Curbside Consult with Dr. Jayne 5/16/16

I’ve been doing a fair amount of travel lately, which usually ends up in administrative tasks being pushed to the side. Although I try to handle things real-time on the road, there are always things that accumulate at home.

I spent most of the weekend playing clean-up, doing such exciting things as organizing documentation for my accountant and making appointments for automotive maintenance and piano tuning. Being in a world where everyone wants to do everything online, I dread having to do business with people or organizations that insist on doing business by phone, yet have limited working hours. I also spent several hours getting information together for a financial planning session, but putting the documentation together just made me wonder if I’m ever going to be able to retire.

With all the turmoil of MACRA, MIPS, and the never-ending parade of acronyms that I’m sure will continue, I don’t have to worry about having enough business as a consultant. I probably work a little more than I want to, partly because I’m still playing catch-up with retirement planning, owing to the decade that I spent with student loan payments that prevented more than minimum savings.

I do some career counseling for pre-med students and always make sure to bring up the debt aspect for those considering careers in medicine. I’m hopeful for the future when I meet with young, idealistic go-getters who are ready to save the world. However, I find that most of them haven’t thought about all the ramifications of becoming a physician.

It’s graduation time, and thousands of recent grads are going to be packing up and heading off to medical school. Although there are more so-called “non-traditional” students in the ranks, the majority of medical school students come straight out of college. Once school starts, they’re immersed in a world that demands all their time and can wreak havoc on families, relationships, and personal well-being. Although there are safeguards now with regards to work hours and student and trainee supervision, it’s still a very difficult path for anyone to choose.

A non-medical friend came across this piece on bullying in the operating room and asked whether I had ever experienced that kind of treatment. Although it was never directed at me, I definitely witnessed it, especially in high-stakes specialties such as surgery and critical care. I did personally experience bullying that was less dramatic but no less distressing. Although those kinds of behaviors are less tolerated now than they were when I was in training, they haven’t gone away.

Organizations spend a great deal of time and money working on cultural problems. For people to do their best, they need to feel like they are part of the team and that their participation matters. They need to feel like their work is meaningful and that the people around them value and appreciate their efforts. Sometimes changing culture isn’t enough. In the case of bullying, there need to be clear policies and procedures around what is and is not acceptable behavior in the workplace. Those who break the rules need to be subject to corrective action that is applied evenly regardless of job title or political status.

When an organization aims to change its culture, it needs to do more than just pay lip service to the idea. I see a lot of groups just going through the motions, saying the right words while they take the wrong actions.

One hospital I worked with hired a vendor to deploy an electronic employee engagement platform while completely missing the point about what their employees wanted and needed to feel valued. They didn’t want to receive boilerplate e-cards – what they really wanted was meaningful feedback from their supervisors during the course of their day-to-day work. They didn’t want to hear about their “total rewards” when the organization eliminated personal days and the ability to roll over sick days from year to year. They wanted to believe that the leadership understood them and their needs.

I worry that the increasing stresses to the healthcare system will further strain employee morale as organizations are going to be asked to deliver more with resources that are already strained. For those of us straddling the tech and healthcare worlds, it’s increasingly difficult to watch tech vendors offer their employees perks such as unlimited vacation and gourmet employee catering when hospitals are cutting benefits and front-line clinical staff barely get lunch breaks. I think some of these vendors have forgotten where the money comes from – ultimately it’s all funded by you and me, whether we’re funding it as patients, payers of insurance premiums, or as taxpayers.

It’s not just IT vendors that are guilty – plenty of organizations are feeding at the healthcare trough. Even though we hear about the most egregious examples of drug markups and Medicare fraud, there are countless examples of profiteering. I recently overheard a conversation in a hospital cafeteria where a medical device sales rep was talking about his new Porsche. Although I believe everyone should have a chance to be successful and should enjoy the benefits of their hard work, bragging about it at a table within earshot of patients who might be choosing between paying for medicine and purchasing groceries is just tacky.

This is the environment that our idealistic future physicians will be faced with as they start their training. I can’t even fathom what healthcare will look like in four years when they complete medical school, let alone in seven to 10 years when they finish residencies and fellowships. Will we see mass exodus of seasoned physicians? Will we see mid-level providers and ancillary professionals delivering an increasing percentage of care? Or will physicians opt out of the new world order and go back to delivering care the old fashioned way, with direct payments from their patients?

What does your crystal ball show for the future of healthcare? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/12/16

I spend a lot of time hearing physician complaints about EHR usability. It’s certainly sensitized me to the issue of usability in general.

Let’s face it – there is some pretty poor software out there, in all spaces. There are some websites I visit that just want to make me scream, especially ones that use technology reminiscent of Geocities circa 1990-something. No matter what industry one works in, if you have to use something day-in and day-out that makes your life harder, you’re not going to be happy.

I was grateful today that I only have to renew my state controlled substance number once every couple of years. It’s bad enough that I have to register with both the federal Drug Enforcement Agency and also with my state, but their website put me over the edge.

I knew it was going to be a pain when the login screen told you to make sure you had enough time to finish the renewal because the system might time out on you. Then, it told me to turn off my pop-up blocker, but not until I had been through multiple screens that had to be resubmitted when I arrived at the pop-up step. They also introduced new fields that had to be completed for each practice location — fields detailing the number of hours per week spent in various activities such as patient care, ambulatory administration, inpatient administration, research, etc. Since I work a varied schedule at more than a dozen sites, this meant pulling numbers out of the air to populate more than 72 fields.

Additionally, when you save each location, it fires a popup that tells you that you need to complete the fax number for the location if it has one, despite it not being a required field. That was another 12 clicks and 12 screen refreshes that I didn’t need to do.

The final usability flaw was when I arrived at the credit card payment screen. Although it leaves the card number and CVV fields blank, it pre-populates the expiration date. If you’re like me and either multitasking or simply get distracted, you look back and the expiration field has numbers in it, so you move on. Unfortunately it then pops up that your card is expired, and sends you back three screens for you to re-key the information.

It felt like an exercise in futility, but what’s a girl to do? Complaining to the board that regulates your ability to prescribe certain drugs feels like you’re just asking for an audit. There’s no competition and no choice, so you just have to pay your fee (which feels like a cash grab, since we’re already regulated by the DEA) and be happy about it. Or if not happy, at least resigned.

On the opposite side of the usability chasm, there are plenty of vendors who are actually getting it done. One of the things I enjoy most about HIMSS is checking out emerging solutions and looking at vendors that are trying to break into the market with something novel. It doesn’t always have to be a “gee whiz” product. but it might be just someone who is doing things better or slightly different than the people who are already in the market.

I recently had a chance to look at iScribeHealth and learn about their journey to market. Their mobile app solution is an adjunct for EHR documentation. It allows providers to enter key data elements such as medications, problem list updates, histories, and more without using the EHR. It also supports dictation and charge entry.

They recently took their first batch of clients live. It’s quite different moving from the development phase to the real world and I’ll be interested to see how things go over the coming months. They’ve got some good hooks in their marketing material – encouraging users to “free yourself from late nights spent updating patient charts and wishing you had chosen a different career path.”

They’re also pushing the patient engagement aspect, allowing physicians to focus on the patient at the point of care and not on the technology. They also have automated reminders and surveys to connect with patients outside of the visit. Personally, they had me with their martini glass icon. Who doesn’t like a cosmopolitan in their daily workflow?

Just when you thought you had recovered from HIMSS16, it’s time to start planning your submissions for HIMSS17. The call for proposals opened last week and runs through June 13. They’re also looking for reviewers to take a look at all the content submissions during the summer months. I’ll let you do the math on how many months it is from the time the submissions are due until the actual presentation and determine for yourself whether it’s easy to keep things fresh with that kind of lead time.

I’ve previously been somewhat down on the American Academy of Family Physicians and other organizations for enabling some of the negative forces impacting physicians today. They have posted some introductory modules covering MACRA and the shift to value-based care. I appreciate their taking it down to the basic level that many physicians need to try to understand what’s about to happen to them.

In people news, today the National Institutes of Health announced the appointment of Patricia Flatley Brennan, RN, PhD as the new director of the National Library of Medicine. She has a long history in the informatics community. I find it most interesting that her doctorate is in industrial engineering and she has worked to leverage that knowledge in health care. The best implementation director I ever worked with was a ceramics engineer by training, so I appreciate what that background and mindset can bring to the table.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/9/16

John Halamka’s discussion of the MACRA NPRM was the topic of conversation at the client I was visiting last week. I’m working with them on a strategic planning engagement and am primarily in contact with senior clinical and operational leaders. People kept referencing it throughout our meetings on Friday and I saw the email link go around at least three times. You can always tell who works their email from oldest to newest and who works the other way by how they forward things that many others have already commented on.

In non-written discussion, it was interesting to see how the content of the blog morphed as it was passed from person to person. By the end of the day, Halamka was alleged to have made a call for physicians to boycott Medicare or quit practicing altogether. He didn’t exactly say this, although he did say, “There are probably only two rational choices for clinicians going forward – become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.”

Having been a salaried employee trying to run a primary care practice within the health system’s model, I’m not sure the former choice is entirely rational. Being employed isn’t always the answer. I have worked with physicians at health systems whose conservative and risk-averse nature caused them to significantly over-interpret the requirements of Meaningful Use to the point where practices were collecting completely unneeded information that no one ever looked at. Physicians in employed models often have little control over things like staffing ratios and productivity expectations, which frequently leads to physicians doing busy work because they are either inadequately staffed or have the perception of inadequate staffing.

As someone with experience in the DIY realm, I appreciated his analogy that, “Sometimes when you remodel a house, there is a point when additional improvements are impossible and you need to start again with a new structure.” That analogy should extend past MACRA and MIPS, however, to our entire healthcare delivery system. I do think we’re reaching the point where we’re spending such a high proportion of our resources on a system that isn’t delivering for our patients. Taking a 20-pound sledgehammer to it might not be such a bad idea.

Although Halamka wasn’t making a wholesale call for people to quit practicing medicine, he did say that, “As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.” I agree with him that it will be nearly impossible for organizations, whether small or large, to implement the rule as written on the timeline that is proposed. Having a final rule come out in November for implementation the following January with a full-year reporting period is absurd. How long did we give merchants to make the switch to chip-enabled credit cards? How long did we give states to implement the provisions of Real ID?

I’m eager to see the comments that are submitted regarding the proposed rule. Many physicians are finally feeling like it’s time to start fighting back, but others are selling their practices or just leaving. I spent most of my family’s Mother’s Day gathering hearing from relatives that aren’t happy that their physicians have retired, with one commenting that a successor physician “doesn’t have the knowledge in his whole hand that Dr. X had in his thumb.” Another lamented that her physician had joined a practice doing some “double billing,” which turned out to be provider-based billing because the physician’s office is considered an outpatient department of the hospital.

I also heard yet again about poor quality care being delivered because a physician is treating statistics rather than treating the patient. I’d love to call my grandmother’s physician and ask him exactly why he thinks tight glucose control with multiple meds is the right thing to do for a nearly 90-year-old patient who recently developed diabetes. Rather than sending her to the specialist to work up a possible inner ear cause of her dizziness, maybe he should have listened to her history of low blood sugars as a potential cause.

I’ve offered multiple times to go with her to her appointments, but she refuses, partly because she doesn’t want to inconvenience me, but partly because she’s of a generation that doesn’t dare question the doctor. Knowing the group he’s a member of, I can bet that the fact that his bonus rides on patient lab values might be playing a role in his decisions with her. Of course, he could exclude her from the calculations, but again knowing the group and their EHR, that would probably take too many clicks if he even knows how to do it.

It’s a fairly depressing time to be in medicine. I enjoy seeing patients and am lucky to work for a great group, but overall, morale is at an all-time low. More than half of the physicians that were in my residency class have left primary care. Most of those that have remained have changed employers at least a couple of times. Everyone seems to be looking for something better, but they don’t seem to be finding it.

There is one little ray of sunshine in the proposed rule, but I didn’t really process it until I read Dr. Halamka’s summary. That’s the change in wording from Eligible Professional to Eligible Clinician. At least someone, somewhere, remembered that those of us that are actually caring for patients are clinicians rather than just nebulous “professionals.” I like it. It also identifies the broadened scope of professionals covered by MIPS, although it’s not catchy enough for me to change my Friday post from EPtalk to ECtalk. Whenever I hear “EC” together, I think of the E-C clamp technique that you use when you’re using a bag-mask to ventilate a patient. That’s just another sign of how doctor brains work – only one of us would think of something like that.

What caught your eye in the proposed rule? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/5/16

Most of my colleagues are lamenting the proposed rule for MIPS and APM, citing the control that CMS is going to have over their day-to-day practice of medicine. I didn’t know until Wednesday, though, that the reach of CMS went even farther into the realm of fire safety. A newly-released final rule applies to hospitals, long-term care facilities, critical access hospitals, inpatient hospices, ambulatory surgery centers, religious non-medical healthcare institutions, programs for all-inclusive care for the elderly, and intermediate care facilities for individuals with intellectual disabilities.

The rule adopts provisions from 2012 fire codes. Unlike the MIPS rules, which require all kinds of work prior to January 2017, this rule gives facilities 12 years to come into compliance with sprinkler requirements. It also regulates the kinds of home décor items allowable in long term care facilities.

NCQA has weighed in on the proposed rules to implement MACRA, coming out in support, which is not surprising. They specifically cite independent third-party validation of Patient-Centered Medical Homes and Specialty Practices as a plus. If there is one thing that does make sense about the proposed rule, it is that patient-centered care is a winner. Practices that aren’t sure what they should be doing might want to consider a serious look at the models if they haven’t already.

I’m doing quite of bit of work lately with a customer who is switching EHRs. It always amazes me how easy people think this is, before they actually dig into it. The receiving vendors tend to over-promise on their ability to lift the data from the old system and place it into the new system in a usable fashion. Of course, they don’t mention that this often depends on the willingness of the legacy vendor to participate. Sometimes the legacy team will perform the data extract and sometimes a third party is used, but there is at least some baseline cooperation needed, especially if the legacy system is hosted.

Depending on the quality of the source data, there may be some degree of massaging of values to map to new data formats. Sometimes this requires clinical input, which can be extensive. When organizations look at the cost of physician time needed, it may impact decisions on how much data an organization decides to bring forward.

In this particular situation, the client is using a third party to perform the extract and manipulate the data so that the receiving vendor can perform the database insert. My client was concerned about some of the proposed mappings, so they asked me to take a look. I immediately identified some issues, and when I asked about them, the extract vendor became evasive. That’s never a good sign.

Working on behalf of the client, I asked to be put in touch with their clinical resources who were processing the data. It turns out they are using people who aren’t necessarily clinical. The extract vendor is actually operating from his home in a resort town in Thailand. On one call, I’m pretty sure I heard waves lapping in the background.

I asked the client to also reconsider their scope for the extract. They had been planning to move all the clinical data, but given that they have more than 15 years of data in their legacy system, it might not be the best clinical decision. If there are issues with data, it’s a lot easier to correct the most recent three to five years of data than trying to manipulate decade-old data that might involve drugs that no longer exist or diagnoses that are no longer valid.

We had already had a very difficult conversation about using the new system as their archive. They had originally planned to migrate all their patients, even if they were expired. It remains to be seen how this is going to work out, but the extract vendor is supposed to be working on another data pull for the client to review with me. I hope they’re successful, but in the immortal words of Han Solo, I’ve got a bad feeling about this.

AMIA has announced its InSpire 2016 event, which is specifically dedicated to informatics educators. Expanding beyond the Academic Forum, the conference is seeking submissions around education innovation. Additional topics include academic career advancement, informatics for curriculum developers, research, and data science.

DocuTap is hosting its annual user group June 15-17 in Sioux Falls, SD. It should be an interesting meeting since they were just acquired by private equity firm Warburg Pincus. The event is free for clients and includes sessions on telehealth, analytics, and target-marketing to payer specific patients. I got a kick out of their “20 reasons to attend” document which included the ability to take extra time off to visit Mount Rushmore and the Black Hills, noting that it is an additional five-hour drive across the state.

Next week is National Nurses Week, held May 6-12. Being in clinical informatics, I’m proud to work with quite a few informatics professionals who are nurses, as well as nurses who specialize in nursing informatics. I’m also eternally grateful to the nurses at St. Somewhere who saved my backside repeatedly during my first rotation in the coronary care unit as a resident physician. They taught me a tremendous amount of real-world medicine.

They also taught me the value of respect – they knew I respected their judgment and knowledge, so they batched their questions for me throughout the night so I could get a little sleep (unlike my counterparts who got paged every 15 minutes because they were jerks).

Has a nurse made a difference in your career? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/2/16

Since the release of the proposed rule for MACRA, many of my colleagues have been heads down trying to digest the content and figure out how to operationalize the requirements. While some organizations are taking the proposed rule and running with it, others are adopting a “wait and see” approach given the anticipated volume of negative comments from the public. They’re hoping that things will change prior to it becoming final, which is always a possibility given this crazy environment in which we all now operate.

Although CMS talking heads have said MU is dead, it must be zombie-dead. It’s just been reinvented as “Advancing Care Information,” which although more flexible than MU, is still too daunting for many practices. Physicians will not be accountable for cost category measures from claims data as well as being pushed towards further tracking and reporting on PQRS.

There are two tracks for physicians, with CMS expecting that most providers will be in the MIPS track vs. Alternative Payment Models. The numbers I saw estimated were 700,000 vs. 60,000, respectively. Unfortunately, providers will have to decide wither to submit under MIPS before they know whether they qualify for the APM track. Many organizations will be doing a belt and suspenders approach.

Several of my friends that work at vendors are extremely stressed out, realizing that federal requirements will dominate development efforts over the rest of the year. Just when they had breathing room to work on usability and customer-requested enhancements, they’re going to be forced back to the grindstone to crank out code that may or may not be what their customers want or need. Vendors have to walk a fine line between speculating on what will be dropped from the final rule and running full speed to get it all done.

Some vendors will start working on the requirements whether or not they think they’ll be modified. Given the way the last few rulemaking cycles have gone, even if a particular element gets taken out of the final rule, it will likely rear its head in a subsequent rule or in another program, so this might be a wise approach. On the other hand, if the rule is substantially modified, there is a risk of significant wasted development efforts. Once the comment period closes, it will be several months before we have a final rule. My friends with crystal balls tell me we’ll have the final rule in October with it taking effect in January. If that timeline holds, there won’t be much time for vendors to shift gears if the modifications are significant.

In the provider space, there is a tremendous amount of chatter about this being the last straw for small or independent practices. The requirements are daunting, especially for practices who haven’t been at the forefront of payment reform efforts. Just trying to read and understand all the rules and keep track of all the FAQs we’ll undoubtedly see could be a full-time job. As CMS goes, so go the commercial payers, and I expect we’ll see them ratcheting down on physicians as well. I’m still trying to fully absorb how this will affect my own practice given that we opted out of MU and haven’t looked back.

One of my colleagues brought up a good point. Although providers may not be ready to go to a direct model practice or all the way to a concierge / retainer model, providers have been slowly transitioning out of Medicare. It’s tricky for these non-participating providers when they want to continue to care for Medicare beneficiaries. Another option is to opt out of Medicare entirely. The complexity of the choices make it difficult for providers to consider leaving, especially when they consider that commercial payers will have matching requirements of their own that the providers will still have to deal with. The seemingly-onerous nature of the proposed rules might be a catalyst for providers to consider moving to direct models.

When you think about it, direct payment models would go nicely with some of the goals of all these efforts. If the goal is to put the patient at the center of their own care and to engage them, what better way to engage them than with their pocket books? Patients who start to see the true cost of care (rather than being shielded by their co-pays) might start choosing their therapies more wisely. Perhaps the generic drug that’s been around forever but doesn’t have sexy marketing will start looking more attractive.

We’ve experimented with that to some degree with tiered co-pays and that has driven patients to ask about cheaper alternatives. I’ve seen some patients question their hospital-employed physicians when the patients start getting bills from both the provider and the facility through provider-based billing arrangements. A couple of organizations in my region have done away with the practice based on negative community feedback.

Understanding the cost of care may encourage patients and families to make end-of-life choices that are ultimately more compassionate – choosing palliative care or hospice rather than expensive interventions that may not prolong life and may even damage the quality of life. Patients may begin to analyze whether the expensive (and life-altering) cancer treatments that may only extend life a few months are really worth it for them or for their families. Maybe we’ll stop ordering CT scans for things that really could be diagnosed with a good history and physical exam.

Of course, this wouldn’t solve all our problems. The cost of care is still prohibitively high for many treatments. Patients would still need insurance against catastrophic medical bills and we would still need safety net facilities and arrangements for patients who have limited ability to pay.

It also doesn’t address the real origins of healthcare costs. Lifestyle and behavior-related factors are 40 percent of the pie compared to medical care, which is a mere 10 percent. Human biology is 30 percent, with social determinants of health at 15 percent and environmental factors at 5 percent. Although patient engagement may help the lifestyle and behavior-related category, there’s still much more work to be done.

I still have several hundred more pages to get through, but I’m not sure I’ll make it. It’s too depressing.

Have you finished the proposed rule? What do you think? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/28/16

My phone started going into shock Wednesday afternoon with the release of the 962-page proposed rule for the Medicare Merit-Based Incentive Program (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models.

Vendors and providers alike have been eagerly awaiting the details hinted at by MACRA when it was passed last year. Providers were hopeful about the potential for consolidation of the alphabet soup of PQRS, VBM, and Meaningful Use.

It starts with the customary glossary of acronyms, which numbers nearly three pages. It also includes an overview of current reporting programs and regulations. For people who haven’t been immersed in the federal regulatory stew for the better part of a decade, it must seem like so much gibberish.

The provisions regarding the “Sunsetting of Current Payment Adjustment Programs” starts on page 35. A section on “information blocking” caught my eye on page 41 despite the fact that information blocking as defined by Congress seems much more theoretical than actual for most of the organizations I’ve encountered. Page 44 brings nearly three pages of new terms which require definitions. I gave it my best effort, but I couldn’t make it more than 100 pages. For those with longer attention spans, the comment period is open through June 27.

Registration is open for the AMIA 2016 Symposium, to be held at the Chicago Hilton. The Student Design Challenge, now in its fourth year, will focus on engaging providers and patients in precision medicine. Proposals are due by June 30 with notifications to authors on August 15.

For those who can’t wait until the fall for your next informatics meeting fix, the 2016 ONC Annual Meeting will be held May 31 through June 2, with the last day being focused on consumers. Agenda details are still forthcoming, so I’m not quite ready to commit just yet.

I enjoy attending conferences and connecting with colleagues across the country to discuss best practices and innovative ways to move healthcare forward. In my own world, though, I’d settle for healthcare that met the bare minimum.

I’ve been in a downward spiral, with several negative ophthalmology experiences over the last several years, but this week’s visit took the cake. My physician (the third in that I’ve seen in the practice) recently went on an indefinite medical leave, so I was called to reschedule with one of her partners. I always book the first appointment of the day so that I can be on time for the rest of my schedule. Unfortunately, my new physician was stuck in traffic.

He phoned the office five minutes after my appointment started. The practice has an open front desk, so I could hear the receptionist talking with him. I was dumbfounded when she told him that he didn’t have any patients in the office yet, especially since I had been checked in with my co-pay posted for 15 minutes.

About five minutes after she finished the call with him, she called me up to tell me what was going on. After another 10 minutes, a technician took me back to an exam room to get things started so I’d be ready when he arrived. She asked my reason for visit, and when I told her, she promptly asked why I was seeing Dr. X because he doesn’t treat patients with my chief complaint.

I reminded her that the practice is the one that scheduled me for the physician and should have known from my original appointment reason in the scheduling system what I was coming in for and that it was going to be a problem. I then got to hear through the open doorway as the staff called the physician in his car to ask what to do about me.

He agreed to see me, which I thought was odd if it was outside his area of expertise, but I decided to keep the appointment so I could get my prescription, which had expired due to the rescheduling with my previous physician’s departure.

When he arrived, he was apologetic, and told me “How great that was that the office was able to get in touch with you and have you come in later so you didn’t have to wait for me?” That’s certainly a creatively editorialized version of what happened, but by this point, I wasn’t surprised by anything. He performed only part of a typical exam, pronouncing my eyes “healthy” and then sending me to the front desk with a paper superbill that included charges for services he didn’t actually render.

I hadn’t mentioned that I was a physician. I wonder if he would have performed the way he did had he known that I was? It shouldn’t matter, though – the things that happened during this visit shouldn’t have happened to any patient anywhere. The fact that this occurred at a major academic medical center was particularly distasteful. Although the office manager was appropriately horrified, I’m still waiting for a call back from the department chair.

I have no idea whether his behavior was a result of his being late or generally poor practice. I’m waiting for a copy of my visit note to see what he documented in comparison to what he actually did and what he attempted to bill. In the meantime, I have an appointment across town to see another physician.

If we can’t even get basic medicine right, what hope is there? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/25/16

I wrote last week about my experience with a client who had been swindled by a practice administrator who had promised far more than he could deliver. A reader commented: “I would have loved to hear a few more specifics on what a practice might do to avoid hiring such an administrator or office manager. It has also been my experience that too many independent practices don’t seem to know what to really look for and consequently suffer down the road.”

I’ve certainly done more than my share of hiring and firing over the last decade. On my own, I’ve employed medical assistants, office managers, and partners. I also had to terminate at least one of each. As part of the corporate world, I’ve had to deal with vetting a host of positions including clinical staff, IT staff, managers, and operations execs. As a consultant, I’ve been asked to deal with errant members of the C-suite and upper management and also to assist in finding their replacements.

The best tip I can offer anyone in a hiring position is an old adage: trust your gut. Nearly every time I’ve gone against my gut, there’s been a poor outcome. Sometimes you can’t avoid it, especially if you’re in an employed capacity or part of a larger corporate entity.

For example, I once had to hire an analyst to run some lab interface work. The health system’s HR department (which usually left something to be desired) was only able to find two candidates who were remotely qualified. Although their resumes were decent, both of them interviewed somewhat poorly. I felt the first one didn’t understand the job we were offering, despite our attempts to explain it and talk about the work she would be doing. She kept going back to what she had done in the past and how good she was at it, even though we were trying to assess whether she’d be a good fit going forward.

The second one was too folksy right off the bat. Don’t get me wrong, I’m a folksy girl myself, but there’s a time and place for familiarity and it’s not in a job interview. I don’t want to hear about your children and your weekend plans – not because I don’t care, but because it’s too easy to get close to discussion topics that are normally a bad idea during the interview process. She seemed to be much more eager than the other candidate, but I didn’t really feel that she would be able to get the job done.

I wanted to go back to HR and ask them to look for other candidates, but was under pressure to fill the open posting immediately to ensure we could get someone in the position before a series of budget cuts that might force us to pull the opening off the board.

Although her interface skills were decent, it turned out that her overly casual demeanor was reflective of casual regard which she paid to all her work. When asked for status reports, it always felt like she was on the cusp of getting to the tasks that needed to be done, rather than actually doing them. She also liked to spend a lot of time chatting with other team members, which impacted not only her productivity, but that of others. It felt like she spent a lot of time doing nothing and then sprinted towards the deadline, which was a poor fit for our company culture.

Although I was involved in the hiring, I wasn’t her direct manager. He didn’t seem to have the wherewithal to deal with her because she interpreted every element of constructive criticism as “being mean.” Needless to say, she didn’t last very long. My failure to fight for my gut feeling in that situation bothered me for a long time.

Besides following your instinct, it’s important to watch out for people that seem too good to be true. Maybe they have a seemingly stellar record of accomplishments, but are willing to work for a salary that is lower than they appear to be worth. Sometimes you can get a bargain, but usually there’s a good story to go along with it. For example, a highly-skilled administrator who moves to a small town to care for aging parents or someone who needs a more low-key role to provide greater work-life balance. Usually these candidates realize that they may seem oddly matched for a position and will take the lead on explaining their desire to move down the ladder.

Other times, though, they might not have a good explanation for why they left their last position, or the references they provide don’t seem to make sense. I admit that it’s getting harder and harder to get a decent reference, particularly from past employers. Often organizations will simple verify the dates that the individual was employed. If you’re lucky, they might tell you if the person is eligible for rehire. Getting a true reference that you feel you can trust is like gold.

Other things that I sometimes don’t see smaller practices do: the consumer background check. They may do a criminal check, but not a consumer one. In this day and age, it’s important to know whether the people you are hiring have had any financial difficulties, particularly if they are going to be a position to handle funds within the office. Of course, that won’t tell you if the employee will make bad decisions, like the front desk staffer that I fired after finding $1,200 in co-pays in the sample closet. Why, you might ask, was the money in the sample closet? Because she didn’t have time to go to the bank and do the deposit each night, so she wanted to keep it somewhere “safe.”

Organizations should also make sure that candidates have valid experience for the position they’re trying to fill. Candidates might not have held the exact same job or title, but should be able to clearly explain how their previous experience will translate to the new position. Especially for higher-level roles, most organizations don’t have time to deal with someone who cannot hit the ground running. I do occasionally see it though, with groups that feel like they can mold someone into something that they may not be able to become.

Administrators should be able to talk about their achievements in previous roles and cite metrics for practices they’ve led. How have their days in accounts receivable been? Even if they weren’t stellar, did they show a positive trend? What initiatives did the candidate lead to try to move things in the right direction?

Potential employers need to have a list of solid questions to ask that relate to the needs of the organization. If you’re planning to become a Patient-Centered Medical Home, ask about that experience. If the candidate doesn’t have experience, ask him/her what he/she would do to get up to speed should they be hired. Anyone worth their salt should be able to articulate a plan to learn about a new discipline or new initiative, especially since the healthcare system we may be operating in over the next few years doesn’t exist yet. If they can’t come up with a reasonable strategy, they might not be a good fit.

Once an administrator or practice manager is hired, the practice should keep close tabs on their performance, not only in the initial hiring period, but in a regular ongoing fashion. Practice leadership (owners, partners, managers, etc.) should be having monthly meetings to review financials and potential problem areas in the practice. If the administrator says everything is rosy all the time, something is wrong. Even in the strongest practices there is always opportunity for improvement or some sort of personnel issue to make management aware of.

Owners or top leadership should also watch out for staffers that continuously spread blame around to vendors, payers, or other staff without showing even the smallest level of introspection about whether they could have done something differently.

Another good question to help assess a potential hire is this: “Given what you know about our organization, if you are hired into this position, what do you see the first six months looking like?” In my experience, candidates who plan to do a good amount of listening and observing before making too many changes are often the best. They’re willing to take their time to figure out what they have to work with, assess the team’s strengths and weaknesses, and make a careful plan rather than coming in with guns blazing.

What’s your worst hiring or firing nightmare? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/21/16

There has been a lot of buzz this week around the announcement of the Comprehensive Primary Care Plus (CPC+) model. CMS hopes to build on the previous Comprehensive Primary Care initiative, this time recruiting 5,000 practices into two tracks. The strongest candidates for participation will be practices that are already involved in care coordination and population management.

CPC+ differs from some of the other quality programs in that the incentive payments are prospective and the way in which practices manage their patients will determine how much of the incentive the practice gets to keep.

Practices will be selected after the identification of 20 participation regions which will be dependent on payer participation. The goal is for the majority of patients in the practice to be covered by one of the participating payers. Although physicians seem interested in the prospective payments, their enthusiasm was somewhat tempered by the need to wait until regions are determined. Payer proposals can be submitted through June 1, with submission of practice applications to follow. I attended one of the CPC+ webinars this week and actually enjoyed learning about some of the nuances of the program.

CMS also announced that those practices participating in the Bundled Payments for Care Improvement (BPCI) initiative can extend their involvement for an additional two years. CMS will use the extra time to evaluate outcomes and determine whether bundled payments are leading to better care while controlling costs. I wonder if their evaluation will also look at the stress levels of providers involved in the initiatives and the ratio of their patient-care hours to administrative time both before and after the initiative.

In other government news, our friends at ONC shared a comprehensive evaluation of the Regional Extension Center (REC) program. Highlights include data that 68 percent of eligible professionals receiving incentive programs under Stage 1 of Meaningful Use worked with a REC. If you don’t want to try to make it through the entire 124 pages, I’d recommend the Executive Summary, which is only six pages.

I’ve been waiting for the HIMSS16 presentations to be available online so I can grab a couple of slide decks. Although I understand they’re trying to be hip with their screen layout, you can only see eight sessions at a time, which leads to a lot of scrolling. I had quite a bit of difficulty finding the sessions I wanted, until I realized that sessions starting with “The” were filed under T.

After locating my sessions and downloading the slides, I decided to watch a couple of the sessions that I missed. The first one had audio which I couldn’t hear despite maximizing the settings of my tablet and the streaming content. I could tell the people were talking, but couldn’t make out any of the words. Good luck to the rest of you hoping to watch the sessions.

Being on the HIMSS website also reminded me that I needed to submit my sessions for continuing education. After my experience with the streaming presentations, I was hoping for a better experience, but left disappointed. Although I liked the fact that it prevented you from accidentally trying to claim credit for two sessions in the same time slot, it did it by refreshing the screen which required the user to re-select the day each time before searching for the next session.

I eventually was able to get all of my sessions selected. HIMSS has to submit them directly to the American Board of Preventive Medicine for credit, so I’ll be checking back in a week or so to ensure they get posted. Given the cost of attending the conference, I want to maximize my returns.

I’ve started to plan my next couple of trips and am excited to report that there will be no healthcare- or IT-related educational components. One trip involves camping in bear country, which is a new experience for me. The other involves wine country, so it should be a good balance.

What are your travel plans for the summer? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/18/16

I recently concluded a long-term engagement with a client. Having started as a small private practice, they had grown to 20 or so physicians and wanted to get larger, but had been running in circles trying to figure out how to grow their business.

I was hired to do an analysis and conduct some strategic planning sessions. After my first call with them, it was clear that a multiple decisions had somewhat sabotaged their chances for success and that much work was needed before we could truly embark on strategic planning.

None of the physicians had really wanted to take the lead in managing the practice, so they hired an outside administrator. For lack of a better description, he was the Harold Hill of practice leadership. He had billed himself as an experienced administrator who could help them grow from 20+ physicians to over 100 in less than two years, so they hired him. I knew he was going to be an issue because he instantly opposed my involvement with the group, with some of his comments being red flags that he had something to hide.

It was clear early on that they had some serious issues with physician satisfaction and employee engagement that would make it difficult to grow at all, let alone quadruple in size. It’s hard to recruit physicians when the existing ones are disgruntled and when you’ve had turnover issues with staff.

When I tried to explore how their staffing ratios looked compared to various professional organization statistics, he couldn’t even cite his own ratios, falling back on the fact that, “Every one of our locations is a little different” over and over. The word “evasive” didn’t even begin to describe him at this point. He also kept going around and around about the fact that “we’re a family” and extolling the virtues of various team members.

In my experience, that’s a technique used to try to distract an observer from the fact that they are overstaffed, underproductive, or both. At many practices I’ve worked with, the sense of “family” often does not outweigh the fact that a staff member is dysfunctional or incapable, but it’s cited as a reason that the issue has not yet been dealt with. Family or longevity can also be a way to try to camouflage overcompensation of resources that haven’t been able to keep up with the evolution / revolution we’re seeing in healthcare delivery.

Once the administrator was hired, the physician partners gave him the reins and stopped checking in on management issues. There were some red flags on the revenue cycle side (lack of clean claims, increased denials, failure to track down slow-pay or no-pay accounts) and it was clear that some of the critical reports available in the practice management system had not been run recently.

The managing partners were shocked to hear that this was going on, although the audit trail data in the software was clear. If he wasn’t running the reports, he certainly wasn’t presenting the information to the practice. However, I had a hard time figuring out whether he was presenting bogus data or no data at all, because the physicians all just stared at each other around the table. When pressed about the lack of reports, he immediately threw the practice management vendor under the proverbial bus, but was unable to provide support tickets for the alleged problems.

In digging deeper into some of the employee satisfaction issues, it was clear that the new administrator had chosen his favorites and wasn’t doing anything to build relationships with the rest of the staff. He had given the favorites control of the other staffers and wasn’t monitoring the equity of shift assignments or the quality of work being performed. What I heard from the line staff didn’t match up with the inspirational posters he had placed around the office regarding the ability of employees to drive the success of the business.

Turnover was a significant issue with the clinical support staff. In working with the practice over several months, it was clear that they had no plan to engage the staff beyond just the day-to-day duties performed in a medical office. Those staffers that showed initiative and drive were quickly shut down by some of the favorite staff, who saw energetic young staffers as a threat. They quickly left.

Some of the remaining staff members were mediocre at best and were interested in punching the clock rather than making the practice great. While I was working with them, two staffers resigned. I asked if I could participate in the exit interviews and learned that they didn’t have them or see a need for them. I instituted them anyway and found that the employees didn’t feel like there was any room for them to grow in the practice, that they didn’t feel valued, and that they didn’t see it as a place they wanted to stay.

One mentioned that the administrator had done an employee survey which was supposed to be anonymous, but they suspected that their responses were identified and were shared with the middle managers who may have used the responses in a retaliatory manner. It’s a shame for an organization to fail to take advantage of employee feedback, but thinking that you can get away with creating a hostile / retaliatory workplace in this day and age is just shocking. Healthcare workers are in demand (particularly skilled ones who are energetic) and organizations should seek to cultivate them and empower them. This means really engaging with them and not just paying lip service to the concepts.

Apparently at least one of the partners had asked about turnover. The administrator’s idea was to put in place a bonus structure that was not clearly documented or well executed. Employees were told they would receive a bonus, and then it would be months before it was paid if it was paid at all (as was reported by two staffers). I’m not completely blaming the administrator for all of this, as the managing physician partners were also responsible for the situation. When hiring someone into a position of authority, organizations need to make sure the transition is carefully monitored and that outcomes are matching expectations. If they’re not, then there needs to be an intervention.

After receiving the results of my initial analysis, the practice decided to have me try to mentor the administrator to see if he could be salvaged. My gut instinct was that this was not going to be possible, but I was willing to give it a go. Working with him on a day-to-day basis, it was clear that he had no strategic plans for the practice and really had no idea what he was talking about in a lot of core areas. We tried to discuss managed care contracting as it relates to practice growth and he quickly became defensive, trying to cover the fact that he was lost in the discussion. We talked about physician incentive strategies and staff engagement and he had no concrete plans or goals. When asked to discuss the practice’s mission and culture, he popped out a canned response but could not elaborate.

After a couple of weeks, it was clear he wasn’t going to be part of their go-forward strategy, but the practice was on the fence about actually terminating him. Practices are often afraid of letting people go for fear of being sued. I explained to them that it’s really a fairly straightforward process, depending on whether you have an employment agreement or not and whether the job description is clearly documented. I suggested trying to document “non-performance of essential duties” strictly through the lack of diligence around the financial reporting requirements, which should have been a clean way to do things.

I was surprised that they didn’t want to go that way and instead wanted additional documentation. I explained that this would require some effort on the part of the managing partners as well as additional risk to the practice while the administrator was allowed to continue to alienate staff and fail to manage the practice. They disagreed, so we embarked on a four-week effort that ultimately did culminate in his departure, although not without a lot of angst among the partners and turmoil in the office.

My partner and I finally got them stabilized and spent quite a few additional weeks creating policies, procedures, and protocols to help take them forward. We took them through a search process and they’ve hired a new administrator who will be carefully supervised by one of the senior managing physicians, according to the steps we’ve laid out for them. My partner is going to continue to work with them on a weekly basis to make sure we can solidify their process and keep them moving forward. We’re planning to conduct the original strategic planning engagement down the road, but want them to show that they can at least keep 20 physicians and the accompanying support staff stable before they decide to try to grow again.

Given the changes in healthcare, I want to root for the independent practices and am happy that they are a large part of my consulting practice. It’s easy to throw up your hands and allow your practice to be purchased by a hospital or health system, but it doesn’t fix anything. Usually it creates more issues. I’m hopeful for this group, but we’ll have to see what the next six months bring.

Has your organization experienced their own Harold Hill moment? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/11/16

Although the majority of my consulting work revolves around healthcare IT, I’ve done a fair number of practice management and operations engagements along the way. Many of the opportunities have bubbled up as a result of a practice or medical group trying to implement EHR.

Going through the process tends to highlight overall inefficiencies, role confusion, lack of management, financial issues, and more. Over the last six months, I’ve seen the requests for those types of services increase, which is part of why I joined forces with another consultant. We’ve written a number of engagements that don’t really have any information technology components.

As we’ve been exploring the different kinds of services we can offer and the needs of our potential customers, we’re seeing more organizations that are at a crossroads. It seems that quite a few primary care organizations are having what amounts to an identity crisis. Should they press ahead towards value-based care? Should they transform their systems and prepare to accept full-risk contracts? Or should they retreat towards their roots with personalized (and sometimes concierge) care? Two emails this week from the American Academy of Family Physicians highlighted this looming crisis.

On one hand, the AAFP has launched what is describes as a “full-court press” to ensure that family physicians are ready for payment reform. Calling it a “ground-breaking, knock-your-socks off change that opens to the door to a whole new era of Medicare physician payment,” the AAFP is positioning itself to help physicians “reap the benefits of a new payment system that, unlike fee-for-service, values the training, skill level… and time that goes into taking care of patients in a family medicine setting.”

In order to prepare for the transition, they’re encouraging physicians to participate in the Physician Quality Reporting System (PQRS). They also recommend that practices review their Quality Resource and Use Reports (QRURs) which will show physicians where they stand as far as future payments for the MIPS track. Most of the primary care physicians I know have never heard of a QRUR and would be put off by the process one needs to go through to obtain theirs.

AAFP also recommends that practices embark on clinical practice improvement activities around access to services, patient engagement, care coordination, and more. Smaller practices (and some larger organizations) are often ill-equipped to try to make these changes on their own. Their articles are pushing physicians towards the new models with comments that the process won’t go away or be delayed, and that “this train has left the station.” There’s going to be a huge market for services around helping physicians make the transition and I’m sure the AAFP teams will be gearing up with offerings of their own.

On the other hand, AAFP is hedging its bets by also marketing services towards physicians who are choosing to opt out of payment reform entirely. They’ll be hosting a Direct Primary Care Summit in July. The meeting is targeted towards not only physicians who have already converted to direct primary care, but for those who are thinking about it or trying to figure out how to manage the transition. They’ll be educating physicians on the legal aspects of operating a direct care practice as well as how to address business development around the new model. The conference promotion materials cite the “momentum” and “growing excitement” saying Direct Primary Care is “no longer a trend” and is being supported by positive legislation across the country.

I certainly don’t fault AAFP for playing both angles. Primary care is at a crossroads. The National Residency Matching Program “Match Day” was last month. This year’s match saw only 1,481 graduates from United States medical schools choosing family medicine. There were some other interesting statistics coming out of the Match:

• Family medicine offered 11.7 percent of all positions in the Match.
• The fill rate in family medicine for US seniors has decreased from 1996 (72.6 percent) to 2005 (40.7 percent) with a slight increase this year (45.4 percent).
• The fill rate in family medicine for US seniors has been below 50 percent since 2001.
• Aggregate primary care positions (family med, general internal med, general pediatrics, and internal med/peds) filled with US seniors at a rate of 50.7 percent.
• Only 12 percent of US seniors participating in the Match selected primary care residencies.

Looking at non-US seniors who matched into family medicine, the numbers are climbing overall. Although I’m happy to see qualified international graduates matching into primary care specialties, I think the fact that US grads continue to choose other pursuits is very telling. Primary care salaries are among the lowest in the physician ranks and primary care physicians report some of the highest burnout levels compared to their peers.

The loss of autonomy brought by shifting healthcare policy over the last decade has hit primary care physicians disproportionately compared to specialists in many markets. Although payment reform may extend that loss of autonomy more fairly across the board, if feels like we’re moving towards the lowest common denominator rather than trying to elevate everyone.

Lots of people are looking at the decline of primary care. A recent JAMA article looks as the expanded use of the term “primary care provider” as having negative consequences for the future of primary care. It asserts that although increased use of the term provider “reflects the importance of a multidisciplinary approach to modern primary care delivery, extending beyond the traditional dyad of patient and physician,” it has also had negative impacts. Patients may not be reaching the appropriate member of the primary care team if they can’t distinguish between different types of primary care providers. A mismatch in care delivery can lead to both over- and under-performance as well as challenges to patient safety and the delivery of cost-effective care.

The article specifically cites the rise of Direct Primary Care as being from “the resultant uncertainty and insecurity about who is going to handle their medical problem.” It also mentions that not differentiating between providers may put some individuals into “situations beyond their level of training and competence.”

I’ve seen this with one of our practice’s competitors, whose push for their nurse practitioners and physician assistants to practice independently is causing them to seek employment elsewhere. Healthcare IT is cited as a potential bridge for providers in those situations, who may be able to use protocols and clinical decision support mechanisms to “help mitigate some of the front-line diagnostic and management challenges for team members facing situations beyond their level of expertise.” I leverage technology often in practice, but it’s not a substitute for experience.

The authors also mention that the provider designation ”risks de-professionalizing” physicians, NPs, PAs, and nurses “who value their specific professional identities.” My favorite part of the article says it all:

Using the “provider” designation in primary care also suggests that primary care is simple care that can be commoditized and delivered piecemeal in a variety of settings by less well-trained personnel operating interchangeably at low cost. As such, use of the term may promote low levels of compensation and diminishes respect for the field, compromising its fundamental mission. Although low-cost approaches to some very basic elements of primary care, such as immunizations and treatment of upper respiratory infections, make enormous sense, they do not apply to the resources, skill, and training needed to deliver the full spectrum of comprehensive primary care in personalized, coordinated fashion, especially to an aging population with multiple comorbidities. “Provider” belies the complexity and amount of effort required. Note that the designation of “provider” has not been applied to such fields as surgery or cardiology, even though these too entail multidisciplinary, team-based care structures.

It goes on to recommend that we “cease referring to and treating primary care clinicians (as well as all other physicians and health care practitioners) as “providers” and address and relate to them as the highly trained professionals they are. If only things were that simple, that we could change some terminology and things would improve. Healthcare seems to just keep riding tide after tide and grabbing after the next shiny object that they think will solve the problems. We hoped for the last decade that technology would solve all our problems, that if we just added automation to the practice of medicine that we’d solve problems. Unfortunately, automation was often poorly applied and shifted the work to physicians.

Now we think that if we make the data more accessible, we can fix the problem. It feels like we’re pinning our hopes on interoperability, but we’re not doing what we need to make better use of the data, whether by physicians and other care providers or by patients themselves. Professional and educational organizations are weighing in, but are somewhat hampered by the lack of details on how new care models will unfold.

“Providers” are tired of waiting and continue to leave practice or pursue alternatives such as Direct Primary Care or to opt out of Meaningful Use or Medicare/Medicaid. The giants of our industry are increasingly reactive rather than being proactive or innovative. Eventually, something will have to give, and I fear it will be the people on the front lines.

Do you think emerging payment models will fix the healthcare crisis? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/7/16

In a previous post, I mentioned Epic vital signs alerts with values that were way out of range. Several readers commented, with one saying this couldn’t possibly be a client value and another wondering what other customer-built “garbage” might be in their system. The original reader who shared the alert sent me a screenshot of the Epic foundation build, showing the Epic-released values that are delivered read-only. Although you can modify it on age-based overrides, the the maximum pulse of 500 is out of the box.

Even worse, I noted that the pulse values all have trailing zeroes. I’ve spent more than a decade arguing with EHR vendor staffers about the concepts of precision and significant digits, and the fact that trailing zeroes don’t belong in fields like these. Since a pulse measurement obtained via traditional clinical skills can’t technically be precise to two decimal places, it shouldn’t be reported as such. Weird News Andy chimed in as well, suggesting that perhaps it was an alert for hummingbirds.

It’s National Public Health Week. Events in our area focused on tobacco, obesity, and diabetes. One of our offices had planned to host a blood drive, but it was canceled by the blood bank due to an “equipment malfunction.” I’m not sure what might be malfunctioning that would prevent us from using disposable collection gear, but we weren’t able to find another agency that had availability. Hopefully we’ll be able to make up for it next month.

Several of my consultant friends have a betting pool running on when CMS will release the MIPS/MACRA proposed rule. It looks like it has gone to the White House Office of Management and Budget, which might mean we could see it sooner than some of us thought. I’m banking on Memorial Day weekend since CMS has made a habit out of releasing it just before long weekends. By law, it has to be released within 90 days, but I think there may have been one recent proposed rule that came out past the 90-day mark. I’m too tired to Google it though, and it doesn’t really matter, so props to those of you who know for sure. I’m seeing a deluge of information from professional societies asking their members if they’re ready for MACRA, which is funny because many of the front line physicians I talk to don’t even have an idea what it is.

I mentioned it before, but the White House petition supporting a voluntary patient identifier doesn’t seem to be getting much traction. Only 6,000 people have signed it since it went live on March 20. It needs nearly 94,000 more signature prior to April 19 in order to receive a response from the White House. Although the Executive Branch can’t actually solve the problem, getting enough signatures on the petition would make a statement. If you’re supportive, please consider signing to have your voice heard.

The AMIA iHealth conference is right around the corner. I’ll unfortunately be attending another conference at the same time, but am interested to hear from readers that may attend. It’s approved for 12 hours of ABPM LLSA credit, so if you’re board certified in Clinical Informatics and haven’t started earning your hours, it would make a nice start. I’m nearly done with my continuing education for the year, which is a good feeling. The only thing I have left is a module for my primary board certification, and I’m waiting until summer when a new MOC paradigm goes into effect for us.

I often have physicians throwing articles at me with ratings and rankings of the “best EHRs.” Such pieces generally drive me crazy, because once you dig into the number of participants and truly dissect the data, it is often poor. In one recent study, the physicians polled couldn’t even correctly identify their vendor and instead claimed they were using systems from vendors such as “CPOE” and multiple acronyms developed by hospitals to brand or market their systems. The prize for the best article of the week goes to GomerBlog, however. Thanks for the laugh because I sorely needed it this week.

What’s your favorite EHR? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/4/16

I had lunch with some of my former colleagues the other day. One of the hot topics was the relatively new Patient-Centered Specialty Practice Recognition program from NCQA. Several of the specialty physicians who were at the table are employed by a health system and are being encouraged to participate in the program as part of an overall accountable care strategy.

The program is designed to recognize specialty practices that are committed to access, communication, and care coordination. Although it should be fairly easy to “encourage” employed physicians to participate as a condition of their employment, the physicians around the table were unconvinced that the independent specialists would be interested.

Our community has many more independent specialists than owned/employed, while the majority of primary care physicians are no longer independent. Several primary care physicians spoke up about the difficulty of trying to achieve Patient-Centered Medical Home recognition since they felt they were being asked to do more but were not allowed by their employers to add staff.

However, at least as primary physicians, they felt they had experience in coordinating care where they didn’t feel that some of their specialty colleagues were ready to take that on. Several complained about narrow insurance networks that require them to work with specialists who have poor communication and coordination skills, using words like “atrocious” and “radio silent” to describe how they hear back from consultants.

I suppose I was lucky to start my career in the days when my employers supported my ability to refer to the specialists I felt were most appropriate and when most of the specialists in the community were credentialed with nearly all third-party payers. The only payer I had difficulty finding specialists for was Medicaid.

As I determined that a given specialist had poor communication skills or was lacking in follow-up or coordination, they quickly fell off my list of consultants. That got me in trouble more than once with senior members of the hospital medical staff, who complained bitterly that a certain new physician wasn’t giving them the referrals they felt they were due. When I was approached about it by a hospital VP who had been assigned to “mentor” me, I explained that I was referring to the junior partners in their practices who were friendly, collaborative, and actually acted as though they wanted to care for my patients. The fact that I was at least referring to the practice seemed to provide cover, but the idea that a specialist would be “owed” referrals due to seniority or status was (and still remains) offensive.

Referring to the specialists I prefer is a bit more difficult now. Our office gets frequent callbacks from patients who are unable to see the specialists that we recommend due to insurance issues. I try to give patients subtle warnings when I am forced to refer them to physicians I would normally not select. I’ll go ahead and provide multiple referral names, putting the people I prefer at the top of the list. but warning the patient that they need to check with their insurance to determine whether they are covered.

Should the patient choose to go out of network, they can. I explain that the less-desirable provider (without using those words, of course) is more likely to be on their insurance and dance around the fact that although they may have strong technical skills and are a “good surgeon” that the patient might experience some “inconvenience” with the office and getting the paperwork back and forth. I hate to have to use a euphemism for “poor care coordination,” but at least it gives the patient a small bit of warning.

My personal friends who are specialists pride themselves on cultivating their referral base and treating their referring physicians well. Should they decide to pursue recognition, I would foresee their main barriers would be dealing with the documentation requirements from NCQA and educating their staff on any tweaks to process or documentation that may result. I know several of them have unwritten policies for how communication and care coordination occur and they’ll need to get these pinned down and consistent across everyone working in the practice.

Another barrier might be cost. NCQA has a reputation for charging more for the PCMH recognition process than other organizations. Specialists have been fairly insulated from some of the nickel-and-dime treatment that primary physicians have been battling for years, so I’ll be happy to have them on board with our cause.

Others may resist in that they believe they are already providing high quality are and don’t feel the need to have someone else tell them they are. We saw that kind of thinking in the early days of PCMH, but things are getting to the point where physicians almost have to have the formal recognition to stay ahead.

I recently read an article about the CareFirst BlueCross / BlueShield program in Virginia, Maryland, and the District of Columbia. Nearly 90 percent of the plan’s physicians are participating. Those that do receive a 12 percent participation fee regardless of performance metrics and without any penalties or risk assumption. It also treats online visits the same as face-to-face ones. CareFirst’s analysis shows that in looking at 2014 data, participating practices took in an additional $41K in revenue above the participation fee. Additionally, 75 percent of its patients had established a relationship with a primary physician.

The program asks physicians to group together in panels that are graded on patient engagement, access, and appropriate use of services. The engagement score holds the most weight and includes patient satisfaction indicators. The panels of physicians are expected to meet monthly to discuss performance and compare notes.

From the provider standpoint, this sounds like the kind of work we need to be doing to help physicians move forward under new care models. Rather than just tell them they need to do a certain thing or achieve a certain outcome, they’re creating support structures for physicians who can work within the collaborative environment to make changes. Participating providers should also receive reinforcement from their peers when they are doing well, in addition to suggestions for changes proven in other practices.

It remains to be seen whether these types of initiatives will appear in the Patient-Centered Specialty Practice realm. I’ll be watching to see whether specialty physicians start gravitating towards this on their own or whether they’ll only head in that direction when forced to by their employers or other external pressures. I’ll be interested to hear what they think of the process and whether it elicits sympathy for the primary care physicians who have gone before them.

What do you think about Patient Centered Specialty Practice recognition? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/31/16

The Journal of Family Practice published an original research article this month looking at notes written by medical scribes. Since we have scribes in our practice, this was of definite interest.

The authors used the Physician Documentation Quality Instrument (PDQI-9) to look at the quality of notes written by 18 primary care physicians prior to scribe use as well as after the introduction of scribes. The study controlled for type of visit (diabetes visits and same-day appointments) and allowed a period of adaptation (three to six months) after the introduction of scribes and looked at just over 100 notes for each period.

Although it makes for a relatively small sample size, the authors found that scribed notes were “more up-to-date, thorough, useful, and comprehensible” among the diabetes visits. Interestingly, they did not find a difference in quality on the problem-focused same-day appointments. The notes were found to be similar in total word count.

The scribes used in the review were medical assistants acting as scribes rather than an independent scribe. Care teams trained for the new model by having the physician and scribes attend two training sessions (two hours each) and a half day of observation and evaluation in the clinic.

I have to admit, I wasn’t familiar with the PDQI-9 instrument. The authors admit that while it is a validated tool, “it relies on subjective ratings of note quality by the reviewer.” They attempted to control for this by having two reviewers (an internal medicine resident and an experienced internal medicine physician) independently rate the notes and then discuss. Once they found that there was >70 percent agreement on the reliability of the ratings (about 20 notes), the resident was deemed “reliable” and allowed to evaluate a random sample of notes to form the basis of the review.

The authors noted concerns about over-documentation when using EHR-based templates. Interestingly, they also noted that “both physician and scribed notes were rated to be of average to low quality because none of the mean scores on the nine individual components of the PDQI-9 reached 4.0.” That would lead the reader to believe that there is opportunity for improvement in documentation across the board, whether scribed or not. Considering that the push over the last 20 years has been “documentation for payment” rather than “documentation for clinical value,” I’m not surprised.

They also noted some potential drawbacks to scribe use, such as lack of EHR innovation since physicians are shielded from poor EHR usability by scribes. I’m not sure that I agree with that assertion. We use scribes in our practice and have documented data on how they impact physician productivity. We also know exactly how excessive clicking in the EHR hinders scribes and we haven’t stopped pressing our EHR vendor just because we use scribes.

In my experience, physicians in a private practice model or even in an employed model where they are responsible for covering their own overhead are sensitive to the scribe’s productivity and will continue to push the vendor for improved application performance.

The authors also note that “incorporating scribing into a practice may also improve the physician experience, a possible benefit that we did not measure.” Although we do have scribes in our practice, individual physicians aren’t always guaranteed to have one. Our scribes are deployed to the locations seeing the highest volumes at any given time. They might work at two or three locations in a given day, following the ebb and flow of patients across the city.

Our scribes definitely improve physician satisfaction, so when we’re lucky enough to get one, we try to hold onto them. As the practice has grown, this has led to a need to have centralized management of the scribes, where a team leader looks at the bed boards across the sites, looks at the patient mix, and makes adjustments as needed rather than waiting for physicians to request or release a scribe.

The publication also notes that although all providers used the same EHR, there may be variations in individual provider templates. Our practices has a single set of templates across the organization, so we don’t see that issue. Having a single set seems to help the scribes be more interchangeable given our staffing model. Sure, we have our favorites, but the preferences are likely more about personality rather than speed or accuracy.

I know that when I have a scribe, generally the entire note is done when I walk out of the patient room unless labs or diagnostic imaging is involved. In those cases, the scribe returns to the patient room with me to discuss the results and plan of care.

Even during the most intimate of exams, I’ve not had patients resist the idea of a scribe, especially when the scribe can also serve as chaperone or assist with a procedure to help it go more quickly. That’s definitely an advantage of having dual-trained scribes who can perform other clinical duties. Patients seem appreciative that I’m focusing on them and their needs and am not distracted by the computer.

I may not be the best indicator of that, however, because even when I don’t have a scribe, my ability to focus on the patient is probably better than that of the average physician. Thanks, Mom, for making me to learn to touch type. It’s not only a great skill for patient care, but also allows me to multitask during meetings and make it look like I’m attentively taking notes.

In doing the modeling for primary care physicians, we sometimes find that physicians can “afford” to have a scribe by deploying their existing staff in a more efficient manner. Sometimes that means redistributing work and sometimes it means moving people to different job roles, both of which can be challenging for practices from an interpersonal and political standpoint. As I tell my clients, though, I’m happy to be their bad guy and help them make the change. I’ve even worked with a couple of larger groups to put together a scribe training program and help them get current staff transitioned.

I really like the training model that our practice has – all scribes are personally trained by the physician owner and are only allowed to graduate to other sites with his approval. It ensures consistent quality, but is not likely reproducible in other practice settings. We also use a variety of types of clinical assistants as scribes – medical assistants, paramedics, EMTs, and premedical students. Having this real-world experience has helped me assist my clients in thinking outside the box.

The authors conclude that as use of scribes increase, more research is needed. I definitely agree and look forward to seeing how we work with scribes in the next five years.

What do you think of scribes? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/28/16

I spent several days this week performing an assessment of a client’s EHR support team. The IT director had been pressing leadership for more employees. The CIO, however, suspected that perhaps there were other issues on the team keeping people from being maximally productive. I had been tasked to determine not only whether there are process issues, but whether the team has the right skill sets to be effective.

You may be asking why a physician or CMIO is doing this kind of work. Even though this type of work can be done by non-physician consultants, many of the organizations I work with have found that the recommendations carry more weight when they come from a clinical informaticist.

Just observing in the office, I found the usual distractions and interruptions – instant messenger, email notifiers, and text messages which kept people from focusing on their work. Additionally, the support staff wasn’t particularly differentiated as far as which types of issues they handled. Working with somewhat of a call center mentality, staffers were expected to handle every call that came through in a round-robin fashion, regardless of the nature of the issue. Staffers were positioned to handle whatever was on the other end of the phone, even though the callers might have neurosurgical problems and the person answering the phone might be a rheumatologist.

The support team had varying levels of experience – some were clinical, some were technical, and some actually had zero healthcare IT experience and minimal training yet were expected to handle calls successfully. Part of my assessment includes individual staff interviews, during which I determined that one staffer in question had never even been to formal training on the application he was expected to support. Worse, he wasn’t a new employee, but had been there for nearly six months, and his manager had continually promised she would get him scheduled for training but never delivered.

That in itself was a red flag. It’s hard to on-board employees when you don’t have a formal training program. The best organizations I have worked with expect new hires to complete specified training and demonstrate proficiency within the first 90 days. At some, this may also include achieving certification from the vendors of the applications they are supporting, if they are not already certified. Usually those requirements are baked-in as conditions of employment, making it easier to break with someone who can’t meet expectations.

The individual interviews also uncovered that some team members had particular expertise that was going to waste considering how they were being utilized. One was a lab expert, another was a nurse, and yet another had extensive process improvement training from a previous position. Given their round-robin deployment on support tickets, their skills were going unused. Several of their responses indicated boredom and frustration.

My interview of the manager was particularly enlightening. She stopped the interview multiple times to deal with text messages, phone calls, and even people walking by the office. Observing her outside the interview, I can only describe her work habits as firefighting. Everything was a crisis requiring immediate attack.

I also interviewed a director and a vice president, neither of whom seemed particularly knowledgeable about the work going on below them. They seemed fairly content to manage from above without accountability for their teams’ performance. One flatly stated that, “Getting results is why I have managers. That’s their job, not mine” even though he acknowledged that his managers weren’t terribly effective in actually achieving the desired goals. The VP admitted he had no experience with clinical systems or working with physician groups and that he had just been given this department when the last VP left.

It was clear that culture issues were at play as well as general inefficiencies, and I included a discussion of that problem in my formal report. I was looking for additional documentation about workplace distractions and came across several recent pieces about email as one of the roots of all evil.

Despite their best intentions, people struggle with email management. This is particularly acute in organizations like my client’s, who don’t have clear policies about email use. When I’m engaged to provide guidance, I always recommend policies which include expectations for response (if you need a response in less than three business days, you need to use phone or in-person communication) as well as a specification on which types of issues belong in email and which don’t.

Interesting in some of the studies was the fact that employees using email were less likely to achieve deep work states. Over the last year, I’ve started seeing more organizations where employees never achieve deep work states. Sometimes they’re constantly dealing with customer “fires,” but more often, I’m seeing employees who are put in that position by a lack of leadership and strategic planning. In workplaces with these cultures, I often see evidence of people working from home or from their phones. When asked about these behaviors, workers often cite “the need to keep up” or the fact that they can’t get anything done at work. Both of these are just symptoms of a larger problem.

In other situations, workers may not understand how the tasks they are performing fit into larger initiatives, which can create frustration. One client I worked with in the fall was running parallel initiatives out of two teams without any coordination of efforts. Leadership didn’t account for the fact that employees have friendships across teams, and when they learned of the parallel efforts, their perception was that their projects were competing rather than complementary. This lead to a spiral of frustration as workers were suspicious that they were being set against each other or that a “losing” team might end up being downsized.

In one organization I recently visited, people were constantly told about the organization’s key objectives and vision, but there has been little to no communication about how they’re actually going to go about achieving those objectives. That type of work environment quickly leads to frustration and then to apathy. I also had concerns about workplace violence, as the marketing department had the corporate focus words imprinted on stones for employees to have as focal points on their desks. I’m betting more than a few of them get thrown from time to time.

These higher-level dysfunctional behaviors were present at my client, in addition to the micro-level dysfunction that I identified looking at their individual work habits. What the client felt was going to be a straightforward analysis of their EHR support team revealed not only a poor staffing plan and misuse of some fairly expensive human capital, but also a lack of strategic planning. There were also some other red flags in dealing with this client. I knew that my findings weren’t going to go over well because they didn’t fully support management’s original theory that the team was overwhelmed or just wasn’t working hard enough.

Fortunately, I had scheduled an onsite presentation of my findings so that we could discuss them rather than just sending them a report after the fact and having a call to review. Although some members of the leadership team seemed genuinely shocked (or at least were very good at making it look that way) the majority of them didn’t seem terribly surprised. Several of them (including the director and the VP) were skeptical of the findings and my recommendations, and based on their responses, I don’t think they’re at a point where they’re ready to make changes.

One of them actually accused me of “muck-raking,” which is a term I haven’t heard since the last time I took an American History class. Another (who apparently missed the memo on why I was there in the first place) said I was just “coming up with make-work tasks to justify my existence.” Those are pretty powerful words to say to someone who was specifically hired to complete a well-defined project, not to mention to someone who was specifically hired by your boss to figure out why your department is a disaster.

I didn’t find their responses surprising at all since they were obviously trying to defend their turf and protect their own necks. We’ll have to see what the CIO decides to do with the findings. Based on the personalities involved and their obvious resistance to change, I’m not too thrilled about the possibility of a follow-up engagement should they request one.

Regardless of where they decide to go from here, I left them with quite a few concrete recommendations for the team in question as well as for their leadership team. It’s sad to say, but clients like this are becoming the norm for me. I’m eager to do work for an organization that has leadership, vision, and focus but just needs a kick in the pants to get it done rather than one that seems oddly happy in their dysfunction.

Have any client prospects? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/24/16

Several readers responded to my recent request for information on EHR vital signs data entry alerts. Epic has not only color changes that indicate an out-of-range value, but the possibility of a hard alert that forces the user to address the value. I got a chuckle out of the warning for our erroneous pulse of “13270,” which read as follows:

I’m fairly certain that a pulse of 500 is incompatible with life, which makes me wonder if this is a vendor value or something the customer configured.

This week has been a veritable news roundup of interesting articles and newsy tidbits. Popular Science featured a wearable patch that can not only monitor blood glucose, but also deliver medication. Using the pH of sweat along with temperature changes that align with a high blood glucose level, when certain conditions are reached, a micro heater in the patch dissolves a layer of coating, releasing the drug metformin via microneedles. Commentary on the recent publication notes that it’s not clear whether the device can last a full 24 hours and whether it will withstand exercise and increased sweat. Its ability to deliver human-scaled drug doses is also an issue. From the physician standpoint, I’m not sure about metformin as the choice of drug due to its mechanism of action, but it’s certainly an interesting technology to think about.

Engadget reviewed a business card with built-in electrocardiograph capability from MobilECG. The card is open source and schematics are posted online, so I’m thinking perhaps my nephews would like to try their hand at building one.

Content vendor Wolters Kluwer has made its Zika Virus order sets available for download. The World Health Organization has declared it a global threat and there have already been nearly 200 cases reported in the United States. The order sets include one for infants to assess for congenital infection, as well as those for emergency department and outpatient settings. Other freely available order sets include Ebola evaluation, ischemic stroke, low back pain, myocardial infarction, pneumonia, and more.

Even though I’m behind the scenes at HIStalk, I still rely on it for healthcare IT news. I was glad to see mention of the AHIMA petition in support of a voluntary unique patient safety identifier program. Being in the healthcare trenches, I’m more worried about incorrect data matching than I am about people misusing my data, so it’s a risk I’m willing to take. It’s not the complete answer, but I can’t help but think that it would be better than what we have.

I also appreciated Mr. H’s mention of the retirement of Groupwise at BJC. I remember using Groupwise fondly – my favorite feature for scheduling recurring appointments, when you could just pick dates off the calendar rather than having to follow a straight formula. It was an absolute necessity when I had to schedule physician advisory board meetings – we alternated Tuesdays and Thursdays so that conflicts would be shared throughout the group. Also great for meetings that occurred the first and third Wednesday, etc. Much easier than sending multiple appointment series. Users can’t convince Microsoft to get rid of the unholy “Clutter” folder in Outlook, so it’s doubtful Microsoft would ever consider this type of enhancement.

HIStalk is also a place where readers can ask for feedback and advice. One emailed me asking if I knew of any companies that might have a “lab” of EHR vendors to connect to. He’s trying to test some integrations but frustrated dealing with individual vendors. If anyone knows of that kind of arrangement, leave a comment to pass along the information.

I mentioned in this week’s Curbside Consult that our practice is seeing an increase in volume that we’re at least partially attributing to the shift towards high-deductible health coverage. Price transparency is one of our talking points. Reader Intrigued asks, “For those of us who missed it or are search challenged, where did you discuss this before? Definitely interested in learning more about your experience.”

I’ve mentioned it a couple of times in passing over the last few months. As for data, we have referral tracking and patient satisfaction survey data which shows the trend. We can capture who has a high-deductible plan from our practice management system and can see who chose us for “cost” in post-visit surveys. We also can see trends on the number of patients who visit us because they can’t access their PCP or don’t have a PCP. There are definitely multiple drivers fueling our growth, but I continue to be impressed by the number of patients who are paying attention to cost.

A reader asked about my recent mention that Institute for Health Improvement courses have been approved for ABPM LLSA credit. I clarified with my source that the approved courses include: Quality Improvement Curriculum, Graduate Medical Education, and the Patient Safety Curriculum. Too bad I already took my mandatory Patient Safety course through the National Patient Safety Foundation, because it sure would have been nice to also get the LLSA credit.

I enjoy reading scholarly articles, although some are best left for bedtime. “Do You Smile with Your Nose? Stylistic Variation in Twitter Emoticons” was perfect for a mid-day break, however. Analyzing the 28 most used emoticons in American English tweets, it demonstrates “that the variants correspond to different types of users, tweeting with different vocabularies.” I shared it with a friend who edits journals for a living and she responded back with this gem, “20 PhD Students Dumb Down Their Thesis.” I’m fairly certain that #5 might have been submitted by one of my medical school classmates.

Chocolate cake as the new breakfast of champions? Thanks to Dr. Lyle Berkowitz for sharing this article summarizing research on the benefits of chocolate. Morning chocolate consumption has been found to have positive influences on weight loss and improved performance on cognitive function. I think I’m going to make chocolate part of my complete EHR implementation plan from here on out.

What’s your favorite vehicle for chocolate consumption? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/21/16

At my clinical practice, many of my partners have been out for spring break. Since the local school districts have staggered break schedules, nearly everyone wanted the overlap weekend off, so I was happy to work the whole thing.

Although Friday’s shift had more than its share of patients bearing the complaint of, “I just started getting sick and I’m going to Cancun and can’t be sick for break,” Saturday trended more towards, “I just got back from Cancun and am sick / hung over/sunburned.” I was starting to question my sanity until Sunday, when some “typical” patients started coming in.

I’ve mentioned this before, but with the shift to high-deductible health coverage, we’re seeing a tremendous increase in volume. Our pricing is transparent and we’re conveniently located and provide quick service, so the business is experiencing exponential growth.

With that comes some growing pains, however, which for me has been felt in the number of new staff members working on the teams. We have a really great training program – new staff members have formal training shifts and each shift has a different focus. One day may be clinical interview skills, another may be labs, and another may be procedures, etc. They work directly with a trainer whose only focus for the day is to train them – it’s not someone already on the care team who is training on the side.

Even after the formal training, some staff may be more green than others. I ran across a scenario yesterday where the staff failed to notice some nonsensical entries in the EHR. Although it should have been reviewed before addition to the chart, the patient care tech missed the errors:

• Pulse of 13270
• Respirations of 99/minute
• Temp of 15

It turned out that the tech had entered the data quickly, was just tabbing through the data entry fields, and was off by one field. The blood pressure field (which should have shown 132/70) was blank and he entered those numbers without a slash in the pulse field. The error then compounded as he tabbed. He was apologetic and immediately fixed the error.

Being in the health IT industry, I quickly flagged it as not only a human error, but also a software problem. Most of the EHRs I’ve worked with have restrictions on various data fields to prevent these kinds of errors. For example, a pulse field might only be able to hold three digits. Active or passive alerts might display for values outside the normal range.

Although the tech should have caught it, my bigger concern is that this happened in a Meaningful Use Certified EHR. I’ve asked the practice’s technology liaison to open a ticket with the vendor and see if it’s functioning as designed or whether there is a defect. If it’s functioning as designed, I have to wonder about the certification standards. I don’t beg to have a command of the details and I know there are hundreds of pages of requirements that must be met.

Knowing that some of the elements that are requirement for certification may not be something that physicians need or want, I’m surprised if there isn’t something in there to require safety checks for straightforward data entry like this.

I first dealt with an EHR that handled data like this in a conversion project more than a decade ago. We had vast amounts of data that couldn’t easily be brought into our new system because the blood pressure field was a single field that would accept numbers, letters, and symbols. Assuming a sample BP of 140/90, users had entered it as:

• 140/90 sit (meaning taken seated)
• 140/90 R (meaning taken on the right)
• 140/90 RA (meaning taken on the right arm)
• 140/90 RALC (meaning taken on the right arm with a large cuff)
• 140-90
• 140.90
• 140s/90d

And so on. Our new system had separate fields for the systolic BP (top number) and diastolic BP (bottom number) as well as discrete fields for position, side, site, and cuff size. Due to the work needed in trying to cleanse the data, we quickly decided that we would just not bring any values into the new system and would start from scratch.

Since that conversion project was so long ago and I haven’t run across the issue since, I assumed that such handling of data had gone the way of the dinosaurs. I guess it hasn’t, or I’ve just been spoiled by more sophisticated systems. But I would have hoped that with all the focus on patient safety and regulations, that we would have moved past this and that consistent handling of essential data such as vital signs would be a requirement for vendors seeking certification. How in the world can you be truly interoperable with data like this?

We’ll see what happens with the vendor ticket and what my practice decides to do about it otherwise. If I was the CMIO, CMO, or medical director and this was my system, I’d be tracing it all the way through to find out what is being sent to the patient portal and what appears on transition of care documents and how extensive the problem might be.

Although this particular scenario was a pretty significant and obvious error, I’m sure I could have missed less significant errors during the last couple of years. Since I’m wearing my hourly staff physician hat in this scenario, though, I’ve notified our leadership and have to let them work it as they see fit. I’ll be spending extra seconds reviewing my vitals going forward, however.

This should be basic functionality, but I guess it’s not. I’m interested in hearing how other certified systems handle this type of data – whether they have field restrictions that would have prevented these errors, and whether they have active or passive alerts to create additional patient safety support. Consider adding a comment and sharing what you’re seeing in the trenches.

Got screenshots? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/17/16

I’ve been spending a lot of time this week on strategic planning for the next wave of healthcare reform. For those of you who thought Meaningful Use being “dead” meant we would be able to catch our breath, there’s an even more challenging sequel. I’m talking about alternative payment models and yet more acronyms – specifically MACRA and MIPS. In a recent blog, John Halamka describes the future:

Providers will be responsible for the care that their parents receive throughout the community — inpatient, outpatient, urgent care, post-acute care, and home care all contribute to total medical expense and wellness. Some of the care may be delivered by people and organizations outside the control of primary care. The only way they can succeed is by aggregating data from payers, providers, and patients/families in an attempt to provider “care traffic control.”

When I first saw it, I thought it was catchy – yet another way to try to describe what primary care providers do. We’ve been gatekeepers, quarterbacks, and now care traffic controllers.

But thinking about the analogy to air traffic control, it couldn’t be farther from reality. Commercial aircraft and their owners are required to obey certain rules across the board. There is a central body making those rules — we don’t have subsidiaries across the nation coming up with their own “local coverage” determinations. The rules are governed by logic, physics, statistics, and experience.

In healthcare, it seems that sometimes we have none of those forces at play. Humans are often irrational (stroll through the intensive care unit sometime and watch the futile and sometimes cruel treatments forced on the elderly by “loved ones”) and our behaviors are determined by a complex interplay of biological, social, and other factors.

Planes in the skies are required to not only identify themselves, but to broadcast their intentions regularly. They have to file a flight plan — they’re not allowed to come up with a confidential or proprietary flight plan, then spring it on the passengers at the last minute. Planes have to be inspected regularly and certified for safety. Pilots are retired for certain medical conditions and after certain ages. Additionally, airliners are required to have onboard tools to help determine what went wrong in the case of a failure. Such failures are scrutinized and the findings broadcast for everyone’s learning. This is far from how healthcare operates.

Lastly, the air traffic controllers aren’t punished for the actions of pilots who don’t play by the rules or airlines who cut corners. They’re not punished when passengers are kept on the tarmac for hours or when flights run late or are cancelled. They’re not personally liable for “oversold situations” or forced to compensate passengers for lost or mangled luggage. Under the “care traffic control” theory of healthcare, we’re asking front-line physicians (particularly primary care providers) to assume the equivalent responsibilities.

It was in that frame of mind that I started trying to work out some strategy for how my partner and I can assist physician and practice clients in navigating yet another seemingly dysfunctional scheme that is coming their way. It was also in that frame of mind that I received word that three more of my former partners from Big Medical Group had taken or were about to take the jump to either cash-only care models or concierge models.

One has been in practice for nearly half a year and interviews all her patients, taking only those who agree to her model of care. She has very little overhead due to her non-involvement with payers and the government, so she doesn’t have to see many patients at all to make ends meet. Additionally, she’s doing a time-share out of another physician’s office and is only paying for fractional use of his staff. But most of all, she’s practicing the way she wants to and finds her work satisfying again.

Not everyone can practice this way, and if we all did, “disruption” would not be a strong enough word to describe what was happening. But it’s an interesting thought and was a nice distraction as I worked through scores of analyses and discussions of where we believe policy and legislation will take us over the next two to three years.

Among all this deep thought, I’ve still been trying to get caught up after HIMSS. Given some of the changes to my business model and our plans to expand our offerings, I’ve been following up with contacts and reading proposals. I still have over 1,000 emails to deal with, and unfortunately, they seem to be coming in as fast as I can dispatch them.

One from today was a notification from Microsoft that they’ve released a fix for the pen issue I’ve been having with Office 365 and tablets. Although it’s only available to their Microsoft Insider group at present, they estimate it will be available to the general user base in a week or two. Although I’m eager to receive it, I’m not eager enough to sign up for the Insider program, which seems like an ongoing beta program with a high potential for workflow disruption.

I was happy to receive a couple of reader emails, including one with photos of the limbo portion of HIStalkapalooza. She managed to capture several people I know in the pics and I’m debating whether to share them with the respective parties or hold them for future blackmail.

I asked last week whether interoperability is really the answer to all our problems and was happy to receive a detailed reader response:

In my mind, not until we find a way to retire faxing. MU didn’t account for the value of narrative and so it left faxing as a safety net, therefore increased faxing. It’s a 40-year-old technology that is still the backbone of communication between practices and from hospitals to providers. Healthcare is wasting millions of dollars in time, money, and hours better used elsewhere dealing with faxing. My organization sends 35,000 faxes a week. Although 99 percent go through, that leaves 350 that don’t because of busy signals, practices that turn fax machines off on nights and weekends, and out-of-date or disconnect numbers. Still 10-20 fax issues come in daily, with the most common being:

• Provider left practice and no one told the hospital.
• Patient isn’t mine. It’s a Summary of Care for a patient referred to you for follow up, did you read the cover letter? Or maybe registration entered the wrong referring, ordering, or PCP?
• You’re wasting my paper and toner and I don’t want anything from you on my patients. (my favorite)

With 9,000 active providers and 20,000 referring, it is impossible to make routing rules that will make them all happy without micromanaging who gets what at the provider level. Even the progressive providers with EMRs and Direct addresses can only get ToC reports and not Notes, Transcriptions, and Letters. Why? Because it’s not in the locked down MU XML specifications. Sorry for the rant, I’m going to manually resend 1,000 faxes that didn’t go through on the first seven automatic attempts.

He bid me a good night, and so I pass it on to you. Sleep well with visions of fax machines dancing in your heads. Or perhaps you had a nightmare? Email me.

Email Dr. Jayne.