EPtalk by Dr. Jayne 10/8/15

It’s funny how you look at things differently when you’re a physician or healthcare provider. I’m always noticing automated external defibrillators (AEDs) when I’m in public places, especially now that they’re nearly everywhere. Most places have them prominently displayed with clear signage and the cases are either red or bright yellow so they’re easily seen. When I was recently on Capitol Hill, however, I noticed that the AED of Congress sits in a nondescript pedestal in a subdued black case. No matter where your politics lie, it’s somewhat ironic that Congress operates in a different world than what most of us know.

Since the Meaningful Use rules were published earlier this week, hundreds of health IT people were spending thousands of hours poring over them. Several of my colleagues lamented that it was a huge waste of time since there’s a high likelihood that Congress will create legislation to delay the start of Stage 3 beyond 2018. Without my crystal ball, though, to know if that will be true and when it will happen, I had to dig into all 1,300+ pages of goodness like everyone else. You know you’re an informatics geek when you’re joining your informatics friends in tweeting photos of the cocktails you’re drinking while you’re simultaneously reading federal regulations.

After a while, they became mind-numbing and I just had to quit and go to bed. When I woke up, I unfortunately did not discover that MU had all been a dream. I did discover invites to some CMS webinars, though, which helped provide an excuse to procrastinate the reading until I could listen to the highlight reel.

I tried to register for the webinar, but kept getting a Windows Live Meeting error. It finally registered me after trying multiple times over the next several hours. I started working some issues with my clients and discovered that one of them only sent out 70 claims for the first two days on ICD-10. Although they didn’t experience any unusual rejections, that’s a fraction of the number of claims that should have gone out with the average physician seeing 30 patients per day and this being an organization with more than 100 physicians.

My client is the IT department. They engaged me to figure out what’s going on. After entirely too many phone calls, we determined that apparently the operations team decided to switch to a system where 100 percent of patient visits receive review by a certified coder. Unfortunately, they didn’t let anyone on the IT side know, so IT has been chasing their tails trying to figure out what is going on.

Although 100 percent review certainly reduces your risk of miscoded claims, it’s not realistic in most organizations. I think these folks just gave themselves a self-inflicted cash flow problem. I gave the IT department some advice on how to quickly transition from 100 percent review to representative sampling, but I’m not sure they’re going to be able to get the operations management to listen.

Fast forward to Thursday, when I attended the CMS Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs Final Rule Overview webinar. I’m curious about the inclusion of an additional 60-day public comment period. Although HHS is “committed to working with stakeholders,” what are they really going to do with the information? The comment period is limited to Stage 3, so it sounds like they’re leaving the door open for further changes even if Congress doesn’t act.

Webinar pro tips from a seasoned trainer: when you do introductions, put up a slide that lists the name and credentials of the person speaking. The first speaker was introduced so quickly I barely caught her name. The entire time we were looking at the title slide for Elizabeth Holland, who was the second speaker. Her title, however, was not listed. Although many people know “everyone” in the MU community, not everyone knows exactly who you are and why you’re speaking. She did apologize for the overloaded webinar and that people that were turned away – it should have been something they could have anticipated based on the issues with the registration.

Due to the vastness of the 752-page rule, the webinar largely focused on modifications to Stage 2 and in particular what we need to know for 2015. Attendees were encouraged to read the entire document to find responses to their questions.

The highlight reel for MU Stage 2:

• No flexibility in using CEHRT certified to previous edition criteria. Providers must use 2014 Edition CEHRT in 2015 and subsequent years until they transition to 2015 Edition CEHRT, which is required for reporting in 2018.
• Much emphasis on aligning 2015-2017 Modified Stage 2 measures to Stage 3, which will be required for everyone in 2018.
• Alternate measures and exclusions remain largely unchanged from the proposed rule. These help providers who planned to attest for Stage 1 or Stage 2 to be able to meet Modified Stage 2. These were essential since the rule was released later than anticipated. They’re fairly detailed and were addressed as each measure was covered. I got lost in the details on a couple of them, so I’ll do like the presenter and refer you to the Final Rule for details.
• CPOE landed at 60 percent for medications, 30 percent for labs, and 30 percent for radiology.
• Hospitals are at 10 percent of discharge meds meeting the same criteria.
• Transition of care requires use of the CEHRT to create a summary of care record; more than 10 percent of transitions of care and referrals must be transmitted electronically.
• Patient education is 10 percent for EP unique patients seen during the reporting period and also 10 percent for EH patients admitted to the inpatient or ED places of service.
• Medication reconciliation remains at 50 percent of transitions of care to the EP or EH/CAH.
• Patient electronic access threshold is 50 percent to receive access within four days for unique patients seen during the reporting period. For 2015-15, only one patient seen during the reporting period must view, download, or transmit. This goes up to 5 percent in 2017. Hospitals must provide access within 36 hours of discharge for more than 50 percent of patients. The VDT thresholds are the same.
• Secure messaging has to be enabled for the reporting period in 2015 on a yes/no basis. For 2016, at least one patient must engage in secure messaging. For 2017, this goes up to 5 percent.
• Public health reporting has four measures and several nuances, so I’m going to refer you to the rule here as well. Frankly this was covered 45 minutes into the call, so I had glazed over a bit. I zoned back in when they were talking about a FAQ on this issue, so my advice is to read all the FAQs and act accordingly. (And by the way, they change all the time, so you might want to appoint someone to check them daily.)
• No changes to CQMs and the period is 90 continuous days.

For Stage 3:

• Removes redundant, duplicative, and topped out measures (no surprises here) and intended to reduce provider burden. Not sure it meets the mark on the latter.
• The presenter started talking about specific measures and their changes without a supporting slide. I got completely lost. They were not reviewed in detail.
• The comment period closes December 15.

Tips for 2015:

• Confirm your stage.
• Update your registration information through NPPES including email and payment information as well as surrogate users. Ensure your 2014 Edition EHR identification information is documented.
• Reporting periods are any continuous 90 days in the calendar year except for hospitals, which can go back to the last quarter of 2014.
• Attestation opens January 4, 2016 and runs through February 29, 2016.
• If users claim they can’t meet the requirements because the rule was so late, they should apply for a hardship exception. Expect the FAQ to be up shortly.

I didn’t really expect it, but I would have liked to have them at least acknowledge the fact that they put a 90-day reporting period in place for this year, yet announced the requirements after the last possible 90-day period had already started. I know that’s what all the exclusions are about, but it just seems overly complex when it’s supposed to be simplifying and consolidating things for us. Being able to acknowledge a mistake is also a good customer service move. Vendors still have to support multiple sets of reporting and performance criteria.

As a side note, I’ve never heard the CAH abbreviation for Critical Access Hospitals pronounced as “Caaaa,” so that was a bit jarring every time I heard it.

Please excuse any typos or errors in my summary. I’m frantically typing it after a long day of “real job” work so Mr. H can get it to press.

Have you finished the rule? What are your thoughts? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/5/15

Now that we have the official ICD-10 go-live behind us, we can breathe a little easier. But it’s not time to let our guard down. In fact, if one more person tries to tell me it was a “non-event,” I’m likely to scream. The fact that things have gone smoothly so far is largely due to the millions of dollars and hours spent making it go as well as humanly possible.

Although I haven’t seen any major hitches, the majority of practices I work with have had only a small percentage of their claims processed. Many practices haven’t even sent claims out the door yet. They’re waiting for providers to finish their notes, for coders to review them, for managers to harass the providers to finish the notes, for pathology to return so codes can be determined, and more.

Two business days is far too early to judge whether this transition has been successful. I think it’s going to take at least two to three weeks to fully understand whether there are going to be cash flow lags or other downstream impacts. Long story short, it’s too early to let our guard down.

Our colleagues on the revenue cycle side need to be watching carefully and communicating as soon as they suspect there might be issues. Although Medicare has said it will not penalize physicians for coding without the ultimate level of specificity as long as the diagnoses are in the ballpark, I haven’t heard from many payers that they’re willing to look the other way.

Still, for those of us that have been heavily invested on the training side of things — particularly on the provider and coding aspects of the transition — the bulk of our work is behind us. This week I’m doing a handful of remedial training sessions for providers who either didn’t pay attention the first time they were trained or had valid reasons to miss.

One of my customers today has been on family leave with a new baby and warned me that he feels like he’s been “under a rock” as far as keeping up with things. He did well with the training, though, and asked a lot of good questions. Based on his performance with practice scenarios, I think he’ll be fine. He said that compared to the recent upheaval of his life as he knew it coupled with ongoing sleep deprivation, ICD-10 seems like a piece of cake.

A lot of people are asking me what I’m going to work on now that I have some relative free time. I’m going back to helping practices work more efficiently and effectively with their EHRs. I’ve already scheduled several clients both large and small for optimization visits. They know I’m going to go through their processes with a fine-toothed comb and look for ways to make them more efficient or at least less stressed. Some will be micro workflow within the software itself, but I’d estimate that nearly 80 percent of what I do is macro process work.

There are plenty of non-IT processes that need tweaking in many offices. Some may be straightforward, such as reducing the need for patients to call the office for medication refills. In a typical primary care office that hasn’t addressed this yet, I can generally free up a staffer for two to four hours a day by streamlining the process. I work with providers to help them understand the benefits of refilling medications for a year at a time (or at least through the next scheduled visit) or to help them consider a refill protocol where nurses or other staffers can do some triage. We educate patients that they can request refills through patient portals or directly through the pharmacy, which allows us to handle them electronically vs. on the phone. We set up efficient processes for those medications that can’t be handled electronically, such as controlled substances.

This is pretty basic stuff that many organizations addressed during EHR go lives. But there are plenty of people out there whose practices were just fighting their way through EHR training and didn’t spend any time on practice redesign or clinical transformation. Now that they have the technology, they’re having to circle back to figure out the best ways to use it. They’re also realizing the continual squeeze that comes from increasing payer and regulatory burdens. They need to free up time for staffers to start doing new work that’s going to bring revenue to the practice – things like care management, patient outreach, and population health.

I’m also seeing a fair number of practices that want my help with technical projects. Some of them bought tools and technology that they never implemented because their attention has been pulled by Meaningful Use and ICD-10. Now that they have a bit of a comfort level with both of those challenges, they’re circling back to see how they can use their new toys or to see if there are features or functions in their EHRs that they missed the first time around. Maybe they were just too busy or maybe they weren’t philosophically ready for them, but it’s always good to revisit and see if you already have tools that can be of help.

I’m doing two population health implementations for small practices. Both of them have solutions from their primary EHR vendors. One never went through training and the tool has just been sitting on the virtual shelf. The other went through training but never fully implemented it, largely due to perceived lack of staff. They recently added a part-time role for care management and population health, so we’re going to dig in and get a program up and running. I’m familiar with the tool they’ll be using and it’s decent. The biggest challenge they’re going to have is figuring out how to narrow their populations to the most high-risk or high-yield patients.

I think physicians see population health solutions and the ability to find all your patients that have X disease or X need, and reach out to them. It’s an attractive concept for those of us who went into primary care to help prevent disease or help patients maximize outcomes. However, the reality is that many of us have been collecting a lot of data, and if we tried to act on all of it, we’d quickly outstrip our practices resources to handle it. That can lead to some difficult decisions for physicians.

In the absence of real risk profiling data, they have to select whether they want to target the oldest or the sickest patients because they’re at the highest risk of complications. Or perhaps they should target the youngest because they have the longer time-burden of disease in their futures and the greatest opportunity to change. They also have to figure out how much staff capacity they have. Do they have enough open appointments over the next several months or do we need to do a project to burn down the appointment backlog first? Do they have enough phone lines to handle return calls from digital outreach and enough people to answer them? Do they have enough hours in the day?

Physicians are always surprised when I suggest small pilot programs first. Many of them are so used to trying to do everything for everyone that it’s counterintuitive to ask them to do less than that. My goal is to do a smaller project where they can be successful, then build on that to involve more patients or more conditions. This lets change happen organically in the practice rather than it being a complete upheaval. We’ve already had enough of that in medicine. We need to try to stop doing everything at once and just take it one day at a time.

What’s your plan for post-ICD-10? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/1/15

ICD-10 Edition

I volunteered to take one for the team today, covering the 11 p.m. to 7 a.m. shift so I could handle any of my practice’s ICD-10 issues personally. It’s usually pretty slow until 6 a.m. and lets me get some sleep in an incredibly comfortable recliner, so I figured I’d be able to get home and have my mini command center up and ready for my consulting clients by the time most of them started adding diagnoses to their charts.

Since we run 24×7, we decided to schedule a mini-downtime from midnight to 1 a.m. to do some testing and make sure everything switched over automatically as our vendor assured us it would. That’s one of the benefits of having hosted software – they do all the upgrades and handle the transition timeline. On the flip side, when things go bad, there’s not much you can do to fix it. We had prepared just about as well as anyone could and have been running dual coding for several months.

This has allowed us to shake out some problems with the ICD-9 to ICD-10 crosswalk and make sure that we were confident our most frequently used diagnoses were converting cleanly. The dual coding in our application is a little odd, though – it takes the ICD-9 code and maps it to SNOMED and then to ICD-10. I guess it’s not using the CMS General Equivalency Mappings, but something else under the hood. That progression would lead to some occasional oddities, but nothing too major had cropped up.

Although I’m not officially in charge of the EHR, I’ve had plenty of opportunity to kick the tires, but as they say, there’s no test like Production. We do a fair amount of workers’ compensation, so ICD-9 isn’t going away any time soon. We’ll still have to do some ongoing conversion to get those claims out the door.

My first surprise of the day occurred before midnight. Apparently some odd mapping was going on, where the ICD-9 code for a symptomatic venomous insect bite was being mapped over to the ICD-10 code specific to venomous snakes. Because the diagnosis code also drives the patient discharge instructions that are printed for them to take home, I had to fix it right away rather than leave it for the billers to take care of.

I also noticed some weirdness with our diagnosis favorites lists. Our discharge instructions for common conditions like sinusitis and bronchitis were no longer linking up correctly. I had someone re-test it about 30 minutes later and they were both working correctly, which led me to suspect that perhaps the vendor was doing some work leading up to the midnight deadline that we weren’t aware of. Alternatively, maybe they were switching everyone over on the Eastern time zone timeline regardless of where they were physically located.

The biggest problem I saw before midnight was one where somehow a diagnosis of “separated shoulder” became mapped over to O32.2xx1, which is “Maternal care for transverse and oblique lie, fetus 1,” which makes no sense whatsoever. We opened a support ticket and flagged the chart for follow up. That was about the time we were scheduled to drop to paper for an hour, so we went ahead and made the switch.

I only had two patients in progress when we went to paper, one for a laceration and the other stopping by to get a flu shot on the way home from work. Neither was a problem as far as documenting on paper, so I let our “official” IT people get on about testing the direct documentation of ICD-10 without dual coding. They quickly ran through our top 50 diagnoses without problems so we decided to go ahead and start documenting in the EHR again before any other patients showed up. I was eager to see how it would function, but the overnight was quiet, so I hit the recliner.

At about 5:30 a.m., we had a couple of patients, one of whom was a workers’ compensation patient coming by for a clearance before returning to work. The patient had already been in and was diagnosed with an ICD-9 code previously, so I just sent that back out on the claim without any conversion. Thank goodness for the “use previous diagnosis” button! The next couple of patients were for easily-documented conditions – cold symptoms and migraine. Both could have been treated at home, but unfortunately both employers required work notes for time missed. Sidebar: In my next life, I’d like to fix all the waste introduced into the healthcare system by employers requiring work notes.

My relief physician showed up early to see how bad it was going to be, but I didn’t have much data to provide an opinion. I signed out the now-empty board and headed home to get ready for my personal clients. The morning has been surprisingly quiet with only a handful of issues, mostly providers who needed help getting their favorite codes added. While researching a couple of issues, I came across some bizarre codes. One was T63.483 “Toxic effect of venom of other arthropod, assault” which I hope I never have to code in practice.

I’ve been monitoring Twitter and it looks like Athenahealth posted their first claim adjudication pretty early this morning. I’ve not heard much from other EHR vendors, but would be interested to hear how things are going both there and at the clearinghouses. We won’t know the true impact until claims make the full circle and payments start coming in.

How’s your ICD-10 going? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/28/15

There was a fair amount of buzz around my recent Curbside Consult on Theranos and its CEO, Elizabeth Holmes. Most of the comments and emails agreed with the need to question the company and its approach.

Thanks for putting a little reality into the mix. Like many in the healthcare field, I’ve been shocked at the money and attention being given to them. A couple of facts: the actual blood draw is a fairly involved and still painful procedure involving a “trained pricker” who prepares the finger for a few minutes with warm towels before sticking you to get the blood out. Personally I find finger sticks more painful than traditional blood draws. Sites still need trained people and it still takes 5-15 minutes per patient. Not very efficient. As for timing, the results don’t come back immediately and I believe it takes 15, 30, or more minutes. Most patients will be long gone anyway, so how is that much different from sending to a lab and getting them back the next day? I’m not sure “point of care” labs are hugely valuable for the typical primary care physician as the results are not immediate, and even if they were, they would only make sense if the patient got labs before the visit.

The reader goes on to agree that the industry is ripe for disruption, but that we need a couple of evolutions first. We need non-invasive testing that can be done almost instantly, as well as tests that are so cheap every patient will be able to come to the office to have them done immediately before seeing the physician. Maybe they’ll be able to do them at home or on a regular basis. He thinks maybe Theranos will evolve to that or maybe some quicker, cheaper company will come along. Another possibility is computerized algorithms that clarify what needs to be ordered and how to understand the results and explain them to patients.

There were also anecdotal stories about the risk of ordering labs without a clear indication.

I am a medical technologist, moving over to IT after having spent over a decade in the reference lab industry. I agree with your statements regarding interpretation of test results. My pregnancies were after age 35 and I chose to have an amniocentesis. A physician inadvertently ordered an AFP test during my second pregnancy. I didn’t know it was ordered, but found out it was elevated after a negative amnio. If I had received the results without the context of the amnio, it would have led to a great amount of stress. I fully support technology to lower costs in our healthcare system and consumer-friendly strategies to expand access and experience for patients as purchasers, but frankly don’t get the buzz around Theranos. Coordination around the right test for the patient at the right time with the right engagement of the patient makes sense. If the patient can get the order fulfilled easily and at a low cost with communication to their care team, than I am interested.

I have also been on the receiving end of tests ordered without my knowledge. Even as a physician, the results were stressful because there wasn’t a clear indication and I was confused as to what the ordering physician suspected. We’ve come a long way from the paternalistic “doctor knows best” days and I fully agree tests should be ordered with patient understanding and consent.

Additionally, physicians should explain why they’re ordering a test and what they hope to do with the results. In addition to justifying the medical necessity, this can get the patient thinking about the potential outcomes and what we might do with the information we get back. Several wise medical school professors beat the fact into my head that you should never order a test unless you’re ready to do something with the result. Unfortunately, I see a lot of tests ordered for no good reason. Some of these orders are influenced by our reimbursement system, which makes it easier and cheaper to order a bundle of tests than the individual tests that one actually needs. Medicare is guilty of supporting, this but I don’t think it’s ever going to change.

Some readers took issue with my assessment: 

Traditionally, physicians have purposely kept patients in the dark in regards to what their lab tests mean. Even today, physicians routinely send “normal cards” to their patients without any explanation as to what the real values are or how to interpret. As healthcare requires increased patient engagement and increased participation in their care, it is imperative that all providers either teach or provide educational materials to start the educational process on what lab tests mean. That would be to understand normal variants, normal abnormal for the patient, etc.

I wholeheartedly agree. Most of the major health organizations in my area did away with “normal cards” for patients more than a decade ago, along with the antiquated notion of “no news is good news.” Our patients have been getting copies of their labs since 2008 or 2009 and most of the time they have physician annotations, unless the labs result on a weekend when the office is closed, in which case they should receive a communication on Monday. At my former employer, physician bonuses helped drive this behavior.

It sounds like this reader is also advocating that we all have a role in promoting health literacy. Dr. Wu commented on this topic, saying,

Health literacy is, as you may agree, embedded in the archaic public health concept of health promotion, which is still rooted in a pre-Internet, paternalistic medical model approach… Perhaps Ms. Holmes’s analogy is ironically correct — a weapon can be used for good (crime prevention) or bad, and how it is used, intent, and training are variables. Giving patients unfettered access to their medical data without context, training in a usable format, accompanied by an actionable plan is like handing a loaded weapon to a random person on the street. Oh yeah, we allow that.

I disagree that the concept of health promotion is archaic or paternalistic. Although it may not apply to all specialties, most family physicians who have trained in the last three decades have been schooled in health promotion as a shared interest between the patient and their care team. Health literacy is an essential part of health promotion and should be all of our responsibilities, whether we’re part of the public health infrastructure or not. As I mentioned above, physicians that order tests without explaining the risks and benefits to a patient are part of the problem.

Reader Long Time, First Time also disagrees:

Is this what passes for critical thinking in the doctor’s lounge? I doubt Theranos or Ms. Holmes has any more obligation to educate patients than your profession does. After centuries of privilege, your profession seems to take little accountability for the ignorance of your “real world patients,” as you like to call us sheep. You seem to think like the clerical elites that one resisted translating the Bible from Latin into the vernacular. In fact, I bet some of these same arguments are used in Saudi Arabia to keep women from driving cars. First they must understand fuel injection before they can drive… So in order to be acceptable, Elizabeth Holmes must first succeed where your professional has failed. I will posit that your professional elite never tried to educate us. This is a false and unattainable standard you are applying to Theranos. The Pot has once again called the Kettle black. I do not know if Elizabeth Holmes is the next PT Barnum of the next Steve Jobs. I do doubt she has any obligation to educate me, either in a moral or legal sense.

I didn’t say she had an obligation to educate patients, rather my hope that she would champion health literacy so that the average person could truly be empowered to take charge of his or her own health. Theranos and Elizabeth Holmes are receiving a tremendous amount of attention these days and could use that to the further advantage of patients across the country. I also hoped she’d find greater connection with the people she’s trying to serve, as I agree with many that her isolation isn’t good for her (or the company) in the long term.

I take issue with your point about making people understand fuel injection before they can drive. Keep in mind we don’t just let anyone drive in this country either – one has to be of a certain age and has to have passed both a written and skills test to do so legally. They may not need to understand fuel injection, but they do need to know the difference between the gas and the brake so that no one gets hurt.

Although I know that many physicians don’t have the time or the skills to truly engage with their patients, there are tens of thousands of us that do so on a regular basis. We do take it personally when our patients have difficulty understanding their health issues, and if we can’t get the job done, we’re not afraid to leverage other members of the care team. I certainly don’t have “centuries of privilege” behind me and was trained in several programs that kept the patient at the center of the care team.

There’s no litmus test that requires Theranos to atone for the sins of other professions, but one would hope they could use the spotlight currently shining on them to do more to help people understand exactly what it is they’re offering and how it could be of benefit. I do, however, think there should be a litmus test for companies that sell products that could be potentially harmful. If we have to put a disclaimer on a set of lawn darts, then we should probably have some protections around patients ordering tests whose results could lead to harm. Most physicians who have had to work up something like a false positive CEA (cancer antigen) test would probably have stories to share about the harm something like that can do and the unneeded fear, pain, and costs associated.

A couple of other readers made similar points that I agree with. From Not From Monterey:

Honestly, and this isn’t a cop-out, I believe that both you and the Theranos lady are correct. It is right to have people (or put differently, consumers) be allowed to buy tests on their own and it is also correct that many, many people in our fair nation would have no idea how to interpret the results of those tests. I think Elizabeth Holmes’s target customers are not the 50+ percent of our nation that are working poor or lower middle class. She’s targeting the young and well-educated who are doing pretty well but would love to get more information about their health. I know plenty of people who are not smart enough to understand the basics of lab test results, and that number of people might at times even include myself. But I also know lots of very smart people who can use Google, compare information across authoritative sites, and ask for advice. The second group is the bunch that Holmes will be targeting. I can’t pretend that this direct model, taking physicians out of the loop, won’t create confusion or misinformation. But it might also help some people. Some people.

I think you’re spot on. As a physician, though, I am morally obligated to serve all types of patients, not just those with the resources or education to manage tests on their own (and I’ve seen plenty of really smart people, including physicians, get in trouble managing things beyond their expertise). I’m happy to support greater engagement to those patients with the desire to be engaged whether they have the financial or educational resources to do so.

I’ll close with one reader’s personal Theranos story from Engaged Patient:

Just read your article on Theranos. I use to be in awe of this upstart who went up against Quest and Labcorp. But that impression changed when I got my own test done there. I have a severe family history of diabetes and had a wake-up call with a hemoglobin A1c of 6.0. I became an avid runner and ate well for three years. August 2015 was my next turn to see what improvements I brought to my health. Theranos did a complete venous draw (traditional test tube) on me, not the much-advertised finger prick. The result came back 6.0 and my PCP advised getting it done with a local reference lab. Their result was 5.4. If three years of sincere lifestyle changes had not moved my A1c lower, I was contemplating medication in the near future.

My issue with Theranos is that they don’t make it explicit to patients that not all their tests are FDA certified. They get undue press attention for the one-drop capillary draw – lots of marketing done for that. But the truth is that they, too require venous blood in huge amounts. How the heck does FDA/CLIA let unverified tests be out there for public consumption? I find Theranos to be dishonest and deceptive. I think we (health IT enthusiasts) are sometimes so deep in our MU/HIE/EHR world that these small, dangerous twists in the mass market go unnoticed. I shudder to think what would happen if a non-health-IT person would use Theranos to make health decisions.

I’m not the expert on laboratory regulation except where it is involved in how results are ordered and rendered in EHRs, so I’ll have to rely on readers to comment on the latter points. But the example brings up another wrinkle, which is that sometimes it’s important to make sure serial tests are being done by reference labs using the same or at least comparable methodologies. Different reference ranges can also cloud results even for tests that are supposedly “standardized.” I once counseled a patient who was in tears about his lab results, which were essentially identical. However, one facility reported them in nanograms (10) and the other in picograms (10,000) making it appear to be a dramatic change.

I don’t claim to have all the answers. If the comments are any reflection, none of us really do. The only constant is change and it will be interesting to look back at Theranos in three, five, or 10 years and see what they accomplished.

What do you want to accomplish in 10 years? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/24/15

We’re just under a week until ICD-10 hits and I’m starting to hear about some potential issues. One of my colleagues received an email from his vendor informing him that although he had taken all required patches and performed all necessary steps, he needs to take another small patch. Needless to say he’s not amused and I don’t blame him. As one of the few independent small practices left in the community, it’s not like he has a full IT staff that he can just hand it off.

I’ll be glad to stop receiving daily emails about ICD-10, especially the ones from CMS including these questionable graphics. Although the cardiology and orthopedics ones make sense, I’m puzzled why family practice is represented by the Star of Life, which traditionally represents ambulance and emergency medical services. If you look carefully, there are two snakes on the staff, making it the staff of the god Hermes rather than the Rod of Asclepius. Wikipedia has a great summary of the “one snake or two” controversy, including some ironic points, if you’re looking for a diversion. At least we’re not represented by an unfortunately stylized uterus or a sad-appearing bear, so I shouldn’t complain.

It will be interesting to see if we have a government shutdown competing with ICD-10 for attention. Regardless, the work of ONC rolls on. Public comments are being accepted on a draft of the 2016 Interoperability Standards Advisory. The comment period is open through November 6. The Advisory includes not only recommendations from the HIT Standards Committee, but also feedback from public comments on the 2015 Advisory.

Primary care physicians are nowhere near the top of the physician salary list, so they’re often concerned about the cost of delivering new models of care. Although they will receive higher payments if they can demonstrate greater quality, it often requires hiring more staff to implement programs to move the quality needle well before the first payment increase arrives. One of my former partners forwarded a Medscape article that lists the cost of maintaining a Patient Centered Medical Home practice at over $100K per physician per year. This represents the extra staffing needed for increased quality reporting, patient outreach, and care management.

The data comes from a University of Utah study that looked at 20 primary care practices across Utah and Colorado. The data assumed a patient panel of 2,000 patients with an incremental cost per member per month of about $4. Physician leaders are using the information to help spur payment reform, including requests for upfront payments to transform practices and train staff. The study looked at practices that were already high functioning with EHRs in place. For less-advanced practices, the cost of PCMH will be even higher.

I’m extremely happy to report that I have delivered my last scheduled ICD-10 training session. I left a few days open for last-minute stragglers, but it doesn’t look like I’m going to have any takers. I’m glad for a couple of days without client engagements so that I can recover from the last six weeks. I can only describe them as a slog. I plan to catch up on Netflix (“Call the Midwife,” Season 4 is beckoning) and rest as much as possible. I’m sure next week will bring some emergency consultations and I want to be ahead on my beauty rest.

It won’t be all fun and games, though. I’ll be attending Monday’s FDA/CDC/NLM Workshop on “Promoting Semantic Interoperability of Laboratory Data.” I’m looking forward to the scheduled panel discussion on LOINC adoption. Although all the EHR vendors I work with support LOINC result codes, I’ve struggled with several reference lab vendors who fail to deliver the codes with results. Even the large national reference labs seem to struggle with this and I’ve had to push some regional lab representatives to deliver what my clients need. It shouldn’t be this hard. There’s also an open public comment section, but comments had to be submitted in advance, so I don’t expect much drama.

I wanted to be a physician since I was small. Thinking back on a career in medicine that morphed into one in informatics, sometimes I’m still surprised by some of the things I end up discussing in casual conversations. LOINC codes are one of those things. I stumbled into a lab normalization project at my health system that led to a clinical repository project that morphed into a standardized order project. After beating my head against the wall with disparate lab systems as they gradually came together, I really became a fan of LOINC and it’s something I enjoy working with.

I have a client who insists on pronouncing it “Low-Ink.” The first couple of times they said it, I had trouble connecting the dots to figure out what they were talking about. While I was cruising the LOINC website the other day, I came across this page confirming it really does rhyme with “oink” and also that the pig is the “unofficial official mascot” of LOINC.

Have you worked with a vendor or a technology that has a mascot? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/21/15

A quote in this week’s Monday Morning Update caught my eye. Billionaire CEO Elizabeth Holmes of Theranos addressed concerns that average patients aren’t capable of understanding their test results:

The idea that I as a human should not be free to access my own health information, especially using my own money – even though I can buy weapons and anything else I want – and rather should be legally prohibited from doing so, summarizes the root of the fundamental flaw we’re working to change in our healthcare system.

While Holmes may be a prodigy and a billionaire, I wonder how much real-world experience she has interacting with real world patients. It’s likely to be minimal, since she readily admits to barely having a life outside of Theranos. She’s quoted as saying she “doesn’t really hang out with anyone any more” and also doesn’t date, saying she “literally designed my whole life for this.” She even chooses her wardrobe based on efficiency and elimination of the need to make decisions.

Certainly she has advisors — some of them might want to clue her in on what the average patient’s situation looks like. Most of my patients don’t have the means to buy anything they want. Many haven’t had the opportunity to attend college and would find it hard to understand why someone would drop out. Some of them barely graduated from high school. General literacy is an issue, pushing health literacy farther down the list. Most of our patient education materials are written at the fifth grade level and even then it’s still not understandable.

I’m puzzled by her reference to buying weapons as well as her premise that we aren’t already free to access our own health information. Although it might be sometimes challenging (as Mr. H has illustrated in his quest to get a copy of his hospital chart), records are generally more open than they’ve ever been. I’m confronted on a regular basis by patients who have received laboratory results directly through a patient portal and are worried about what they see since it’s often delivered without context. I have had several patients bring in printouts from an EHR patient portal and ask for me to explain high or low lab values when they see them on the weekend and can’t get in touch with the ordering physician.

Unfortunately, they’re often out of context even for me. If I don’t have access to the ordering physician’s thought process or other benchmark values, I can’t really advise the patient one way or the other. Maybe it’s a low value and it’s trending up or maybe it’s getting worse, but it’s often impossible to tell. Knowing that many patients don’t understand the idea of reference ranges (defined by statistics – so that you can be “out of range” but still healthy) it’s likely they won’t understand more complex concepts such as the positive predictive value of a test or its ability to rule in or rule out a disease.

In the interview Mr. H referenced, the examples of breast and prostate cancer are mentioned. Screening tests can lead to false positives and unnecessary procedures. Over the last several years, we’ve seen PSA testing fall out of favor, but patients still request it. Once I discuss the evidence, a good percentage of patients decide to opt out. Given the availability and accessibility of cheap testing, patients might opt in to testing that could be dangerous to their health. Theranos has been instrumental in creation of Arizona laws that allow patients to order their own tests. Based on the fact that tests aren’t without risk, I’m not sure I agree with that approach.

I also disagree with their premise that 40 percent of people don’t get blood tests ordered by their physicians because of the fear of a traditional blood draw. Holmes is admittedly “terrified” of traditional needles. I agree with her assertion that cost is an issue that prevents patients from receiving recommended tests, but I’ve only seen one patient in my career with an actual fear of needles.

I do agree our healthcare system is broken. If Theranos can compete with the large reference labs, everyone will benefit from reduced costs, improved access, and less-invasive testing. If they inspire patients to take charge of their health, even better. But I’d challenge them make sure they’re putting their proverbial money where their mouth is by also providing education, not only to patients, but to the greater community.

Holmes is experimenting with life in the outside world and has been speaking to young women to promote academic achievement. I’d love to see her champion health literacy so that the average person can truly become empowered to take charge of his or her own health. Theranos has multiple job postings for creative, sales, and marketing positions – what better way to leverage them? Even though she’s dedicated her life to solving a narrow problem, she may find other ways to think about it as well as experiencing a greater connection with the people she’s trying to serve.

What do you think about Theranos? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/17/15

Even though I’m no longer on staff, I’m glad that my former employer still hasn’t taken me off its mailing list. The quarterly Medical Staff Newsletter is a nice way to keep up with my former colleagues. I was excited to see that the hospital recently launched a new community outreach program. In an attempt to prevent readmissions, it uses paramedics with advanced training to perform scheduled home visits. Patients can be assessed for signs that their chronic health conditions are progressing are becoming unstable. The paramedics also provide disease management counseling.

For an initial panel of pilot patients, emergency department usage was reduced by 67 percent. Since I work in a couple of different practices, I wondered how they are contacting the providers of record and whether we’d be seeing any communications in our EHR. Unfortunately they are using a standalone system that was designed for home health and it isn’t connected to anything but the hospital’s clinical data repository. The mode of communication to attending physicians: fax.

I also chuckled at its promotion of staff physicians who appeared in the “Best Doctors” edition of a local magazine. The methodology used by some publications to create those lists is sometimes questionable and reminds me of a high school homecoming court election. People often vote for the names they’ve heard most often, regardless of personal experience or knowledge. Two of the providers on the list have been gone from our community for more than 18 months, so they’d be hard to refer to. Another one is retired. My favorite entry is a physician who has been disciplined multiple times and who sexually harassed me in the operating room. It’s bad enough that they were included on the magazine’s list, but I’m embarrassed at the hospital using them for marketing purposes.

The newsletter also included the first communication I’ve seen about the new EHR conversion project. The vendor was officially selected in December, but planning has been kept fairly quiet. They’re still not saying which facilities will go first, but they’re at least warning clinicians that it’s going to take more than three years to complete the migration across all business entities. Although I wish them the best, I’m glad to not be fighting in that particular skirmish.

A reader sent me this awesome ICD-10 countdown clock, which I’ve added to my personal website. As I continue my practice road show, I’m seeing people who are seriously worried about the crash of the revenue cycle as we know it.

I’m thinking about making one of those construction paper chains that we used to do in elementary school as we counted down to holiday break. Tearing off a link each day as we march towards what some are describing as “billpocalpyse” might be therapeutic. One physician I trained today actually talked about provisioning a safe room in his house in case staff comes with pitchforks and torches when he can’t pay the bills. Although I think it was a joke, at some level I think he was actually consider it.

Several readers wrote in about their ICD-10 training experiences. One works is tasked with helping clients navigate the transition. At a recent client forum, he describes comments that, “Most of the training that is out there is useless. The only content that had any agreement on whether it was not it was useful was CMS’s Road to 10 specialty content – specifically the coding scenarios for each specialty.” As a physician (and purveyor of training myself), I agree that scenario-based practice is essential. In addition to making sure they know how to code items that are on specialty-society or CMS lists, providers should also ask their IT staff to run a list of their top 10 or 20 diagnoses and practice coding those. If your docs haven’t done it, please make the suggestion. You’ll be glad you did.

Another reader commented on my recent mention of electronic prescribing of controlled substances. Apparently Imprivata has a hands-free authentication solution, capturing the token code from a cell phone without requiring manual entry. I’m pretty sure we could get away with having phones as long as they stayed in our pockets. I’m definitely going to check it out and appreciate the tip because as much as I try to stay on top of new products and offerings, it’s impossible.

As part of one of my ICD-10 engagements this week, I also presented to a group of physicians about Meaningful Use. Although we know a final rule for Stage 3 is imminent, many of my colleagues think it has become a big joke. I’m hearing from more and more that they’re willing to take the penalties just to regain control of their practices. Of course I’m not hearing that from physicians who sold out to large health systems or to hospitals – they’re stuck with whatever is handed down. Many organizations have already budgeted the incentives and planned not to incur penalties and don’t seem open to altering the future balance sheet.

Have you opted out of Meaningful Use? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/14/15

We hear a lot of chatter about big data and the ability to conduct analysis and draw conclusions from enormous volumes of information. I know I’ve written previously about attempts to determine whether Agatha Christie was developing dementia through analysis of her writings. I’d love to do analysis right now on some of the physicians I’m connected with through social media. Based on some of their posts, one might extrapolate a far-reaching conspiracy, mass paranoia, psychosis, or all three.

What has them so excited? It’s ICD-10, of course. Apparently quite a few hospitals are just beginning their ICD-10 preparations. For physicians who are on staff at multiple facilities, the training requirements are converging to form a perfect storm of regulatory madness. One of my friends from medical school reports being required to complete training programs at all three hospitals where he has medical staff privileges.

Despite having completed two previous programs, the third hospital is requiring him to complete more than 20 online training modules. Even though he’s a particularly specialized surgeon that deals with a part of the human body smaller than an elementary school milk carton, he had to sit through courses on coding for OB/GYN, neonatal diseases, and specialties he’s never going to use.

Since this was his third go-round, he timed the modules. They took more than 15 hours. He also reports that the narration was done by someone “with no idea how to pronounce medical terms.” I hope he was multitasking during the non-relevant portions or at least enjoying a cocktail because I know I would have gone crazy if faced with the same scenario.

It’s been entertaining to watch the back-and-forth as other physicians respond to posts complaining about ICD-10. One friend asked, “Is it just me or is ICD-10 going to make the practice of medicine more inefficient? Does it seem like it was created by bureaucrats who are trying to assert a rationale for their existence?” Another responded that the second question provides the answer to the first.

A third friend answered that without required ICD-10 courses, new regulations, and more hassles, “the woman who doesn’t know how to pronounce medical terms and lots of other people like her wouldn’t have a job, so they come up with new rules to keep themselves busy to justify their jobs.”

Indeed, that sounds a lot like some of the bodies that have been making an increasing number of healthcare regulations over the last several decades. There was a comment that ICD-10 is a conspiracy “to force physicians into the arms of hospital networks.” Certainly one might be inclined to only be on staff at one or two facilities rather than three or four if one has to take redundant training. I sympathize with what he’s going through – I once went live on the same EHR at two different hospitals and had to complete the entire training curriculum for both, even the parts of the system that are not client-configurable.

Another friend suggested just blowing through the slides and taking the end of module test since “doctors are some of the best test-takers in the country.” One physician chimed in that she has so many emails in her inbox about ICD-10 that it would take days to go through them. She plans to take a course at a local medical school and hopes it will be “helpful rather than soul-sucking.” Unfortunately, many of the ICD-10 courses I’ve heard about represent the latter.

One of the best follow-up comments I read was from a friend of a friend of a friend (funny how social media works that way) who said his hospital offered an animated course with a cowboy and a talking horse/donkey character. I certainly haven’t heard of that one, but would love to see it if anyone can point me in the right direction. Just thinking it reminds me of my own hospital’s HIPAA videos, which had a questionably-executed gangster/flapper theme.

It’s all too easy to get sucked into social media and I didn’t want to waste much more time than I had already spent. Before I closed my browser, though, I did come across this video  of a woman surfing in stilettos. I thought it was pretty impressive, but one of my shoe diva friends commented it was a way to ruin a good pair of shoes for sure.

What’s the best ICD-10 training you’ve seen? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/10/15

I was pleased to see that Vermont finally legalized electronic prescribing of controlled substances, making the process now legal in all 50 states. According to Surescripts, only 2 percent of physicians are electronically prescribing controlled substances. Early on, even if it was legal in your state, it was still a challenge due to lack of pharmacy participation. Now nearly 80 percent of pharmacies can accept controlled substance prescriptions and I’m guessing that the cumbersome workflows involved are contributing to the low numbers.

The two-factor authentication options offered by my primary vendor include a key fob token or a soft token installed on a cell phone. We have a strict “no cell phones” policy (even for physicians) so that option is out and my partners weren’t too wild about having to carry a token. We dispense most of our controlled substances in-house, so our practice hasn’t adopted yet. Since we dispense, we’re not afraid of being able to meet the controlled substances requirements, but I have several friends who are nervous about the auditing and reporting requirements.

This week, CMS is urging practice to contact their software vendors, clearinghouses, and billing services to “ask about testing and training opportunities.” We’re three weeks out and I think it’s a little late in the game if practices are just starting this process. I continue to be amazed by the number of practices that are way behind on their preparations. A solo physician contacted me today, finally realizing that we’re not going to get a reprieve. He forwarded a 26-page “checklist” of to-do items from his software vendor. It was more like a novella than a checklist and had cross-references to more than a dozen other documents, each with other check lists.

Although the document was overwhelming, I can’t fault the vendor too much because their checklist outlined a timeline that was to have begun six months ago. Had the work been done on the vendor’s suggested timeline, the steps would have been relatively small and manageable by any practice. Trying to tackle it at the last minute though is like standing at the bottom of a cliff and hoping a flying elephant can help you get to the top. I’m going to do some ICD-10 coding training for him, but had to refer him out for the technical pieces. I haven’t adjusted my fee schedule for the last-minute rush, but I bet clients will be paying a premium for technical services as we get closer to the deadline.

CMS also released webcasts for Dental, Lab, Pharmacy, and Radiology clinical concepts. In addition to new documentation requirements, the presentations cover physician perspective. I’m sure the physician perspectives they present are pretty far from what many of my colleagues are thinking, which ranges from, “Why did I go into medicine again?” to, “I should have gone to a cash-only practice when I could.”

Last week, Mr. H mentioned a study that looked at episodes of “Grey’s Anatomy” and “House” and how on-screen patients fared with CPR. They survived at twice the rate of real patients. Thanks to Netflix and some quality time on the treadmill, I’m finally caught up on “Grey’s” and was happy to see Dr. Miranda Bailey discuss her end-of-life preferences with her husband even if he didn’t agree.

HIMSS recently sent me a “Connected Health” survey that asked about my organization’s plans to expand technologies in the next year. Most of the organizations I’m working with are delaying any strategic planning sessions until after the Meaningful Use final rule is released. Between the uncertainty of the requirements and the strain of ICD-10 and related upgrades, everyone just seems to be running out of gas.

A reader made my day with this piece in The Onion: “Health Experts Recommend Standing Up at Desk, Leaving Office, Never Coming Back.” I’ve definitely had days when I feel like taking their advice to use my lunch break “to walk until nothing looks familiar any more.” I sent back an email of thanks and was rewarded with this gem from Gomer Blog detailing an EHR upgrade gone wrong.

Have you ever had a week when you feel like you’re going to have to send your IT team to a safe house? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/3/15

CMS is pushing their “ABCs of ICD-10.” Although this week’s focus is on “B,” I hadn’t seen the campaign before. As a physician, I couldn’t help but think of the fact that when we hear “ABCs” we immediately tend to think “Airway, Breathing, and Circulation” as we’re trying to resuscitate patients. Based on some of what I’m seeing in the community, I think we’re going to be resuscitating more than a few providers and billing supervisors as their practices are decidedly not ready for the transition.

I was on the phone with a client today who has decided not to take its vendor’s mandatory ICD-10 patch and instead will try to customize the system on their own. They plan some brute force workarounds if that doesn’t work. At this point in the game, I just don’t have the stomach for working with people in that mindset. I told them that if they agree to take their vendor’s patch I’ll be happy to assist, but if not, they’re on their own. It’s just too risky when there are fewer than 30 days on the clock and there are tested solutions available.

Interestingly, the “B” campaign stands for “Be sure your systems are ready.” They recommend practices test to make sure they can generate and submit claims, schedule appointments and procedures, verify eligibility and benefits, submit quality data, update patient histories and encounters, and code encounters. If you’re just thinking about testing these items now, you have a lot of work in front of you.

Speaking of the October 1 date, I’ve seen an uptick in requests for last-minute locum tenens placements spanning the go-live date. I am not sure if people are thinking the system will grind to a halt and want to staff up or if small practice providers are deciding to take vacation during the transition and return to practice when things are stable. I see more specific EHR information in the listings than I have seen in the past.

I had to laugh though at one of them, which was not only trying to recruit a “Physican,” but also said the small-town practice includes “tell a med.” I can only infer that telemedicine is involved, but there were enough problems with the listing to make me worry about what one might be walking into (including spelling the name of the EHR wrong and failing to capitalize “September.”) The one site only sees 6-10 patients a day and that’s certainly tempting, but I doubt the locum agency’s ability to handle professional liability coverage and credentialing when they can’t spell.

My former hospital made me chuckle today by announcing (at 11:30 a.m.) that they would be taking the hospital system down from noon to five for a scheduled upgrade. Seriously, who performs upgrades in the middle of the work day? They’re offering a special support line from 5-7 p.m. then going back to regular support hours. I suppose they assume all bugs will present themselves in the first two hours after the upgrade. There was no mention of what the upgrades would bring or how users should anticipate their workflows might change. Needless to say, I’m feeling pretty good about having jumped ship when I did. I just hope they keep me on the distribution list because it’s been amusing.

I’m always happy to feature companies that are giving back to the community. While the Epic User Group Meeting is in full swing, Nordic Consulting is partnering with local organizations to make the world a better place. Monday night at their open house, Nordic served a custom-brewed Nordic EHR IPA. For every pint poured, they donated $1 to The Road Home program at Rush University Medical Center, which helps veterans return to civilian life.

For beer connoisseurs, the EHR IPA contains Equinox, Hallertau, and Rakau hops. It’s also on tap at more than a dozen bars and restaurants in Madison, so grab a glass if you can. Their open house also featured cookies from The River Bakery, which provides job training and placement in the baking industry. Everyone knows how much I love pastry, so this made me smile.

From Eager Reader: “Re: keeping up. I’m working on an informatics project and wanted your take on something. How do physicians with extremely busy schedules keep up with new scientific data? Do you rely on certain sources now, or do you have to grunt through the medical journals on your own?”

That’s a great question. The short answer is that it’s hard to keep up, especially if you’re really in the trenches. I have a few key journals that I read. Unfortunately, I don’t read them regularly, but rather stack them up (I’m still a paper girl at heart), and when the pile gets so tall, then I curl up and read the articles that are pertinent to my practice and my clients. In addition to new articles and reviews, several also have “tips from other journals” sections that may lead me to read parts of other journals.

I’m also a big fan of the Wolters Kluwer Health UpToDate product as far as researching the most current thinking on a given condition, especially when you have someone in front of you with a condition you may not have seen in years. In my clinical setting, I’m often working alone and don’t have a colleague I can grab between patients and bounce ideas off of them. I do have clinical decision support in my EHR that links to the literature, but I rarely use the links. With my current vendor, I trust that the physician informaticists on staff did the right thing when it was built, but I’ve seen some crazy bugs in previous systems.

How do other physician readers keep up? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/31/15

A reader recently contacted me about strategies for dealing with providers that are struggling with chart completion:

My outpatient physician group is struggling with chart completion after conversion to an EHR. Some physicians have no issues, but others are having considerable problems. Not surprisingly, the ones struggling are the same physicians who had trouble on paper and had stacks of charts in their offices before EHR. Our policy is that charts need to be completed within two days. However, we have physicians who have hundreds of charts open and are months old and therefore not billed.

We are considering a policy that states charts over two weeks old will result in fines, which is similar to one of our competitors. We are estimating over $100,000 of accounts receivable that we will not be able to collect due to the age of the charts. There is another $25,000 in incomplete charts being added on a weekly basis. I wonder if any of your readers can share their approach.

The reader wanted to remain anonymous, which shouldn’t be hard because there are probably hundreds of organizations in this same position. I’ve personally worked with dozens of them.

Ideally, this problem is best addressed while the organization is still on paper. This allows leadership to get a handle on undesirable behaviors without physicians blaming the EHR. I can count on one hand the number of physicians I’ve seen who were delinquent on paper charts but got faster with the addition of an EHR, so confronting it head on is the best way to handle it.

Unfortunately, many organizations don’t have the resources to optimize their workflows before implementing an EHR. This leads to one of two things: either the EHR implementation team is forced to deal with problems and behaviors that are potentially outside their area of expertise or the behaviors simply don’t get addressed and the EHR takes the blame.

Like the reader, many organizations are motivated to action when the delays start to impact the revenue cycle and some let it get significantly out of control. The last client I helped with this problem had almost $6M in unbilled encounters before they realized they had a problem. Needless to say, they also had other revenue cycle issues which led to it getting that bad.

Meaningful Use throws another wrench into this process, particularly with the need for eligible providers to send out clinical summaries with pertinent information within a set number of days. Although some organizations go ahead and send out the incomplete summaries (a reader shared his or her own story with Mr. H) others hold the summaries which will cause the provider to fail attestation if they can’t meet the threshold.

Generally most approaches to this problem fall into either the carrot or stick categories. In the incentive space, physicians may receive cash bonuses for timely documentation or receive advantages in the creation of on-call schedules or vacation requests. Although some physicians (particularly ones earlier in their careers or with young families) respond well to this, not everyone cares about extra money or call schedules. Some physicians also aren’t motivated by the desire to get information to patients in a timely manner (via MU-required clinical summaries) either, so that may be off the table.

When organizations decide to employ a stick, usually it is a financial one. My residency program did this to the faculty and it was successful. (The residents had their grades withheld if charts were delinquent, so they weren’t a problem.) Charts older than five business days resulted in a fine, which came directly out of the faculty member’s paycheck. It took months to get it set up with the accounting and payroll departments and the physicians had to sign a contract addendum agreeing to it. The faculty did it grudgingly and most of them waited until the last hour, but at least the charts stayed current.

Another group I worked with also made it contractual. Physicians had to meet chart-completion standards in order to be eligible to receive a bonus. They also had to use the EHR in a prescribed way (entering data discretely rather than free texting) in order to reach the bonus round. Bonuses were then calculated based on clinical quality measures, patient satisfaction scores, and a couple of other factors. It was successful because it could completely block the physicians from getting any bonus at all, but again took a contract amendment to give it teeth.

I’ve seen two clients hire scribes for physicians that had documentation issues. Whether or not they charged the cost of the scribes back to the physician depended on the physician’s impact on the bottom line. For example, a high-volume surgeon who was bringing in millions of dollars in revenue was not charged for the scribe because the money recouped from non-delinquent charts more than paid for the extra overhead. At another group, a primary care physician who swore up and down that the EHR was at fault was charged for the cost of the scribe because all of his partners were getting their charts done on time and were unwilling to subsidize or reward his lack of compliance.

This does come up in my consulting practice all the time, so I’m also interested in hearing other approaches. If someone has a great way to do it that doesn’t require a major overhaul of dozens (if not hundreds) of employment agreements I’d love to hear it.

How do you deal with delinquent charts? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/27/15

For the last several months, people have been asking me what I think is going to happen on October 1. Will vendors be completely ready? Will customers have time to take upgrades and patches? Will users have enough time to test and practice new workflows as well as learning new documentation standards? Will things come to a screeching halt? Or will it be like Y2K and turn out to largely be a non-event?

I’ve been telling them that I think the majority of systems are going to be ready, but I think that there will be some glitches. Although I don’t anticipate complete chaos and the breakdown of civilized medicine, I have been recommending to my small practice clients that they should prepare for delays in cash flow and consider having access to a line of credit to cover expenses if there are lags in payments. I’ve helped most of my clients develop business continuity plans so they’ve already thought through various scenarios and it’s just a question of applying ICD-10 problems to existing plans.

Larger practices, especially those owned by or affiliated with hospitals and health systems, appear to be pretty well prepared. Several that I’ve worked with have fleets of staffers dedicated to ICD-10 preparedness, from coders and compliance officers to EHR trainers. Nevertheless, most of them have increased the amount of cash they have on hand. They have also prepared to bring on extra staff to help them power through the glitches through a combination of manual data entry and brute force if it is needed.

All of the groups I’m working with have come to accept that the odds of a delay or reprieve are miniscule. I’m encouraging them to be cautiously optimistic but to continue preparing and drilling. There are so many moving pieces in the medical billing process and so many different systems and vendors involved. Although a practice might be prepared, what if their billing clearinghouse drops the ball? Or what about failures on the payer side? There are bound to be glitches.

Unfortunately, there will also be catastrophic failures. I came across one of those situations today when I received a frantic phone call from a prospective client. They’re using a specialty-specific EHR that started behaving erratically this week after turning on the ICD-10 dual-coding functionality. Apparently the system didn’t have the level of code mapping they anticipated, but it wasn’t discovered before it went live because they didn’t thoroughly test it.

They are unable to revert the feature and were told by the vendor that they need to very quickly do a code mapping and setup project. Due to the number of providers, the complexity of the build, and the skills of the IT support team, there is no way the practice can fix it in time for ICD-10, let alone fix the issues they’re currently facing.

Several of the problems are patient safety issues. On a pediatric chart, selecting a simple diagnosis of sore throat in ICD-9 is recording an ICD-10 diagnosis for Ludwig’s Angina, which is not only uncommon in children but also life-threatening. Needless to say, the physicians are struggling and the practice is in full freak-out mode. Although I’ve not worked with this specific system, I told them I was willing to take a look under the hood and see if I could help.

I had to wake up my database guy early on a Sunday morning, but luckily he’s always up for a challenge. After a couple of hours of massaging the data in their test system, we put together a plan and the client agreed to our proposal. We extracted the data from the relevant tables and I’ve spent most of the day comparing it to the CMS General Equivalency Mapping data. Our goal is to very quickly identify the data that is correct and stage it against their historical diagnosis patterns. We’ll validate their most frequently used diagnoses first and load it back into the system in batches every night. Then we’ll work our way through the rest of the data in order of frequency of use.

Although we can’t turn the dual coding feature off, we’ve completely wiped out the ICD-9 to ICD-10 crosswalk so that they can at least code without fear of adding incorrect data to their charts. Once we start adding data back in, if there isn’t a clean ICD-9 to ICD-10 map, they just won’t get an ICD-10 code. I was able to juggle some of my other commitments and hope to be ready to test the first batch of data later tonight. In the mean time, we’ll have a contract coder going through the charts where ICD-10 codes have already been applied, suggesting corrections as needed.

Due to the volume of codes that we need to examine and the premium they’re paying me to do it quickly, I’ve been chained to my laptop most of the day. I see code tables when I close my eyes and I’ve started to feel like an ICD-10 apocalypse might be on the horizon. I found some tips from AHIMA on how to survive such an event.

Do you have your medieval mace and leather armor ready? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/20/15

ICD-10 is roughly six weeks away and CMS is launching an ICD-10 Clinical Concepts Series for specialties. Each guide contains specialty-specific information that can be shared with providers, including common ICD-10 codes and their counterparts. It also includes clinical scenarios for practice and links to case studies and other resources. If you’re looking for supplemental materials for your physicians, it’s worth a look. Specialties already released include Internal Medicine, Cardiology, Pediatrics, OB/GYN, Orthopedics, and Family Practice. They seem to be all on the website, but CMS is still sending out separate emails announcing their availability.

As a side note to CMS (rant alert) can we please come into the 21st century and start calling my specialty Family Medicine? There are still plenty of EHR vendors who can’t get the name of the specialty correct, either. The American Academy of General Practice was founded in 1947 and in 1971 became known as the American Academy of Family Physicians. We’ve never referred to ourselves as Family Practice. The MD certification board was originally called the American Board of Family Practice, but changed its name to Family Medicine in 2005. The DO board was originally the American Osteopathic Board of General Practitioners and changed its name to the American Osteopathic Board of Family Physicians in 1993.

CMS continues to use taxonomy codes that have not been updated to reflect the changes in specialty certification nomenclature that occurred up to two decades ago. CMS specialty code 08 (associated with provider taxonomy code 207Q00000X) still refers to us as “Family Practice.” With the increasing number of Nurse Practitioners (across many specialties), continuing to use outdated terminology is confusing. Physicians generally want to be referred to as such – for example, Internal Medicine physicians should not be referred to as “General Practitioners.”  Physicians who care for children are Pediatricians rather than pediatric practitioners. 

Thanks for putting up with my brief history lesson. It’s good information for those of you in the implementation trenches who may wind up on the receiving end of a physician’s unhappiness at finding the name of his or her specialty butchered in the EHR. It may seem like a small issue, but physician psychology is often complex. I’ve lost physicians at the beginning of a training session because they’re fixated on the idea that if the system can’t even get their specialty right, it can’t be that great of a system. It’s hard to overcome that kind of negativity if you run into one of those providers.

CMS isn’t the only governmental body that might be inadvertently offending physicians and other clinicians. I registered today for a meeting on laboratory data interoperability sponsored by FDA, CDC, and the National Library of Medicine. Although the registration form had checkboxes for MDs and PhDs, apparently DOs need not apply. I guess they don’t realize there literally dozens of disciplines that take part in the care and feeding of laboratory systems and interfaces. If they couldn’t provide a more comprehensive list, they should have just made it a free text field and let users enter whatever credential they feel is appropriate.

I had a near-miss in the office today as a result of another unexpected downtime. Usually the labs that are performed in-office are transcribed from the little analyzer printout slips to the EHR by the staff, which does a peer review to make sure there are no transcription errors. The EHR flags the results in different colors and bold type if they are out of range. I missed a significantly abnormal lab result at the time I reviewed it, only seeing it at the end of day after it had been loaded into the EHR and I was catching up on charts. Fortunately the patient had been admitted to the hospital for other reasons and the abnormality was addressed there, but that doesn’t make the experience any less horrifying for a physician.

In thinking through the event there were several potential causes:

1. General chaos in the office due to the downtime.
2. Trying to see a number of patients quickly to catch up from our initial delays.
3. Reviewing the data in an unfamiliar format.

Having the little cash register-type tape use color or having it in a more standard format that made the result stand out would certainly have helped, but it wouldn’t have countered the impact of general chaos or the fact that I was moving fast. I’m exceedingly thankful that the patient didn’t have any negative consequences. It’s a lesson learned for my next downtime experience, which based on the odds this week could happen at any minute.

This is the first time I’ve experienced system outages on a vendor-hosted system. In my past life, we’ve always been self-hosted and have been able to provide regular updates to the users. This week the practice’s owners have struggled with the vendor and it feels like the communication is not very good. In addition to system outages, the vendor’s telephone system went out today. I don’t know if it was related to the customer downtimes, but it’s adding up to be a perfect storm.

Speaking of outages, my former employer had to take down the EHR today at several hospitals for “urgent maintenance” at 9:30 in the morning. Despite my resignation, they haven’t removed me from the distribution lists, so I get all the notifications. The announcement came at 9:15 after the system apparently became so sluggish it was unusable. That’s not a lot of notice to give people in the swing of a busy hospital morning when you have hundreds of patients receiving procedures and treatments. It’s one of the peak times on the operating room schedules, so I can only imagine the magnified chaos going on there compared to my own downtime experience.

Do you agree that downtime is the gift that keeps on giving? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/17/15

Dr. Jayne Does Downtime

Although I have a steady urgent care gig, I occasionally cover locum tenens assignments. It’s a great way to be able to use multiple EHR systems so I can see what vendors are doing for Meaningful Use and overall EHR usability.

I knew I was in trouble this week when I arrived at my assignment to find the EHR down. It’s a small practice with multiple locations and they have contracted IT support, which the staff had already called. With little chance of the system being up before patients arrived, we decided to activate the downtime procedures.

I was initially impressed. The staff knew where to find the downtime documents on the shared drive and started printing them out. They began to put packets together for each scheduled patient and started digging out a pile of clipboards. The front desk team pulled out an old-school credit card imprint machine and readied a cash log. Staff started rooming patients.

As I saw my first patient, I realized they had no way of accessing a patient summary. There was no local downtime solution. I couldn’t even get a medication list or problem list on the patients. Staff was asking them to summarize their histories, which was going to take a long time based on the number of geriatric patients on the schedule.

As I flipped through the downtime packet, I realized there wasn’t a SOAP template for the physicians to write their notes. There was a page that said “Findings” and “Plan,” but that was it. It had huge ruled lines on it that weren’t very practical for writing a patient care note. I divided it into virtual quadrants and started figuring out my own note format, while sending out a text to a physician working at one of the other locations asking for advice. All the locations were down so I figured he’d be in the same boat and may have a better idea.

I realized that the “Findings” sheet didn’t have a patient name or date of birth on it. The staff had written that vital information on the top sheet of the packet only – the sheet which was the directions for how to use the downtime packet, and had nothing to do with the care of the patient. I scribbled on the patient’s two identifiers to at least preserve the integrity of my notes and hurried to the next patient.

She wasn’t quite ready to be seen, so I waited for the medical assistant to come out of the room and asked for a quick summary. The medical assistant was beyond agitated. Apparently the idea of working without a chart and not knowing anything about her patient was making her anxious. I looked at the size of the medication list she had jotted down and empathized, knowing that they’d have to backload a significant amount of data once the system came back up. She didn’t respond well to my reassurance and looked like a deer in the headlights. I told her to take a minute and gather herself and let her know we’d make it through the day.

Minutes turned into hours, and before I knew it, we had been down half the day. A new kind of anxiety emerged as the staff realized they would have to have the data loaded into the system before they left for the night. I asked if they really needed to load all the data or if there was an identified subset of information to load. Unfortunately they had been told that they had to load everything that had been documented on paper. Several were worried about being able to get out of the office on time to pick up children and keep other family and personal commitments.

In my past life as a CMIO, we had a subset of “Core Clinical Data” that had to be loaded after a system outage. It was the vital information that would be useful in ongoing encounters, such as medications, allergies, diagnoses, problem list, immunizations, lab orders, charges, and plan details. The physicians could also identify other key data or particular exam findings to be loaded on top of the core data, but the expectation was not that every single scrap of data would be loaded. Practices had 24 hours to get the data loaded rather than trying to get it done by the end of the workday. We had experienced more than our share of downtimes and it worked well for us without a lot of extra overtime or anxiety.

The system came up shortly after lunch. We were excited and ready to catch up, only for the system to go down again after about 30 minutes. We continued plugging away, but it was frustrating because we weren’t getting any updates from the IT support team or from the vendor. I asked the staff what the expectations were and no one seemed to know. I suggested someone pick up the phone and ask what the schedule was for expected updates so that they would feel less in the dark. It hadn’t really occurred to them to do that.

As we got closer to closing time, I asked about any plans to cancel patients for the following day. It turns out we didn’t have the option since they only print patient schedules one day in advance. We had no idea who would be on the following day’s schedule or how to reach them.

The system came up for good during the last scheduled patient appointment of the day. We got the office administrator to agree to letting the backload process extend into the following day. The staff relaxed considerably and we were able to get about 30 percent of the charts loaded before they had to start heading home for the night.

There is a fine line between a smooth and polished downtime and complete chaos, but the steps to keep it closer to the former are pretty straightforward. My advice of “must have” elements:

• Practices need a solution to obtain at least a brief history on existing patients without asking the patient to provide it. This can take the form of a daily download of patient summaries to a local server and at a minimum should include the patients scheduled for the next work day. Ideally one would want a download on all active patients in the practice.
• Practices need to actually practice for downtime. Especially if you’re in a situation with a stable system and it never happens, staff needs to be aware of the policies and procedures and be ready to deploy them when needed. Surprise downtime drills every month aren’t a bad idea and it doesn’t have to be a “live” drill – it could be a tabletop exercise at a staff meeting where everyone talks through what they need to do in the event of a system outage.
• Identify the core data that needs to be loaded once the system is up. Don’t sweat the small stuff if it’s already documented on paper and scanned. Be sure to reference it, however, so that users looking at the chart in the future will be aware of the presence of additional details should they be needed. Any paper forms that are to be used should be clear and concise, with review and approval from the teams that have to use them.
• Make sure you understand the service level agreements with your IT support staff and with your vendor. Don’t expect hourly updates if they’re not obligated to provide them or you haven’t asked for them. If you feel like you’re not getting the information you need, speak up.
• If you don’t have a local copy of the system that shows at least several days’ worth of appointments, print at least several days’ worth of schedules in advance or save them to a local drive. It’s a few extra steps, but well worth it to not be surprised when people show up at your reception desk.

By the time I was cleared to leave I was exhausted, so I can only imagine how everyone else felt. I headed back to my hotel and picked up some take-out on the way so I could get into bed early. Even if the EHR is completely cooperative, it’s going to be a long day.

How do you handle a system outage? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/13/15

CMS continues to remind everyone that the ICD-10 transition is less than 50 days away. Unfortunately this seems to be news to some. I’ve been absolutely inundated with requests for ICD-10 training. I suspect the previous delays encouraged some providers to procrastinate, thinking there would be another reprieve. I’d be seriously surprised if there is one, so if you haven’t started prepping, now is definitely the time. My free consulting advice:

• Every provider should have a list of his or her top 50 diagnoses and should practice documenting those diagnoses in the EHR, either with dual-coding on a live system or otherwise in a test system.
• By specialty, providers should know what common codes might have pitfalls and be ready to diagnose them.
• Organizations should follow their vendors’ ICD-10 readiness checklists. Some EHRs require updates and there may be nuances on how they need to be applied compared to “typical” updates given the number of moving parts for ICD.
• Each office should identify an ICD-10 point person to handle issues on October 1.
• Everyone should dust off their business continuity plans. Your office may be OK, but your clearinghouse or payers may not, so it pays to think through the possibilities.

CMS also sent out a link to the National Broadband Map, where providers can see if they will qualify for certain Meaningful Use exclusions based on the availability of broadband service. I don’t qualify for an exclusion, but the page did have some interesting information about my county, including racial and ethnic data, median income, poverty rate, and educational status.

My former employer still hasn’t figured out how to remove me from all its email distribution lists. From time to time I still receive confidential information, including physician performance data. This week I received a system-wide bulletin stating that in order to prepare for ICD-10, effective next week the hospitals are no longer going to accept only ICD-9 codes for the patient diagnosis. Physicians must include a narrative description of the diagnosis if they want their orders to be processed. Quarterbacking from afar, I think a week’s notice is pretty short and the lack of a grace period isn’t very provider-friendly. They also didn’t mention what they would do when orders are received without a narrative. Will the patient be turned away? Will someone try to contact the provider? Heaven forbid will someone whip out a code book and scribble a narrative on the order so the patient can be taken care of? I’ve asked a couple of my former colleagues to let me know how it goes.

I wrote a few months ago about a friend who had knee surgery and some of her experiences while I played patient advocate for a day. She still hasn’t gotten a full copy of her records, but watching the bills and insurance Explanation of Benefits statements come in has been entertaining. Although it’s been more than four months and she’s 90 percent back to normal activities, the surgeon still hasn’t billed her. The hospital sent her a mysterious refund check with no explanation even though her insurance statement indicated that she actually owed money. Given the slim margins that some of us operate on, it surprises me that anyone would leave money on the table.

The DME vendor has double billed her and two other vendors have failed to submit to insurance prior to billing her. The only vendor that seems to have its act together is the physical therapy provider. The bills arrive monthly and are detailed and accurate. Even though I’m in healthcare and understand the markups, the actual dollar amounts are pretty amazing. Overall she was billed more than $45,000 and insurance has adjusted off about 75 percent of that. She’s got tremendous insurance, so her out-of-pocket cost has been manageable. Not being in healthcare, I’m pretty sure she has decided that our entire industry is simply crazy.

PricewaterhouseCoopers (you have to love the arrangement of that name) is projecting a potential increase in healthcare costs. The cost of security for electronic systems is cited as a factor, along with new and expensive specialty drugs hitting the market. Increasing employment of physicians by hospitals is also cited, particularly with the practice of billing out physician office visits with a hospital facility charge. Team-based care is predicted to help lower or stabilize spending. Not surprisingly, they predict that patients with high-deductible plans will be more cost conscious. It will be interesting to see what the data shows in five years and whether patients who forego medical services due to high deductibles end up having larger expenditures as conditions are left underdiagnosed or undertreated. The proliferation of such plans feels a bit like an experiment being conducted on people without the benefit of an institutional review board to protect them.

What do you think about healthcare spending trends? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/10/15

The continued consolidation in the EHR market is often a cause of concern for physicians and hospitals that haven’t chosen the dominant players. There are still plenty of specialty-specific of niche products out there that are certified and do a great job and their users may not be looking for a change. For those groups on a mid-sized system or looking to participate more actively in value-based care programs such as accountable care organizations, the desire to move is much more tempting.

I’ve written over the last year or so about how my own health system went through the process. It was very organized and quite transparent, with all kinds of end users and technical staffers participating in the process. An initially large vendor list was narrowed to three. Then structured analysis of the products was performed. Ultimately we had on-site demonstrations and a variety of metrics were assessed and scored for each of the vendors to assist in the final decision.

We knew we had a handful of existing vendors that would be de-installed regardless of the final selection. We communicated our intent with them throughout the process. We worked with not only our designated front-line support team, but also with vendor executives to help them understand the forces that led us to the decision to sunset their product.

It was dicey at times, because even though we ultimately decided on a single vendor for ambulatory and inpatient clinicals, we ended up keeping another vendor’s enterprise financial system for inpatient. We were clear about our needs and what we felt were challenges with keeping any other individual systems and made sure that our vendors knew where we stood at all times.

Although until recently I’ve spent most of my CMIO career within a single health system, I’ve collaborated with many other CMIOs as we shared our struggles and victories. I’ve seen the system replacement process through at least half a dozen different lenses as colleagues have worked through the process. It’s always been fairly collaborative with the vendors much as my own experience was. With that in mind, it’s been interesting to watch one of my friends’ hospitals go through a fairly hostile system selection process.

He’s always been a bit of an outsider, a CMIO without the title who the administration grudgingly put into place when physicians complained about the poor quality of the EHR. Although he didn’t have formal CMIO training, he’s taken the proverbial bull by the horns the last two years and really made a place for himself. He’s led the charge for overhauling their EHR governance and standardizing the system. This has allowed for retirement of customizations that were crippling workflow while improving physician satisfaction. Training quality has improved and the IT teams have been restructured.

I’ve been mentoring him on how to work with his vendor to help his hospital move forward. Initially the primary EHR vendor (which we shared at the time) was being blamed for everything, regardless of whether it was actually relevant. I reviewed and critiqued some of his strategies for helping the users understand that a lot of their pain was self-inflicted and supported him through a couple of upgrades which he used to steer workflow to a much better path for everyone.

Knowing how hard he’s worked to improve relations with his vendor, I’ve also watched his pain as the hospital decided to migrate off the system. He’s shared some of the email threads with me as a way to vent his frustration, so I know he’s not exaggerating. The vendor was told several months ago that the hospital was looking at a potential system replacement (largely due to a failed hospital implementation of a different vendor) that would also potentially impact the ambulatory systems. Rather than be honest and open about the process, the hospital appeared to ignore the vendor’s attempts to be kept in the loop. My friend has been increasingly frustrated at the way his administration is acting, but they’ve made it clear that he doesn’t have a seat at the table.

Most frustrating is their complete disregard for the end users in this process. They haven’t done any significant engagement of physicians, nurses, or other end users. They haven’t done any demos or site visits. Instead, they went ahead and contracted with a different vendor behind closed doors. Even more offensive is that my friend found out that a contract had been signed when he saw the press release. I feel bad for my friend – that kind of treatment is just inexcusable. But I also feel bad for our formerly-mutual vendor.

Sometimes I guess customers forget that vendors are people, too. Even if you don’t want to continue to do business with a company, hopefully you have developed at least some semblance of a relationship with the people who support you and work with you on a regular basis and may have done so for years. It would be nice to let them know of your decision before a press release is issued or before they read about it on HIStalk with their morning bagel. I’m aware of the adage “it’s just business,” but sometimes it also needs to be personal. After all, we’re people.

Some of my best friends in the healthcare IT space work for vendors. Getting to know them and understanding how things work on the other side of the stream (or river, or gorge, depending on how well you mesh with a given vendor) has made me a better CMIO and a stronger advocate for my own users. Many of them have gone to work for other vendors in the industry, allowing me to be exposed to different strategies and technologies that I might not have known much about while working at Big Health System. They’ve definitely helped me be a stronger contributor to HIStalk (even though they may not know it) and for that I’m grateful. I feel sad whenever one that I’m close to moves on. I sincerely hope that our paths cross again.

I’m sad for my friend (and his hospital) and also for the vendor and its team. I hope that there is more transparency during the actual migration project, for everyone’s sake. Whether the relationship is working or not, it’s still a relationship.

Have you hugged a vendor lately? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/6/15

I’ve always been an early adopter of technology. When personal computers first came out, my parents made sure we had one. Sure, it was an Apple II+ and it TYPED IN ALL CAPS ALL THE TIME, but it put us on the cutting edge. It also put me on track to disassemble and modify devices after the Apple IIe came out (with its functional shift key) and I figured out you could run a jumper wire to make the II+ stop YELLING. My brother procured a used modem from his football coach and there we were, dialing up all kinds of trouble.

I learned the virtues of the “pretzel” key with a Macintosh Classic, then finally joined the world of color monitors with Windows Millennium Edition. After surviving a medical school that made us use Lotus Notes, I headed off to residency at a hospital with a half-baked Cerner system and finally found myself in practice with Medical Manager. I felt like I was really on the cutting edge, especially since some of my private practice colleagues still billed using ledger cards and made their appointments in the same kind of schedule book used by my hair stylist.

Through my continued interest in technology and a willingness to serve as a guinea pig on multiple occasions, I worked my way up in the world of “big” hospital IT. Having spent a good chunk of the last decade convincing physicians to add technology to their practices, I never thought I’d find myself feeling such a backlash against technology. According to USA Today this week, “46% of physicians report burnout: cynicism, less enthusiasm, low sense of accomplishment, too much bureaucracy.” Physicians feel overworked and are unable to cope with the stressors they currently face. They report being less empathetic toward their patients. Many cite EHR use as a key part of the problem, but I think there’s a lot more to it than that.

I’m wondering whether we as a society are becoming increasingly burned out and think that technology is a significant part of the problem. Instead of freeing us, smart phones are increasingly tethering us to the workplace. One of my friends recently reported working nearly 10 hours during her week-long vacation, citing the need to “protect” her boss from covering while she was out. I was certainly guilty of checking email on vacation when I was an employee, but I always felt supported in taking time off and knew I could forward critical emails to the person covering me so that she could address them. In turn I covered others while they were away. Eventually I learned to not even open Outlook.

Through social media, we’re under constant pressure to document every moment of our lives and share it so the world can see how interesting our lives are. There are plenty of studies citing Facebook and other social media services as actually making people feel like their lives are less meaningful or less satisfying than others because of what they see posted. Luckily most of the people I follow on my personal Facebook account are pretty mature – there are rarely photos of what they’re eating (unless there’s a great story attached) and don’t post their every move throughout the day. Although they post some spectacular vacation photos, when I see them I’m more likely to tease them about the risk of having their houses burglarized since they just advertised they were away than I am to be jealous.

I didn’t think too much about how technology is changing us as a society until I had the recent pleasure of taking my nephew on a trip to the East Coast. We visited several historical cities and quite a few monuments and landmarks. I was surprised to see that the atmosphere was very different than when I was in the same places just a few years ago. Rather than taking photos of the sights, everyone seemed to either be trying to take a selfie with the monument in the background or to take pictures of each other at the monument, blocking others from even seeing it in some cases.

Some of them were so obsessed with getting the perfect picture that they completely missed out on what they were supposed to be seeing. At one museum, I watched a mother force her children to wait in line to have their picture taken with an artifact and then she immediately bustled them off to do the same thing with another artifact. None of them spent any time looking at the phenomenally interesting collateral around it. (Moon landing note: Did you know the Apollo command module had to detach from the module with the lunar lander, turn 180 degrees, and re-dock with it? What could possibly go wrong? Learned it reading the sign.)

My brother is a photographer and once made a comment about his children’s generation being the most photographed but least seen. With the advent of digital technology, people don’t have to ration their shots any more. I tried to explain to my nephew about film coming in cartridges of 10 or rolls of 24 to 26 pictures back in the day. You had to choose your subjects carefully and you certainly didn’t take a picture of every single thing you found interesting. Although you might entertain your family and friends by showing them 35mm slides projected on a bed sheet (carousel if you were fancy, stacker if you weren’t) you definitely didn’t take hundreds of photos at a museum and make a nuisance of yourself. At one location, there were so many people taking pictures with tablets (including full-size iPads) you could hardly see the exhibit because of the air clutter. I hadn’t intended on seeing the world through someone else’s screen held aloft.

It turned into a teachable moment. My nephew and I had a good discussion about the psychology of all this and how technology makes people feel. We also talked about how it can physically affect people as well. He mentioned hearing that Disney had banned selfie sticks, and after this week, I think it’s a fantastic idea since I was almost hit a couple of times. I’ll be interested to see 10 or 20 or 30 years from now how immediate access to information has impacted our ability to leverage human memory. Personally I think we’re losing the ability to make good memories – rather than being in the moment and experiencing something, we’re either multitasking on our phones, listening to music, or trying to take a picture of ourselves doing it.

What’s worse is seeing people allow their children to be cheated by the lure of technology. At one famous site, I watched a family of four sit next to each other, completely absorbed in their devices. The pre-teen daughters were playing games, the dad was checking sports scores, and mom was just surfing. None of them were talking about the history of the property or why it was significant to our country’s history. Technology could have been a tool for them to talk about the site or the Civil War (which I also heard referred to as the War of Northern Aggression, which was slightly amusing in 2015) but instead it was a distraction. They certainly weren’t giving it the reverence it deserved as a burial site.

We also watched people on the subway interacting with children in strollers with some clearly generational behaviors. Older individuals (who appeared to be grandparents or hired caregivers based on some of the conversations) turned the strollers to face them so they could keep an eye on the children, which also meant they were interacting. Younger individuals tended to leave the strollers facing out and often had earphones in while using a smart phone, so there was very little interaction. If this is a common pattern, will it cause attachment problems, anxiety, or other disorders? And what about the toddlers using electronic media for hours a day? We know that’s an issue. While kids need to learn patience and how to deal with situations they may find boring, it’s helpful for parents to engage with games of “I Spy” or “Twenty Questions.” (Some of the answers this week: Robert E. Lee, Thomas Edison’s light bulb, and a bald eagle.)

As technology professionals and leaders in our field, I think that some re-examination of how technology impacts our lives may be warranted. We may not be able to change the technology demands of our organizations, but we can certainly advocate for wise use in our workplaces. Let’s start with rational email policies. My favorite boss had a three-day policy – if you needed a response within three business days, you weren’t allowed to send an email but had to actually talk to another human being. It was one of the most cohesive teams I’ve ever experienced. We also need to support our employees and colleagues in taking real vacations that don’t involve the expectation of checking email or voice mail. If something doesn’t change, we’re going to need a bunch of new ICD codes to address it.

What do you think about the pervasiveness of technology in today’s society? Did you know that you can turn your toast into a selfie? Email me.

Email Dr. Jayne.