traditional work week. There are many more providers on the floors than the weekends, as physicians resume covering patients that may have been covered by an on-call partner over the weekend. Additionally, patients may be coming in for tests that might not be performed on the weekends or were postponed because they weren’t urgent.

Many of the hospital’s component systems were already in full use prior to this project and that definitely helped things run smoothly. Knowing that your laboratory, radiology, communications, scheduling, bed management, pharmacy, and other systems would be under control definitely reduced the stress level for providers.

In walking through the nursing stations during peak rounding hours, the most stressed group of individuals were the unit secretaries and unit clerks. Many were concerned that providers would be hostile to them as they tried to redirect the providers to enter their orders using the CPOE module rather than accepting paper orders for transcription as they had in the past. Although we had a few providers who “forgot” that it was go-live day (not sure how they could have forgotten it given the hordes of support staff in bright green shirts everywhere one looked), those few were easily redirected to the computer for 1:1 assistance. Having enough hardware available for everyone to do their work was a critical piece of our strategy, and in looking at this morning’s statistics, we only had a couple of situations where people were waiting for a computer.

Speaking of statistics, we’re aggressively monitoring the provider roster and tracking who has logged in and what they’re doing on the system. We already have a list of physicians who were strong users prior to the reimplementation and I’m not very worried about them. However, as we see new physicians access the system, round on a number of patients, and use the various modules, we move them to a “live” tracking category.

As we prepared for this, we investigated the processes that the larger medical groups use to round on their patients – whether each partner sees his or her own patients or whether they rotate by day, week, etc. We know what those schedules look like and have a hit list of providers that we will need to be targeting over the next several weeks. With that kind of data, we can adjust schedules accordingly, reaching out to providers before their next rotation on the floors to make sure we have support staff ready to meet them as they start their days. Although conventional go-live wisdom assumes that the need for support will taper over time, their first day may be several weeks out and they will still need significant support.

In addition to dedicated support team members (a mix of IT staff, clinical super users working dedicated support shifts, and contractors) we’ve also identified clinical super users who are working their normal shifts and are prepared to field questions and assist providers. I often get questions on the best way to recruit and retain super users. This hospital took my advice that they should select nurses who have been proficient users for a long time and give them extra training on the physician workflow and how to best train and support physicians. The paid training sessions that they attended counted towards their average weekly schedule requirements, so they weren’t being asked to attend training on top of their already heavy shift schedules.

Additionally, they had to demonstrate a certain level of proficiency before they received the official title. I did lobby for additional hourly payments or cash bonuses for nurses working in the super user capacity during their normal shifts at go-live, but this didn’t happen due to contractual and tax issues. Instead, we’re doing our best to reward them with gift cards and other bonuses to make sure they know we appreciate their work.

The administration also took my advice to have leadership actively participating on the floors, even if they couldn’t field questions themselves. The CMO, VP of nursing, and CIO are spending a good chunk of time this week being out with the users and assisting in whatever way they can, even if it’s just dialing the desktop support team to ask for password resets.

Speaking of password resets, we did take the hard line of resetting the password of everyone who didn’t attend training. We did this immediately prior to our midnight go-live so that if they did try to use the system, they’d have to call in first and we’d be able to dispatch a support person to their location. We can also dispatch an administrator to them, ready to help manage any unpleasantness or reluctance to accept support. We knew we only had a handful of people in this situation, but they’ve been difficult in the past so we wanted to be prepared. So far, three of them have logged in and received on-the-job training without incident.

The physician super users we had previously identified were also out with their peers, delivering pre-scheduled 1:1 support for those physicians who were most concerned about the go-live. As expected, we saw that once those physicians were able to complete documentation on several patients in a safe and supported environment, their concerns were markedly reduced. Just talking to a few of the physicians involved, it seems that simply knowing that we have physician super users that are part of the informatics team and will be looking out for physician interests going forward has been a powerful factor in bringing reluctant physicians on board.

As I suspected, even though the system has been live for a while, having a greater number of users engaged has identified some defects and some concerns with some of the order sets. Physicians who hadn’t previously participated in the creation of the defaults are now concerned with their content, so we’re documenting those concerns and will invite those physicians to participate on the committees that approve content. What we’re not going to do though is create individual order sets for the physicians who are complaining. If there is a clear and compelling reason to add a particular order, it can be added to an existing set as optional. Leadership is on board with this and having solid decision making and change control will serve them best in the long run.

As far as the defects, we’re classifying them as technical, operational/workflow, or application and are involving the appropriate groups for expedited resolution. We did engage our vendor to have a couple of application specialists available (two on site and two remote) should we need them.

One of the other things we’re doing today is starting our post-mortem review of the go-live and our entire process. Even in the excitement and activity of a go-live, it’s important to start gathering that information and determining what worked and what didn’t work so that you have a jump start on the next project. One of the things that worked well here was including the business case for many features as we trained them. For example, requiring a diagnosis on every medication, not just an indication on PRN medications. Although this should be fairly straightforward, we explained exactly what the hospital was doing with that data – formulary management, pricing negotiation, patient risk stratification, and more.

We also did a lot of education around the use of discrete data and its impact on monitoring clinical quality and potentially on research projects. The majority of physicians had no idea how the data was being used beyond “because you have to” and that helped transform what might have been perceived as extra clicks into something of value. We also opened the door for physicians to receive more data about their patients and the work they were doing, including access to ad-hoc reporting on patients they are seeing in the hospital. Due to some previous physician engagement surveys conducted by the hospital, we suspected this would be a good approach.

We also did some specific pre-work to look at how providers wanted to be trained and where they wanted to be trained. We did perform some 1:1 offsite training for providers and I think that was a good way to achieve buy-in and participation. Although we weren’t resourced to do this for every provider, we did do it for those that specifically asked. During the design phase of the rollout, we also held listening sessions with providers who were concerned about the process. Many of them were under the assumption that this would create more work for them. We were able to present the actual workflows at those sessions, demonstrating that although the work would be different, it wouldn’t necessarily be more. They were able to see in person what we were planning and we believe this reduced resistance.

Although today has gone smoothly, we know this is a process and the needs will continue for the next several weeks until all of the active physician staff members have been to the hospital at least a couple of times. I anticipate some blips but think our preparations have been solid and we’ll be able to get through them.

Don’t you love it when a plan comes together? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/18/16

As a consulting CMIO, I often get asked to help organizations develop or refine their provider adoption strategies. Convincing people to do things that they don’t want to do can be tricky, especially if they’re not being incented to do so.

Creating incentives for employed physicians is fairly easy. Usually they are under contract and expectations regarding EHR use can be added to that framework. Creating incentives for independent members of the hospital medical staff can be challenging. Often we’re asking them to use new process that may add to efficiency for the hospital, but will lower their personal efficiency.

I’m working with a hospital that thought they could drive physician adoption strictly by saying use of the EHR was required. They had implemented various pieces of an EHR over the last decade, but use has always been optional. Physicians were allowed to continue writing paper notes that were scanned and they were allowed to continue writing paper orders that were entered by nursing staff or unit secretaries.

Because use of the systems (plural) was optional, the hospital never put the time and effort into ensuring that physicians had the training and support they needed to be successful. It was a vicious cycle of non-use costing them tens of thousands of dollars each year, so hospital administration simply decided that using it would be required.

You can imagine the revolt that immediately occurred with the medical staff. Physicians threatened to take their elective procedure business elsewhere, and did. High-dollar specialists left in droves. Now the hospital is trying to woo them back, having let some members of the administrative team go following the aftermath of their poor decisions.

I know the CMO from medical school, so he invited me in to work with them on a strategy to get things back on the rails. It was no surprise that simply “requiring” use of the systems drove providers away. Physicians weren’t presented with a compelling reason for the requirement; nor was it clear whether they were going to be retrained, supported, or left on their own to figure out how to document in the systems. Having been on the receiving end of bad policy decisions previously, they assumed the latter.

One of the first things I recommended was that we analyze their medical staff makeup, identifying what percentage of the physicians are using the systems as desired, and of non-users, how many were actually on staff when the various systems were originally deployed. Institutional memories can sometimes be short, and people were surprised to learn that the vast majority of medical staff members had joined long after implementation and training of the key systems was complete.

With that data, we were able to persuade the administration that we needed to essentially re-implement the systems. Rather than trying to target individual physicians, we’d do it over and do it right.

The VP of nursing was immediately on board since her staff had grown increasingly frustrated by having to support multiple workflows and data sources depending on the behavior of admitting physicians. The CIO was also on board, having had a sneaking suspicion that if physician adoption wasn’t achieved, leadership might decide that his systems were at fault and demand a replacement initiative. Another interesting result of the data analysis was that there was a small group of proficient users who could be leveraged to help move provider adoption in the right direction.

The CMO and I have been working together to use those power users as physician champions, helping their peers understand that fully using the electronic systems can actually make their rounding more efficient and reduce phone calls and interruptions for them. The excitement around re-implementing the system has allowed him to build a small clinical informatics team, so that the hospital has knowledgeable and trusted resources to not only help the physicians through the transition, but to carry them forward through all the changes that healthcare reform will surely throw in their direction.

Of those power users, we identified one with formal informatics training, who happened to be a community-based admitting physician. He had done a fellowship thinking he was going to go into academics, but personal circumstances put him in a small city where he didn’t think he’d get to use his expertise. He has been fun to work with, since he really gets it as far as what we’re trying to do and what else the hospital will need to accomplish over the next several years. He’s been a great help with the change management piece as we convince the physicians that this is the right thing to do for a variety of reasons, none of them being because someone said it was required. He’ll make an excellent CMIO if he’s ever willing to reduce his clinical commitments.

Rather than implementing the systems separately as has been done in the past, they’re treating it like a big-bang go-live, which I think is wise. That brings a lot more visibility to the project and allows us to have a greater number of support resources available for the providers – saturating them for the first few weeks rather than having fewer support liaisons for each of multiple system go-lives. The advantage for adoption this time around also includes the fact that the nursing staff has been live on the system for years, so they’ll be able to assist with some of the workflows that are common between nurses and providers.

Instead of only offering classroom training, we offered multiple methodologies including Web-based didactic, Web-based interactive, scenario-based training, classroom, and one-on-one. Over the last 10 years I’ve seen much more recognition of the different ways that people learn, and for those that have difficulty absorbing information, we scheduled the offerings so that providers could take advantage of multiple types of training if they found that what they selected didn’t work for them. Using this type of approach isn’t cheap, but when you look at how much they had been spending to run a fragmented, double-entry approach, it will pay for itself in short order.

I’m on site with them for the next few days, getting the command center ready for Monday and tidying up loose ends with provider preferences and favorites in the production system. We’re actually going live at midnight for in-house physicians and will be in full swing when the community physicians arrive for morning rounds. It’s been a while since I staffed a go-live like this and I had forgotten how exciting they can be. They can also be exhausting, and I’m sure by the end of next week I’ll be more than ready to head home.

Although it’s not a traditional go-live given the time the software has been in place, I’m sure having greater numbers of users doing many different workflows will still yield a number of bugs and issues that we’ll have to track down. Seeing this organization grow over the last several months gives me hope that they’ve arrived at a place where their technology and transformation efforts will be sustainable. It’s been a good recharge for me as well, since this type of work is where I got started. I’ll be on site next week and will let you know how it goes.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/15/16

There are a lot of people in the clinical informatics field who have participated in vendor focus groups and other information-gathering activities. Those can be a lot of fun as well as a great way to meet other physicians in the field. They can also be a great opportunity to see the “next big thing” as it evolves and makes its way to market.

I’ve made some good friends in the marketing space. They’ve introduced me to other organizations that might be looking for some physician input on their product campaigns. Over the last year or two, I’ve had the opportunity to work in depth with a couple of organizations.

The first engaged me to assist with questions around their functionality. Although they had a strong development team, their clinical input was limited to a handful of informatics physicians and end users of their current product. This is fairly common with startups, who might not have the to put a physician on the payroll. Sometimes they do have the funding, but are spending it in areas other than clinical expertise, and it becomes my challenge to help them see the value that regular physician input might bring to their products and their development process. It’s much easier to have someone who can vet your designs immediately rather than having them get close to release and be shot down by a focus group because you missed the mark.

In addition to working with them on product development, they also engaged me to assist in marketing efforts and in ensuring that the script for their product demonstrations was both medically accurate and clinically relevant. I can’t understate the value of having solid clinical input in this area. There is nothing that causes a physician’s brain to shut off like being presented with a clinical scenario that makes no sense or is insultingly dumbed down. It’s one thing to use a straightforward scenario, like a visit for an acute illness, so that you can highlight the product’s abilities and not distract the user’s attention. But it’s another thing entirely to work through a scenario choosing nonsense data, explaining it away “because it doesn’t matter.” Especially where features such as clinical decision support are involved, the information needs to make sense for it to be believable.

They were also one of the more fun groups I worked with. They brought me back to do some product naming work, and although none of the names we came up with in our working session were ultimately chosen, it was exciting to be part of that process and to use the creative side of my brain. I was so proud when their product launched and every time I see it in the wild, it’s fun to know I had a hand in it.

My next adventure was with a startup EHR company. One of the founding partners fully realized that they needed physician input to ensure they were spending their clinical development resources wisely. Unfortunately, the other founding partner was not completely with the program. They were more interested in bells, whistles, and flash than they were in creating a product that could meet the needs for complex documentation, and what they ultimately produced could be described as Franken-EHR. Parts of it were beautiful and glossy, but lacked the clinical functionality that physicians want these days, such as the ability to link scanned images to open orders. Other parts of it were intended to allow robust documentation with plenty of discrete data, but ended up being a complete and total click-fest. Yet another piece of it looked as if it had been clearly lifted from another vendor where a third founder had once worked. I realized a bit later that it had – when I went to remove some of their code from my laptop, I found that one of the embedded components had a license linked to another vendor. Oops!

Another group engaged me to help recruit clinical participants for a focus group. I’m also working with them to gather materials to use when the group meets. The project is primarily around selecting images for a redesigned website and some marketing slicks. I’ve been visiting quite a few competitor websites to identify potential points that might resonate with physicians so that we can present them to the group. In the course of that project, I’ve stumbled on some great marketing efforts and also on some that are truly awful. One made me question whether the vendor (who happens to be large and very successful) even had marketing professionals involved in the creation of their materials, or whether they just threw some stuff together.

In putting together stats about the clinical representations – whether they showed the physician practicing, with a patient actor, or in home/leisure pursuits – I was struck by how much stereotyping I saw in some of the ads. The majority of the physicians represented were white males, with leisure pursuits of golf and skiing represented. One did have a physician testimonial showing him having more time for his grandchildren, which was a nice change. In the majority of campaigns I’ve viewed, women are largely featured in supporting roles as are non-white males. That certainly doesn’t look like the medical world I practice in. I was surprised at how often I saw those patterns.

My absolute favorite marketing piece (in the humor category) was all around being able to see your schedule from anywhere. This was primarily funny because pretty much every single product these days has that feature, so it’s hardly a market differentiator, yet the company had latched onto that idea and featured it prominently on their home page. It was even more funny because they included an embedded animation with a clinician at the gym, lifting weights. He stops in the middle of a set, grabs his phone, makes a couple of taps, then does some kind of smile/chuckle thing.

I don’t know about the rest of the clinicians out there, but it’s rare that I look at my patient care schedule and chuckle. It looked more like he was seeing an inbound text or a witty Facebook post, and the whole “multitasking at the gym” thing just felt a bit off-putting. We’ll see what the focus group says, because we’re going to include similar content to see what the participants think. If they’re anything like the physicians I talk to regularly, they’re more likely to be checking their schedule while they’re in the carpool line trying to drop off their kids at school, or while trying to hustle to the hospital to round on patients over lunch. Either way, once a feature becomes commonplace, I’m not sure why you’d market around it, but at least we’re going to find out if we do want to market a time-saving feature, what the best scenarios might be.

With the consolidation in the EHR market and the boom in add-on solutions, there is plenty of marketing out there. I’d be interested to hear from readers what kind of marketing they feel hits the mark, and what should be sent to the hall of shame.

Got marketing stories? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/11/16

It seems like every year I run into some kind of trouble with my HIMSS registration. I learned quickly that you have to make your hotel reservations early. When I went to make them this week, I quickly ran into an issue. It seemed like every hotel I looked at was sold out for Wednesday on. Mind you, the conference runs Sunday through Thursday.

No matter how far away from the convention center I looked, the blocks looked the same (except for a few of the pricier hotels). I looked on the hotel’s direct registration site as well, but it didn’t even appear as available on my desired dates. I went ahead and booked to depart Wednesday, since I didn’t feel like switching hotels.

I’m not sure what prompted me to do it, but today I went on the hotel website and tried to book for just Wednesday. Guess what? Rooms available, and lots of them! Apparently the HIMSS block only extends through Tuesday night, which seems pretty ridiculous for a conference that runs through Thursday. Needless to say, I have two reservations at the same hotel for adjacent dates. From experience, this will likely turn out fine, but it’s just one more needless aggravation. Especially for those of us paying out of pocket for the less-than-cheap experience, it’s doubly annoying.

Hot on the heels of my recent Curbside Consult addressing the gap for professional development for healthcare workers thrust into IT roles, ONC will host an informational webinar covering the Workforce Training Program available to healthcare IT professionals. It specifically says it will address new training programs available “to help health care workers and others stay current in the changing healthcare environment.” Training includes both online and in-person sessions and have been organized to address IT skills needed by various members of the care team. The webinar is on August 24 and registration is open. I’d love to hear from anyone who has firsthand knowledge of the Workforce Training Program.

I had mentioned back in the spring that I was waiting for Ringly to release a silver version of its bracelet. They put one up for pre-order a couple of months ago, so I took the plunge. I knew they wouldn’t be available until fall, and with everything that has been going on for me recently, I somewhat forgot about it. I was happy today to see a sneak peek of their packaging, so at least they’re getting closer to shipment. I’ll definitely do a product review once I have it in hand (or on the hand, as the case may be).

Speaking of fashion, Jenn alerted me this week to a recent statement by the American College of Surgeons regarding appropriate professional attire. Highlights include:

• No dangling masks
• Operating room scrubs worn outside the operating room should be covered with a clean lab coat or other “appropriate cover up”
• No operating room scrubs outside the hospital proper
• Operating room scrubs should have a distinctive color so violations of above are obvious
• Soiled scrubs should be changed before speaking to family members
• Scrubs should not be worn for encounters outside the operating room

I’m always horrified when I see people in surgical shoe covers outside the hospital because you can’t wear them back into the operating room and who knows what has been tracked out of the OR. I’d have liked to see something specific to that, although I bet they thought they implied shoe covers when they addressed scrubs.

There was a nice section on the wearing of the surgical skullcap as symbolic of the profession. It didn’t go into a debate on the use of the skullcap vs. the bouffant cap, which was a detailed topic of conversation during my surgical rotations as a student. The last surgeon I interacted with (as a family member agonizing in the waiting room) was wearing a Saints cap, which was appropriate given his recent fellowship training at Ochsner. I wasn’t that impressed, however, by his white rubber rain boots, into which he had tucked his scrub pants. It was a unique look that got more than a few funny looks by waiting loved ones.

I also received some updates from the Aprima user conference, which was held last week in Dallas. Apparently they were sharing hotel space with a Mary Kay cosmetics conference, where some attendees sported beauty queen sashes and tiaras. My correspondent said it reminded her of HIStalkapalooza. Educational highlights included Chronic Care Management tools, Patient-Centered Medical Home pre-validation, and MACRA readiness. There was also a Casino Night social event as well as the opportunity to help make blankets for the Children’s Medical Center in Dallas. Sounds like a good time, even with the Texas heat.

The annual user group season is upon us. The Allscripts Client Experience is going on this week in Las Vegas including a party on the Mandalay Bay beach. Next, Epic will host their “An Adventure in Wonderland” event September 19-22. Anyone want to lay bets on Judy being costumed as Alice? NextGen is holding their annual event November 6-9 in Las Vegas, with attendees hopefully remembering to absentee vote since their client event is being held on election night. Cerner rounds out the fall with their meeting November 14-17.

What makes a user conference worthwhile for you to attend? What’s the best social event you’ve experienced? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/8/16

I started my consulting work assisting small practices and that’s still the sweet spot for a lot of my consulting business. My partner does much more revenue cycle work than I do, so he sees more large clients than I do.

Based on what I hear from my clients and their needs, there are numerous areas where our current incentive programs have missed the mark. While they’re encouraging providers and organizations to try to improve clinical quality and reduce costs, they’re not providing much support to organizations who are struggling to actually get the work done.

It feels like we need a second push for organizations like the Regional Extension Centers. The RECs were initially aimed to assist practices through the EHR adoption process, including vendor selection, implementation, and achievement of Meaningful Use. Although the larger healthcare organizations and larger provider groups are doing well, many smaller groups either stalled along the way or failed outright. In working with practices over the last several years, I see some themes. Although some are technology related, many are related to a lack of business and operational skills among quite a few physicians.

Of course, this doesn’t mean all physicians – many are quite savvy and run highly-functional practices. Some of my best physician friends are MD/MBA type individuals who can tell you the exact cost of the services they provide and can closely predict what their profit margins will be prior to adding a new service or expanding their practices. They are successful at managing their employees and developing staff to be able to adapt to the changing healthcare environment.

Others need a tremendous amount of help, and maybe something like a REC to assist with the non-technology needs could be of benefit. Although some of these services are already provided by state and local medical societies, risk management vendors, and of course consultants, practices often feel like they are having to cobble things together to meet their needs. Then again, there are the needs they don’t even know they have, which aren’t necessarily recognized by assisting organizations with a narrow discipline.

Physicians don’t inherently know how to take members of a clinical or operational office staff and turn them into technical support or technical assistance resources. Even though practices could hire consultants or use vendor resellers or other third parties to fill that gap, often the perception is that the cost is prohibitive. Groups then try to use their own in-house resources to manage complex projects such as Meaningful Use, PCMH, PQRS, and accountable care participation. Often these assignments are under the “other duties as assigned” category that staff members struggle to achieve on top of their regular job functions.

Adding to the problem is the increasing turnover that we’re seeing in many primary care practices – often these offices are running on a shoestring, and may choose their resources based on cost over quality. It’s hard for any business to balance this, but when you have a physician-owned practice where the business skills are lacking, this becomes increasingly difficult. Owners may have difficulty explaining expectations and may underestimate the complexity of what they’re asking their staff to do, or the skills required for success. This can lead to cycles of failure when staff members become frustrated and leave, so the process starts over and over again.

Although some vendors offer support and assistance in these areas, the quality of help provided varies dramatically. Even with the best vendors that offer free staff training and ongoing learning opportunities, I see practices struggling to help their employees find the time to even attend sessions, let alone master the skills needed to change how a practice operates. This process is challenging enough when the practice is committed to a certain course of action, but when you have practices that are fractured in their approach, it becomes even more difficult. Maybe the partners don’t agree on how quickly or fully the practice plans to transition to value-based care; maybe there are members of the staff that openly sabotage efforts; or maybe everyone is just not on the same page about how things should be accomplished.

I’m happy to be part of the solution to the problem and have held the hands of many providers as we have moved into this journey. As a small consultant, I’m a lot more reasonable from a cost standpoint than some of the larger firms, but I can also only assist so many groups at a time. I take the primary care approach to helping offices solve their problems – serving as quarterback to get it all done, while looking out for the overall health and well-being of the practice. Similar to the original intent of the RECs, maybe we could benefit from a public health approach to solving the problems practices face as they try to transform how we deliver healthcare in the US.

Most of the incentive programs place the burden on the providers – perhaps they assume that physicians are smart enough to figure out how to make it happen. The reality is that everyone has different skill sets and some of us are better than others at putting all the pieces together and driving change. Some know to reach out for help (and can afford good help) but others continue to struggle.

I would hope that as rulemaking processes continue and we continue to make the process more and more complicated, that someone would think it would be a good idea to put additional resources behind helping providers make it happen, not just telling them what needs to be done. There may have been an assumption that vendors would assist, but that hasn’t fully been borne out for smaller practices. As the old saying goes, Rome wasn’t built in a day. Massive undertakings like transforming the healthcare system require an enormous amount of resources as well as strong leaders who are willing to help people be successful rather than just telling them to get to a destination.

What’s the solution for helping providers achieve success? Is there more we can do? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/4/16

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

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

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

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

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

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

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

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

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

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

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

What gives you a little boost? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/1/16

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/28/16

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/25/16

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/21/16

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.