Curbside Consult with Dr. Jayne 1/18/16

My inbox lit up last week after Andy Slavitt’s comments about the end of Meaningful Use. My clients were asking for immediate analysis of “the new rules,” but among friends, the emails were more along the lines of, “Did I miss a memo somewhere?”

I think Slavitt is overly optimistic in stating that MU will be replaced by “something better,” because ONC and CMS haven’t done such a great job of making things better in the modifications and revisions we’ve seen already. Frankly, I’m not sure they even understand the definition of “better” as it might be applied by a practicing physician.

Some of the emails had links to articles which either took the comments out of context or overly simplified the situation. That’s not surprising given the fact that we live in a society driven by sound bites, tweets, and Snapchat. Even if CMS wants to make the program go away, it may not be able to do it without a little bit of legislative assistance. MU is tied into the MACRA law, with MU being one of the elements contributing to the physician performance score that will drive payment adjustments.

I also take issue with his comments that, “We effectively have technology in virtually every place where care is provided.” That’s not really true – I know of quite a few primary care practices that still haven’t made the leap, largely because they’re in rural areas and are too busy actually caring for patients to deal with what they consider government nonsense.

One of my best friends from residency is one of those physicians, who has been in solo practice for many years and just splurged on the “luxury” of hiring a physician assistant to help support the practice since she’s been on 24×7 call for nearly a decade. We’re still lacking EHR in many care settings (home health, and nursing homes, anyone?) Not to mention that even though we may have computers in offices, that doesn’t mean that they’re used effectively or that they’re doing anything actually improve patient outcomes.

In my consulting practice, I see dozens of clients who may be meeting the letter of the law through workarounds and administrative processes, but who aren’t using their expensive EHRs to do anything truly meaningful. The ways in which vendors exploit vagaries in the requirements are often shocking. The CMS Frequently Asked Questions are sometimes confusing and occasionally contradictory, so I imagine it’s tempting to use what loopholes you can find.

I spend a lot of time counseling clients that, although they may be able to check the box for attestation, they’re cheating themselves and their patients out of the improvements that systems were intended to drive.

Some of my correspondents had conflicting thoughts on what the end of MU as we know it might do to the EHR industry. One was adamant that it would cause market consolidation since there are too many products out there that are certified but not terribly useful. Another felt that it would cause the return of diversity to the market, as vendors could focus less on certification and more on functionality and the ability to deliver improved patient care outcomes.

I tend to think that we’re headed for more consolidation due to economic and other factors. It won’t be easy to tell whether the proposed demise of MU really played a part.

It’s unclear how this will impact vendors who aren’t at risk for consolidation. Will this allow them to shift some of their development dollars back to usability and needed enhancements that were placed on the back burner due to certification requirements? Or will they still be dealing with regulations and calculations, but just in different forms? My physician friends that work in the vendor space share horror stories about the number of people vendors have dedicated just to keep up with ever-changing regulations. It’s not only federal, but state and payer regulations, too. The burden is endless, just as it is for providers in the trenches.

Personally, I’d like to see the regulators go after other parts of the health delivery system and spend some time regulating them in a way that will help all of us. Want to mandate that physicians include lab data with LOINC codes in their EHR? Then maybe you should require the lab vendors to transmit LOINC codes with their results. I spend a lot of time helping clients manually code around this issue because the lab vendors refuse to send codes.

That to me seems unconscionable — to force providers to clean up after other vendors who are in a better position to do something to make things better for patients. Want interoperability and portability? Force nationwide or multi-state lab vendors to standardize their various business units onto a single lab compendium rather than forcing EHR vendors and customers to code around it.

Let’s mandate that home health agencies, therapy providers, and other ancillaries also adopt electronic records and start communicating with us in a way that fits our new workflow. I still receive handwritten, barely legible reports from home health and PT providers, yet I’m held to the standard of doing everything in discrete and codified data.

While we’re at it, let’s also look at extended care facilities, nursing home providers, and everyone else that touches patients. Let’s back off on the providers and invite everyone else to the party, whatever ONC and CMS decide it should be.

What do you think of expanding Meaningful Use to other entities? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/14/16

In the early days of Pay for Performance, many physicians and patient advocates worried about the practice of cherry-picking patients. They feared physicians would refuse to take more complicated patients who might negatively impact their quality metrics. We didn’t see a significant spike in situations where patients were terminated from the practice, but in those days, the stakes were significantly less high than they are today.

Today we not only fail to realize an incentive if our quality doesn’t measure up, but we are at risk of actually being penalized. This grates on those of us who strive to do right by our patients but simply can’t control their behavior no matter how much motivational interviewing we conduct, what support systems we provide, or how well we try to partner with our patients.

I’m wondering if we’re about to start seeing the feared spike in patients who are asked to leave physician panels. My suspicions started when I saw a recent article in one of the throw-away practice journals that talked about the “right” way to terminate a physician-patient relationship. Some of the overtones involved patient non-compliance.

I’m not against the idea of terminating a patient for failure to follow the care plan, but have only done it when the patient’s failure to follow the plan was directly putting their life at risk and I felt that we had reached an impasse where they no longer trusted my judgment and I could no longer be effective as their physician.

Since that first article, however, I’ve seen at least three more. The most recent one specifically addressed the idea of terminating patients when their failure to comply impacts quality measures. Some of the concepts discussed were well past the “slippery slope” stage, so I hope this isn’t where we’re headed.

I had a recent experience where a patient who was branded as a controlled substance drug seeker turned out to have a much more complicated situation. Although she indeed had become dependent on narcotic pain medications while appearing to have no physical findings to support the need, she was eventually found to have an extremely rare condition that was only identified after visits to multiple specialists across several disciplines. Her pain was legitimate, but vague enough to make her potentially appear as if she was a liability concern.

I personally had only seen her once before and she expressed concern about making sure that her records reflected her recent surgery. The only problem was the fact that she was again at the urgent care with pain, stating her regular physician was unreachable and that the medications she had at home were not working.

Thinking about it from the other direction, though, putting on my value-based-care hat, it would certainly be cheaper to keep her in an ambulatory practice and just keep her supplied with pain pills than to get her into a pain management treatment program or have her turn up in the emergency department (at least in the short term). That’s where the equations measuring quality, cost, and access become less reliable than they might otherwise be.

A reader asked about my recent purchase of a Surface Pro 4 just prior to the holidays and what I thought about it after several weeks of use. Other than some self-inflicted casualties (like deleting my Outlook data file on accident and purging my trash before I realized it) it’s been a generally good experience. I love the fact that it’s more powerful than my previous laptop yet much lighter, although the keyboard is such that I can’t use it on my lap without a lap desk. I haven’t used it much in non-keyboard mode but the ability to use the touch screen while typing (just reach up, swipe, tap, whatever) feels like it’s more efficient than mousing or using the keyboard’s touch pad, especially when working with PowerPoint.

I had some initial bad experiences with the charging cable. Although it’s cool and magnetic, it’s at an odd place on the tablet and the cord seems pretty short. Because of the length and position position, it’s always bent at a 90-degree angle, which I’m guessing will wear it out. It would be “plugged in, not charging” for no good reason. That seems to have settled down quite a bit, but I haven’t figured out the battery life.

On my trusty Dell laptop, when it hibernates, it uses no power at all. The Surface seems to consume power even when it’s in sleep mode, sometimes akin to the way that college students consume tequila on spring break. It’s intermittent, though, and I can’t find a pattern.

The only other negative is because I’m a creature of habit, and that’s the problem that I can’t run Microsoft Money on Windows 10 without hacking the registry. (Yes, I’m using software that was sunset in 2009, because it’s free, works well, and provides continuity for my data.) I’m looking for new financial software, though, and would appreciate any recommendations. I use QuickBooks for my consulting business, but it’s more trouble than I need for home finances.

Bottom line though, I’d still buy it again. Two of the vendors I work with have gone to Surfaces for all their executives, which is what finally convinced me to take the leap.

I finally had some quality time to sit down today with the HIMSS agenda. I was hoping to plot out a strategy for trying to obtain the American Board of Preventive Medicine LLSA credits required for those of us who are board certified in clinical informatics. Those of us who certified in the first year have to finish 30 hours by the end of 2016 and unfortunately my recent trip to the AMIA Symposium didn’t net me as many as I had hoped.

Although the conference says it’s approved for up to 19 hours of LLSA credit, I couldn’t figure out how to determine which of the 300 sessions were approved. ABPM is fairly picky about how they give credit and attendees generally have to complete questions for each activity, so I want to make sure I do it right. I found a couple of links but unfortunately became trapped in a circle of “page not found” errors.

Have you cracked the code for LLSA credit? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/11/16

Even though I haven’t been their CMIO in some time, my former employer continues to include me on many of the communications as they move forward with their migration to a single EHR platform. They just sent out a “year in review” listing some project highlights.

Although we were always strapped for staff, they’ve mysteriously found the budget to bring on more than 300 positions, the majority of which are incremental additions. I shudder to think of what we could have done with the “old” platform if we had even five more staffers. It always felt like we were holding things together with bubblegum, baling wire, and duct tape. The software was often blamed for problems that were, more often than not, due to our implementation or processes.

They also listed how many hundred hours of training, design, and decision sessions have occurred. Again, I know that had we been able to pull people away from their daily work, we could have made a tremendous difference in their user experience as well as in patient care.

Leadership appears to be on board, but I wonder if it’s because they really believe in the project or whether it’s because they know it’s a substantial financial commitment and they have to be on board. Maybe it’s also the “me too” effect since we’re the last health system in the region to move to a single product platform.

I was amused by their back-slapping about being on a single “seamless” record because they seem to be overlooking the fact that they carved out the lab systems and the revenue cycle systems. Of course they’ll be interfaced, but that’s not always what it’s cracked up to be.

I was surprised though to read that they’re going to allow the platform to be hosted outside of their corporate data centers. The mere idea of hosting anything externally was enough to make them cringe when we brought up our HIE the better part of a decade ago. I still remember making the rounds trying to twist people’s arms since I knew that independent hosting was the only way to get the community-based physicians on board.

Although they’re consolidating clinical applications, they’re bringing several new vendors into the fold. I’m not surprised since they tend to come along with some of the big-name systems these days. They provided a detailed list of what they’re keeping and will integrate with the new system and it was significantly larger than I expected.

There are whole hospital departments that will keep their same software, although it will interface to the central EHR. In some areas, the physicians will keep documentation in an external system but the nursing staff will document in the new system, which although likely intended to keep the physicians happy, feels a bit like a recipe for disaster.

Not two emails later, I received notice of the monthly fixes to the inpatient application that was written in a new format (probably in honor of the new year) that was extremely difficult to read. If you have to use multicolored highlighter on every single item, you’re probably not writing clearly enough for your audience. The amount of color on the document was enough to make my head spin. For a few moments I contemplated sending them back a user interface document on effective and appropriate use of color, but figured that I’d much rather them not know I’m reading so I can continue to play along with the home game and not risk being removed from the distribution list.

Although the EHR consolidation project is at the top of the scale for visibility, promotion, and funding, I’ve heard there are rough waters ahead. There may be an impending shakeup in the clinical leadership and possibly in the IT leadership as well.

It wouldn’t be the first CIO that we’ve seen sign up for a major initiative like this and then step out the door, although usually there are cost overruns or delays first. Maybe the CIO in question was planning to use this endeavor as his swan song all along – it’s hard to tell sometimes. I’m putting money on the fact that he won’t until go-live, though.

Reading all the updates reminded me of how much I miss the CMIO role. Being a consultant definitely isn’t easy and the travel isn’t glamorous, fun, or sometimes even tolerable. However, it’s been a great way to see under the covers of dozens of hospitals and health systems and to learn in a way that I would not have been able to had I stayed in my previous role.

Unlike Mr. H (who just got his Global Entry), I may be ready to put my rolling luggage in the closet permanently. I’ve decided to hold on accepting new clients while I consider going back on the market as a CMIO. Spring is just around the corner and I’m ready for some new growth.

Who else is planning to job hunt at HIMSS? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/7/16

Lots of buzz this week about practices getting ready for Meaningful Use attestation. One of my independent colleagues reached out to me about an offer to provide batch attestation for all physicians in the practice for less than $1,000. Looking at the amount of time that practices can spend doing an attestation, it certainly sounds tempting. Given the risks of a badly-done attestation, I’d make sure that I read the fine print and included some kind of language on performance or lack thereof. If anyone has used one of these services, I’d be interested to hear about it.

AMIA as requesting submissions for the iHealth Clinical Informatics Conference to be held in May. The submission deadline is January 22. I’ve been to Minneapolis and enjoyed it. I’ll likely attend if I don’t have a conflict with a client engagement. I’m still working to get all my Maintenance of Certification hours for Clinical Informatics. I know there are some available at HIMSS, but I’m not sure if the courses are going to work with my social schedule. I did finally complete the required “patient safety module” for the certification and am grateful for ABPM for giving a six-month grace period to those of us who were in the first certification class.

I’ve received quite a few LinkedIn announcements lately that are congratulating people on new positions that they’ve actually held for some time. This usually makes me think that they’re buffing up their profile in preparation for job hunting, especially if they couple it with a “please endorse me” message. The one I received today was particularly amusing as it was from a former colleague who has habit of overstating his qualifications. I’m not likely to put my reputation on the line for that. In other cases, people might just have been delinquent in updating their profiles, but it’s more likely to be the former.

Speaking of job hunts, a reader responded to my recent comments on Glassdoor suggesting several more companies whose reviews are downright entertaining. I almost spit wine all over my new computer, so he’s lucky he’s not buying me new hardware. Feel free to send me your funniest examples and I’ll put together a top 10 list.

Now that we’re in the new year, I’m starting to get excited about HIMSS and have secured my date for HIStalkapalooza. This year it’s someone clinical, so it will be interesting to hear feedback from that perspective. I’m starting to work on wardrobe and of course accessories. Last year I had a wardrobe malfunction involving my handbag becoming tangled up with my dress on the dance floor, so I’m not eager to repeat that episode. If you have any great wardrobe finds, let me know.

The new year is also a time of stress for many patients. I was at my own doctor appointment the other day and watched multiple patients being turned away because of issues related to a change with their insurance coverage. Some didn’t have referrals and others didn’t realize the physicians they were trying to see were out of network on their plans.

One of the patients had an interesting situation where she has a PCP on her HMO insurance but actually sees a “direct primary care” physician for her primary care needs. Although she had a consultation request from her actual PCP, she didn’t have one from the PCP on her card who she had never seen, so the practice wouldn’t see her unless she agreed to pay in full. Most of the patients were extremely frustrated, which is not surprising. The way we deliver care in the US is just crazy.

My visit was frustrating for other reasons. I was having stitches taken out from a skin biopsy and had received the results by phone the other day. The medical assistant offered me a copy of my results and I said yes, since I hadn’t received them through the practice’s patient portal and wasn’t sure they did pathology that way. She then said, “Oh, I need to go talk to the doctor and see if you need a re-excision” and walked out of the room leaving me with a giant “!?!” hanging in the air. Certainly people shouldn’t be calling with results if they don’t know the whole care plan or if it’s not documented anywhere.

She returned a few minutes later saying, “You’re good to go,” but didn’t have the result in hand. I was pushing being late for a client call and will just request my own copy of the results so I didn’t argue the point, but it was not the care I expected from a major university health system.

Once I made it home and finished my client call, I was glad to see this blurb from another reader with a fondness for unusual news. Possibly some competition for Weird News Andy? A suburban Chicago funeral home recently received approval for a liquor license. They’re hoping to partner with a nearby Italian restaurant to offer the refreshments and build the idea of funerals as a “life celebration.” I think EHR vendors could offer similar refreshments at their training centers – it certainly would make the experience more pleasant.

What do you think could be done to enhance EHR training? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/4/16

This year started with a bang as I received my first request to bid on a new consulting engagement over the weekend. I need to do quite a bit of discovery before I decide whether or not I’m going to take it, but I admit I’m seriously intrigued.

It’s from a group of physicians that consults at various extended care facilities and nursing homes where documentation is still done on paper. They’re looking at ways to better manage the use of potentially harmful medications in the elderly. Their needs initially sounded like more of a traditional “assistance with system selection” effort, which I’ve done quite a bit of. That’s how they heard about me. But the more we talked, I understood that they’ve already narrowed it down to three vendors and are looking for some very pointed critiques of the approaches.

In hearing overviews of the proposals, they range from moderately serious to what sounds downright comical. They seem like they would be a good bunch of people to work with, although I’m halfway tempted to tell them they need to choose Door #4 and go back to the drawing board. I can tell from several states away that the one proposal was cooked up by some sales team who really doesn’t understand the business or the needs of the providers and I’m tempted to take the job just to skewer them. I’m not sure I’m going to be able to dedicate enough time to this job as it would likely need, so I may have to take a pass depending on their timing and some other factors.

I worked New Year’s Eve in the trenches, which is always a good time. My experience over the years is that staff members working the holidays tend to be motivated to help move things along as quickly as possible, since you never know when your next rush of patients is going to arrive and you don’t want to be caught behind if you can help it. My shift ended before midnight, though, so I didn’t get to see a lot of the more story-worthy patient visits.

I can say honestly, though, that influenza season is here in full force. If you haven’t received a vaccination yet, there’s still time and I would encourage everyone to do so. If this weekend is any indication, there’s a high potential for this season being quite challenging.

I spent the rest of the weekend getting caught up on email and around the house. My goal this year is to not have an inbox that is perpetually full.

I took particular delight in clicking “delete” on a couple of emails from CMS. One was regarding batch upload for 2015 EHR incentive program attestations. Although I’m still peripherally involved in assisting my clients through this process, I am glad to not be personally accountable for managing the process for my own physician group. The attestation period for Medicare programs starts today and runs through February 29 for those of you playing the home game.

I also enjoyed deleting a CMS “year in review” email celebrating a look back at ICD-10. There were several emails from CMS and ONC covering their joint effort to address quality measure reporting under the various inpatient and ambulatory reporting systems as well as the EHR incentive program. They’re trying (again) to streamline the reporting process and reduce the burden to users, organizations, and vendors, but I’ve not been impressed by their previous work in this regard.

I also found an email from CMS about the new Medicare Drug Spending Dashboard and spent a few minutes checking it out. Drugs were selected for inclusion on the main dashboard due to high total program spending, high annual spending per user, or a large increase in average cost per user. Some of the drugs having the highest jumps were generics – why is digoxin up 298 percent? It’s been generic as long as I’ve been practicing. It’s still relatively cheap in the grand scheme of things, but I was surprised by the numbers.

Not surprising was the inclusion of several medications that are extremely expensive and often-prescribed despite being only marginally more effective or tolerated than the traditional / generic / cheap competitors. There were more than 20 drugs on the list which have more than $1 billion in total spending (2014 data) with some in the $3B range. The original email about the dashboard mentioned that HHS convened a group of consumers, providers, employers, vendors, payers, government agencies, and others to discuss how to balance “the dual imperatives of encouraging drug development and innovation while ensuring access and affordability.” I’d personally like to see Medicare beneficiaries take this list to their doctors and if they are on some of these high-dollar drugs, discuss whether there are alternatives and how much benefit they’re really getting from the Cadillac vs. the Buick vs. the Chevy and how that meets their life goals.

I shudder when I see patients in their 80s and 90s who are on medications that are adding little to their health besides higher costs and an increasing risk of complications due to polypharmacy. I remember when a patient in her early 90s came to “interview” me as she was shopping for a new doctor. She and her daughter (who was 70) came to talk about my philosophy of geriatric care. She was reasonably healthy and shared a home with her daughter and had only been hospitalized once in the previous five years. I honestly told her that I didn’t have a lot of patients in her age bracket, but if she were to join my practice, my main goal would be to prevent as much as possible and to give her medications only if absolutely required. I must have made an impression because she transferred her records the following week.

Some of the reporting around the CMS drug dashboard data shows the shift in disease burden as different populations join the Medicare rolls. Hepatitis C treatment has a significant cost impact along with cancer, diabetes, and pulmonary disease. It also mentions that this is only part of the relevant data – it doesn’t include spending data for commercial payers, Medicaid, the VA, or the military and doesn’t show whether there are rebates or other cost-shifting arrangements.

I expect Medicare to be insolvent by the time I’m 65 and out-of-pocket costs to be absolutely insane, so I’m doing what I can to keep chronic disease off my doorstep. Although I’m not the most disciplined when it comes to food choices (the pastry therapy doesn’t really help either), I’ve got a pretty solid relationship with my treadmill since I upgraded it early last year. Committing to be on it as many days as possible is as close to a resolution as I’m getting.

What’s your New Year’s resolution? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/28/15

I must have been very good because Santa brought me a new Microsoft Surface Pro 4 to play with. As much as Windows 8 gave me fits last year, the transition to Windows 10 has been just about seamless. I’m enjoying its small size and the touch screen even though it has run through a couple of upgrade cycles in the few days I’ve had it.

The only downside has been that I haven’t been able to get my Outlook .pst file to import into Office 2016. I’m not sure if it’s because I’m making a large jump in versions or because I’m going from regular Office to 365, but it’s going to be a non-starter if I can’t get it done before my next client engagement.

I can’t believe 2015 is coming to a close. It’s certainly been an interesting one, with lots of ups and downs for everyone. Many of us have bonded through the trials and tribulations of ICD-10, although more than a few people have expressed their happiness that they’ll likely be retired before another version of ICD goes into use.

Depending on how fast that becomes a reality, I can probably arrange to be in that category if I keep picking up extra shifts at the urgent care and invest well. I’ve spent so much time on the road this year that my living expenses have been lower than usual, so once I finish my taxes, I might be able to make a pretty good contribution to my nest egg.

I knew I had been on the road a lot since going the consultant route, but it really hit me when I started receiving the year-end summaries from my frequent traveler programs. I gained status on one airline and lost it on another – too bad we can’t use accumulated miles to buy our way up because I’d be able to keep status for a long time. I rarely use my free miles since I’m usually out with clients.

Since I was in quite a few smaller towns, I ended up splitting my hotel nights among three major chains, so I didn’t have enough nights at any of them to keep the highest reward tier. Two are merging, though, so we’ll have to see what happens with that. My favorite summary was from National Car Rental, which not only listed the number of rentals for the year, but also the total miles driven. I’m very glad I wasn’t putting that mileage on my own car!

Also in my mailbox were some year-end messages from vendors. Although most were of the folksy greeting variety (pine trees, snow, fireplaces) one was extremely salesy and seemed to have the undertone of a company desperate to meet quarter-end numbers. It probably would have been OK a month or two ago, but in the flurry of holiday niceties, it stuck out like a sore thumb. It wasn’t surprising, though, because this particular company has been in a relative tailspin for some time and constantly misses the mark on knowing its audience and managing social media and other communications channels. If you think this might be your company, I know some tremendously savvy PR people who could help if you’re interested in making a change.

Just for entertainment, I did a random sampling of the 100-odd pieces I wrote for HIStalk this year. There were definitely some consistent themes across the year, including data breaches far and wide and the push for interoperability. Hackers have also been big news, although it feels like they’ve been busier with other industries besides healthcare. Our harm is more likely to be self-inflicted although no less alarming. If hackers decide to consciously target healthcare rather than banking or other industries, it’s certainly going to be a wild ride.

There was also a consistent theme of market consolidation through vendor mergers, acquisitions, and closures. That can often be bad news for physicians and hospitals, although I suppose it could be a good thing if you have a bad vendor and are the kind of group that has to be pushed in order to jump.

Even among customers that aren’t struggling, there have been quite a few de-installations and it’s obvious that Epic will continue to dominate in the large health system space. My former employer is knee deep in migrating to a single vendor system and I enjoyed catching up with some of my old colleagues last week. The project is already behind and over budget in the first year after contract signing with the first go-live being almost a year in the future. It should be interesting.

Other big news included the repeal of the SGR payment system through the so-called “Doc Fix” bill. In addressing other new payment models, it’s going to add complexity for many customers and vendors who will have to add code to address new requirements and the need for additional robust reporting around shared risk arrangements. Less-prominent government-driven news included reporting from the Open Payments law, which is still less accurate than needed, but a good start.

The end of 2015 also saw the final state approving e-prescribing of controlled substances. Although it’s legal in all 50 states, that doesn’t mean it’s well-adopted. Most of my clients don’t have it live due to lack of pharmacy participation, but maybe we’ll do some projects around that in 2016.

In consumer news, the topic of whether wearables have peaked was fairly big news, as was the rise and fall of Theranos. The latter should continue to be an interesting topic in 2016 and I expect we’ll hear more tales from the inside as some of the investigations continue.

Interoperability was a huge buzzword and there has been a lot of push around it, but I’m not sure it’s making a huge difference in the lives of the average physician unless you’re just referring to being able to see data across your entire health system or hospital platform. I’m certainly not seeing competing hospitals doing any data sharing at all and it looks like RHIOs and HIEs are on their deathbeds in some parts of the country.

This year gave me several things to celebrate, including being able to practice my way from multiple part-time and locum tenens gigs to a steady one working for people I not only respect, but have a lot of fun with. Their decision to opt out of the Meaningful Use program (and the subsequent removal of many time-consuming and sometimes useless clicks from the EHR workflow) was one of the highlights of my year. I also made it to AMIA and caught up with old friends, made some new ones, and learned a few things along the way.

This is the close of my fifth year writing for HIStalk, which has been a tremendous experience. It seems like just yesterday I was sending Mr. H my humorous “Top 10” list of reasons he should hire me. It’s been exciting to watch us grow beyond the blogs to hosting webinars and supporting the next generation through the DonorsChoose projects. I’m looking forward to another year of healthcare IT news and opinion.

What are you looking forward to the most for 2016? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/21/15

The year is rapidly coming to a close. Typically this is the time when things are relatively slow in the industry trenches, at least until the first of the year when the frenzied run-up to HIMSS begins.

I’ve got my countdown page ready, not because I’m dying to go to HIMSS, but because I’m excited to see many of the friends I’ve made in the IT world that I only get to see once a year. Although we stay in touch through email, it’s just not the same as being able to get together in person, share a drink, and swap stories. Of course I’m also excited about HIStalkapalooza, although I haven’t given a single thought to my shoe wardrobe yet.

Several of my colleagues are still waiting to see if they will be able to make it to HIMSS. Those who are vendor employees have seen cuts in the number of attendees sent by their companies the last several years. Others from the provider side sometimes find HIMSS to be not only overwhelming, but given the current economics of medical practice, not worth the cost. There are also those who work at faith-based organizations that will not pay for conferences held in Las Vegas, but at least those folks know outright that they’re not going to attend unless it’s in Orlando since everywhere else seems to be out of the running.

I’m wondering what the big buzz will be about this year. Meaningful Use is old hat, although there will still be some picking over the bones of Stage 3. Value-based reimbursement has been on the rise, although for many, it’s more of a buzzword than an actual strategy.

The reality of putting together some of the IT infrastructure required to maximize the promise of value-based reimbursement is daunting. Although the large health systems and academic medical centers can be demanding about their networks and try to control their physicians, it’s put a terrible strain on independent practices and also on patients who want to see physicians across multiple systems but are being steered to stay within the vertical. It was bad enough when insurance networks were restricting choice, but to have your physicians negatively incented to refer you to the consultant of your choice is another thing entirely.

Many people think that interoperability should solve this problem, but the reality for many physicians is that interoperability is a joke. Not only are there incentives biased against sharing from the hospital side, but as an independent physician, I can’t even get access to the hospital web portals in my area because I’m not on staff.

Being a member of the medical staff has not only a financial cost but a professional one, with many hospitals requiring physicians to provide call coverage for patients in the hospital. Although that requirement can often be shifted to a hospitalist physician, they also require physicians to be available for outpatient follow-up, which is nearly impossible when you are a part-time physician at a practice that doesn’t have scheduled appointments and doesn’t provide primary care.

I would love to be able to log into a hospital portal and get follow up on the patients I have to transfer to the hospital. We’re seeing more and more of them as cost-shifting drives them to urgent cares when they really should have been in the emergency department in the first place. Although we’re pretty advanced at my facility, the last few shifts I’ve worked have included multiple ambulance transfers for people who were actively having heart attacks. There was one just the other night with a life-threatening stomach bleed, which let me tell you looks pretty much exactly like it does when they show it on TV medical programs.

All of the patients I’ve had to transfer have cited cost and access as the primary reasons they chose us instead of another facility. Since my roots are in primary care, I always wonder how they are doing, but I never see a discharge note or any kind of communication from the hospital despite my multiple Direct addresses that should make it easy. Maybe I should head to the mall and ask Santa to bring me some discharge summaries for Christmas. I’m not sure if the elves have signed a BAA, however.

I’m winding up the year with a last-minute lab interface project that is keeping me pretty busy. The client is super nice and had an issue with their lab vendor canceling their contract with minimal notice, so they’re in a hurry to get a new one live before their interface is shut down. The work is somewhat tedious, but that will be good to keep me busy.

Today is the shortest day of the year and I’m glad it’s here. I’ve missed having light in the evenings and have had to spend more time on the treadmill than I like. I’m looking forward to longer days and being able to get back on the streets without fear of a broken ankle from tripping over something in the dark. We certainly can’t have that in the run-up to HIMSS. Once this project is done, I’m laying low until the New Year.

What are your plans to wind up 2015? Email me.

Email Dr. Jayne.

EPtalk by Dr.Jayne 12/17/15

Time is flying and it’s hard to believe that HIMSS16 is barely two months ahead. My annual preparations have started, including the creation of the social schedule. It can be difficult to juggle meeting up with colleagues I only see once a year, sessions, sponsor events, and of course stalking the exhibit hall with some of my BFFs.

I booked my flights really early this year and didn’t realize that HIMSS had shifted to the Monday start, but it was easy to fill Sunday with some spa time. I have a penchant for something called Watsu, which is water-based Shiatsu massage, and there aren’t many practitioners in my part of the country. The Bellagio has a wonderful therapeutic pool, so I’m definitely going to get my Watsu on so I’m plenty relaxed for the week.

Flu season is upon us and we’re already being inundated with patients, many of whom opted out of vaccination. It’s not too late to get yours if you’re interested. Although it takes several weeks for them to reach maximum effect, flu season runs through April, so it can still be useful.

I was surprised to learn that payers are playing games with vaccination payments. Vaccines are one of the most cost-effective interventions we have in our arsenal and the flu vaccine is pretty inexpensive in the grand scheme of things. We have one payer who refuses to cover any vaccines when administered at our practice, simply because we’re an urgent care. Even if a patient comes in with a laceration that merits a tetanus shot, we can’t give it unless the patient pays out of pocket.

Patients are already paying big dollars for their healthcare premiums and don’t want to have to pay cash on top of it, so some of them decline and plan to follow up with their primary care physician. That can lead to gaps in care, and frankly PCPs have better things to do than give vaccines sometimes, like managing chronic illnesses and diagnosing new problems. Plus, the hardship of patients having to go two places to be treated for a single problem when we should be able to do it all at once is just a waste of resources. Just another aspect to our broken healthcare system. Although coverage is mandated, payers are finding a way around it.

I’ve been spending a lot of time in the practice and have picked up some kind of a respiratory virus. If we weren’t so focused on patient experience I’d love to hang out a sign that says, “If you’re not sicker than the doctor, you need to go home and try some cold remedies.” That’s not how we roll, though, so I apologize to the patients who are subjected to my sniffles. I like to think that I’m providing some level of patient education, since if I’m still sniffling it’s clear there’s no magic bullet to resolve all the symptoms.

I’ve been sad ever since the decongestant phenylpropanolamine was pulled from the market, because it actually worked. One of the most-used products around, phenylephrine, has been re-examined and found to be ineffective. But it’s easier to obtain than pseudoephedrine, so a lot of people try it anyway. Still, I’ll keep up with my humidifier and hot tea and hope for the best.

I’ve been playing around this week with my new technology purchase, a Microsoft Surface Pro 4. I am enjoying it, although I can’t get Outlook 2016 allow me to set up my inbox like I had it on my old computer. The change is just enough that it’s making a mess of my muscle memory, but I’ve tried everything I can think of. The settings screen looks just like it does in Outlook 2013, but it doesn’t behave the same way. Maybe it’s a bug or maybe I should just get used to it.

Speaking of bugs, the American Medical Association emailed yesterday to offer me tips and resources on how to pass the USMLE Step 3 licensing exam. Since I’ve been licensed for more than 15 years, they’re a little late. They did send a follow-up email asking me to disregard it and to enjoy my complimentary 2016 resident membership, which is even funnier.

Speaking of funny, I spent some time surfing Glassdoor looking at reviews for a couple of employers that are clearly in a downward spiral. A friend had sent me a few links and the email arrived at a time when I really needed a laugh. For the one employer, it’s clear that they have someone occasionally posting anonymously that the company is great, but 95 percent of the other reviews are negative and the themes go back several years.

I’m sure disgruntled employees make up a good chunk of the postings, but everyone has disgruntled employees and when you look at similar companies, you don’t see that kind of skew towards the negative. If you’re in HR and you haven’t looked at your own employer’s reviews, it might be worth a few minutes of your time. Reviews with titles like “Rome is Burning” should definitely catch your attention.

I’ve also been catching up on my holiday baking, and in the spirit of the holidays, I’ll share one of my favorite recipes. Double Chocolate Peanut Butter Chubbies are one of my favorites the last few years. They’re insanely chocolatey and you can modify the recipe by using different kinds of chocolate (or non-chocolate if you prefer) chips or different kinds of nuts. Personally, I like mine with Hershey’s Special Dark chips and chunky peanut butter.

What’s your favorite holiday cookie? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/14/15

In my experience, this time of year is always a mixed bag in health IT. Sometimes it can be extremely busy, with groups trying to frantically spend any remaining budget before the end of the year if their fiscal year follows the calendar. Those are always interesting clients to work with because some of them just want to book the work and not really do anything until after the holidays, while others want to try to cram the work in as well as getting it on the books. I try to avoid the latter since I typically plan for a lull at the end of the year so I can enjoy some downtime.

Then there are other kinds of clients who have either run out of money (often long before the end of the year) or are short on staff and are trying to figure out a way to complete projects before the end of the year. I also try to avoid these clients if possible since it’s often someone’s bonus requirements that are driving the work. There is typically a lack of planning (hence the end-of-year approach) and the team is often not resourced correctly to get the work done even with support. The handful of times I’ve done consulting engagements around projects like this, I’ve always made sure that I have enough backup resources to just do the work for the client rather than with them.

I was approached by a client last week who was clearly desperate and fell into multiple categories. It’s a small practice that has been working on Meaningful Use. They attested to Stage 1 in 2013 and planned to attest to Stage 2 in 2015, but their project went way off the tracks. They have four providers and about 10 staff members, but have not been able to figure out how to dedicate anyone on the staff to shepherding a Meaningful Use project.

They spent the first half of the year knowing that they needed to upgrade their EHR to a version that would support MU2, but doing everything possible to avoid it. Much blame was placed on the vendor despite the practice not having adequate servers to support an upgrade. They had worked with another consultant to get through the upgrade, which luckily included a migration to a hosted platform so that servers won’t be an issue moving forward.

Despite having upgraded over the summer, the practice hasn’t done much to further their MU efforts. They haven’t been running reports to see how they are doing on their quality metrics and haven’t really checked their workflows against the best practices recommended for MU documentation. They also haven’t yet purchased (yet alone installed) a patient portal. They were under the impression that all they had to do was to get the portal installed, which is why they called me. It never crossed their mind that they would actually have to have patients live on the portal or actually using it. They just thought they could hire me to run interference with the vendor, get a proposal, get the contract signed, and then “turn it on.”

I know the vendor is more than happy to send them a contract immediately, but scheduling an installation during the holidays never goes well. Not only do many vendors have people taking time off, but usually people who work in a medical practice also hope to take time off to spend with family and friends. Not to mention that hurrying this through isn’t going to help their cause with Meaningful Use since there are many other requirements that they are not meeting.

I’m not typically one to turn down work, but in this case I elected to take a pass. Not only would it add a lot of stress to my planned downtime, but I just don’t think it’s the right thing to do for the client.

What the client really needs is a solid sit-down with the owner to actually create a strategic plan for the practice. He needs to figure out whether he really wants to participate in the Meaningful Use program and if so whether he is willing to dedicate resources (either a single staffer who can own the project or money to hire someone outside to do the job) to create a comprehensive plan. If he is agreeable to that, then he needs to commit to dedicating time for staff members to receive training and adapt their workflows for success.

In addition, he will need to get the employed providers in line with the expectations. He needs to agree to a plan that not only covers the installation of a patient portal, but also a campaign to engage patients and get them to sign up and to incorporate the use of the patient portal into the daily workflow of his office.

I tried to schedule a meeting with him to discuss all of this, only to find out that he has taken the rest of the year off. The fact that a practice owner would just hand off a task to staff such as, “Hey, let’s do a patient portal” and leave town is just shocking.

As a consultant, it’s also a key indicator of marked unhealthiness in the practice. It’s unlikely that I’ll be doing any work with them even as much as I like a good challenge. The longer I’m in this business, the less interest I have in total train wrecks regardless of how well they pay.

I’m going to maintain my planned downtime and continue contemplating my career plan. Although my clinical employer’s offer was somewhat open-ended, I don’t want to keep them waiting if that’s the way I’m going to go. During the lull, I have some craft projects planned and of course some pastry therapy.

What are your end-of-year plans? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/10/15

A couple of reader comments on my piece about employer wellness programs caught my attention. I have to thank Al Lewis, who provided my laugh of the day when he asserted that, “There is no adult supervision in this field, so vendors can do things that doctors would get sued for doing.” He goes on to call out a vendor who provides carotid artery disease screening even though the US Preventive Services Task Force (USPSTF) specifically recommends against screening the general adult population. I didn’t know this was creeping its way into employee wellness programs, so thanks for the warning.

I have, however, seen mass carotid artery disease screening in a promotional offering for senior citizens that I can only describe as predatory. For an upfront cash fee, it touts the benefits of multiple “screening” tests that aren’t recommended. In addition to the carotid artery test, it also offers abdominal ultrasound screening (only recommended for men aged 65 to 75 who have ever smoked, and selectively recommended for men in this age group who have never been smokers). It also offers screening for peripheral arterial disease via an ankle brachial index (insufficient evidence to assess) as well as multiple blood tests that aren’t necessarily recommended for average-risk individuals.

When looking at the flyer and the number of tests offered, it may be easy for some to come to the conclusion that it’s a good deal based on the sheer volume of diseases they talk about. However, no test is without risk and just getting them because they’re cheap and available is a bad idea. Although we did tend to “shotgun” batteries of tests on our hospitalized patients when I was in medical school, by the time I reached residency training, the focus had shifted to doing fewer tests and only those that were evidence-based. That was good, because I can’t even count how many wild goose chases we went on due to abnormal labs that should never have been ordered in the first place.

The worst wild goose chase of my career still haunts me and I wonder if a different attitude (and better interoperability) would have prevented it. The patient was a delightful lady with significant and complex medical problems who had been my patient for three years during my residency. When I decided to stay in town and open a practice, she asked if she could follow me. Although I said yes, I cautioned her that there would be a two-week period between when I graduated from the training program and when I hung out my shingle when I would have no malpractice insurance and could not be her doctor. I advised her to remain with the residency clinic for continuity until my doors were open.

Unfortunately, one week into the gap (while I was cramming for my board exam) I received a call from the emergency department of my “new” hospital where the patient’s caretaker had taken her, not realizing I could not yet care for her. She was admitted and placed in the care of a hospitalist and three specialists who were working up her problems, unaware that they had been worked up thoroughly in the past. Because the patient was non-verbal, her ability to consent to the evaluation was limited. She had abdominal pain and her exam was challenging due to her other conditions, so someone ordered a cancer antigen test, which was positive. They didn’t realize it had been positive for some time with a completely negative workup and a previous informed consent decision to stop pursuing it.

I attempted to reason with one of the house doctors, begging them to request the chart from the residency program so they could provide good care. Unfortunately the goose chase persisted and the patient remained hospitalized, developing a life-threatening problem with her platelet function. This was in part due to the blood thinner injections she was given in the hospital to prevent blood clots due to her immobility. Oddly enough, the patient has been immobile for the better part of 50 years and survived without blood thinners, but the doctors were just following the hospital protocol for giving heparin to immobile patients.

The cancer workup was completely repeated, including several invasive procedures. By the time I assumed care of her barely a week later, she had suffered multiple complications, including a heart attack, and was being considered for bypass surgery.

Thank goodness I was able to corral things before that happened because the patient and I had previously discussed her surgical prospects and she had clearly indicated that she didn’t want anything like that done. I realized that for most of the hospitalization, she had been without the computer she uses to communicate with people (she has mobility of one hand and creates computer-generated speech using it) and probably hadn’t consented to most of what she had been through.

At that point, my goal was just to get her out of the ICU, and then out of the step-down, and then to the regular floors, and then home – one day at a time. Eventually we accomplished all of those and she did well despite the “care” she received. Even years later, just thinking about this scenario wants to make me track down whoever ordered that initial (inappropriate) blood test and give them a good talking-to. Whenever one of my students or supervisees orders an unnecessary test, they hear this story. I hope it sinks in.

Another comment was from John Lynn, who asks that if a patient showed up in my office and said they were healthy and wanted to stay healthy, what would I do? I agree with him that some doctors would offer a physical and try to find something wrong. However, many physicians (especially those trained in family medicine and other primary care specialties in the last two decades) would know exactly what to do. We’re well trained in health promotion and disease prevention, but many of us don’t get to use those skills often enough. My personal recipe includes the following:

• Find out if the patient has any concerns about their health, even if they think they’re generally healthy. Those concerns should be addressed through additional history and a targeted exam and a specific workup if warranted.
• Take a detailed family history to review the patient’s risk factors and discuss ways to mitigate those risks or avoid developing additional risk factors.
• Discuss general health behaviors (diet, exercise, tobacco, alcohol, caffeine, sexual behaviors, seat belt use, etc.) and advise accordingly in line with current evidence. Refer to appropriate resources as needed (nutritionist, smoking cessation, psychology, social work, etc.)
• Assess psychosocial and other determinants of health as needed (social supports, financial ability to get care if needed, etc.)
• Targeted physical exam as recommended for evidence-based screenings and to establish a baseline rather than “looking for” something.
• Recommendation for additional screening tests and preventive services as appropriate based on evidence-based recommendations. This may include in-office services such as vaccines or external testing such as mammograms, colonoscopies, etc.

There are more things involved, but you get the idea. It’s about the doctor and the patient sitting down and talking about things. Which in our system doesn’t get you paid very well, and because of that, we don’t have anywhere near the time we need to do it right.

Add in the fact that patients often have to change doctors every year or two due to insurance changes and it’s hard to develop the rapport needed to work together on some of the more challenging situations that come up when you actually talk to people and get to know them. I’d love to be able to have a solid hour with patients to do a wellness visit and to leverage proven techniques such as motivational interviewing, but that’s just not how it works.

In my ideal world, I’d not only have the time to do it right, but the resources – access to other clinical professionals as needed (psychologist, social work, nutritionist, health coach, etc.) at times that work for the patient so they don’t have to take off work. I’d also like to see these preventive services fully covered by insurance. Although the Affordable Care Act mandates coverage for preventive services recommended by the USPSTF, patients on so-called “grandfathered” plans may still not have coverage. Until recently, I was on one of these plans so know exactly what is involved.

I’d love to see all preventive services fully covered. Not only because it’s the right thing to do, but also because they have been proven to be cost effective. I remember the first time I realized that Medicare wouldn’t pay for blood sugar monitoring supplies for certain diabetic patients but they would pay for amputations. I was appalled.

If that ideal world existed, I’d likely still be a primary care physician rather than a mercenary CMIO and part-time emergency doc and blogger. It’s something for the politicians and pundits to think about when they talk about the shortage of primary care physicians and wanting to bend the cost curve. But unfortunately, I don’t think it’s anything I’m going to see in my lifetime.

What’s your ideal care paradigm? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/7/15

A Tale of Two Articles

I subscribe to quite a few news digests, including some from the AMA and other professional organizations. The headlines are always attention-grabbing, so “Framework evaluates 20 top EHRs – and they don’t quite measure up” definitely caught my attention. It links to a usability analysis done by the AMA and MedStar Health’s National Center for Human Factors.

Using an EHR User-Centered Evaluation Framework, they looked at data that 20 vendors (15 ambulatory and five inpatient) provided to meet ONC certification requirements. The Framework goes “beyond the ONC’s criteria… to encourage the ONC to raise the bar for usability certification.”

Being a good clinical informaticists means being a critical reader and making sure that one understands the information being presented before coming to conclusions. That approach has served me well when providers would storm into my office with “conclusive evidence” that our EHR was bad, waving copies of articles in my face such as a reader survey that had a grand total of 13 respondents using our product from a nationwide sampling.

In reading the introductory information carefully, one can see that they’re somewhat comparing apples to oranges. They looked at what vendors submitted for certification, not the totality of what a given vendor did or did not do with regards to user-centered design.

I have several friends who work for vendors and have heard that providing more than what is required for certification is the equivalent of being on the witness stand and offering more than a single-word answer to a yes or no question. The “just the facts, ma’am” approach seems to be preferred.

You can’t blame them. Vendors don’t want to get tangled up in showing something not required that might lead to questions. The certification process is already onerous enough.

The AMA blurb goes on to conclude that, “Out of those 20 products evaluated, only three met each of the basic capabilities measured.” I’m not surprised by this since they were measuring information from a data set that was designed for a different purpose than that for which they decided to use it.

I fully understand that they’re trying to make the point that they think the ONC certification process for usability best practices isn’t robust enough. Unfortunately, it seems to tar and feather some of the vendors despite the process they’re actually doing (but didn’t include in the ONC documentation because it wasn’t required).

The AMA blurb also didn’t include clear language that was included in the actual MedStar Health documentation on the User-Centered Design Evaluation Framework. It clearly says it is not designed to look at actual usability by clinicians, but to look at vendor practices as reported to ONC on the eight required patient safety capabilities.

I’ve personally used many of their top-scoring systems and found them to have major usability issues. Casual readers aren’t going to dig into the details. This piece is likely to be misleading.

I found the whole thing even more interesting when I opened this month’s JAMIA to find an article by the same lead author, Raj Ratwani. This time the researchers actually visited 11 EHR vendors to look at their user-centered design processes. I found this data much more interesting (not to mention peer-reviewed).

Six of the vendors visited have more than $100 million in revenue, with the top three being over $1 billion, so you can guess who they are. Interestingly enough, four of the six were found to have “well-developed UCD” processes and another was found to have “misconceptions of UCD.” I actually laughed when I read this, likening it to delusions of grandeur somewhere in the back of my mind.

The specifics of what the researchers define as misconceptions include that, “vendors do not have any UCD processes in place although they believe they do.” This also includes vendors who cite being responsive to user complaints and feature requests as evidence of UCD.

The overall distribution of the vendors was four with well-developed UCD, four with basic UCD, and three with misconceptions of UCD. The authors go on to cite the fact that even the “misconception” group is certified by ONC, illustrating why certification requirements may need an adjustment. They do at least mention the challenge of creating requirements that lead to improvement for the poor performers but don’t hamper those that are already doing well.

My favorite quote of the article is one vendor who stated, “Our product is used by thousands of people every day. So if it was that bad, it would already be out of the market.”

I certainly prefer the scholarly approach of the latter article, although I’m sure it didn’t get anywhere near as much press as the first one. I was trying to figure out what category my EHR vendor fell into. It turns out they weren’t one of the participants.

How does your vendor perform on UCD and what do you think about it? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/3/15

I engaged this week in what might become my favorite annual holiday event – crashing the medical staff Christmas party at a hospital where I’m not on staff. My good friend Anjali called, again asking me to be her rent-a-date. Last year her husband had to travel, but this year he’s apparently studying for final exams for his master’s program. I think it sounded like a convenient excuse to avoid being around doctors talking shop, but was happy to go with her again even though last year’s party had more EHR discussions than social time. Now that I’m freelance, it doesn’t hurt to network when I can.

Last year there were some, shall we say, “senior” physicians wearing some rather loud plaid jackets. I almost died laughing when I saw that some of the more junior physicians had taken the trend to an ironic new level, sporting so-called “Ugly Christmas Sweater” suits. The first gentleman was wearing the blue and red number above with a pair of white patent leather shoes. I tried to get a photo, but with the dim lighting, it was impossible and I didn’t want to be too conspicuous with my flash. Several of his companions had similarly awful ties and cummerbunds and I can’t help but think that this is going to be a new trend and I’d better secure my invite for next year’s party early.

I ran into a couple of old friends who recently moved from my previous employer to this hospital’s medical group. It was somewhat gratifying to hear that they found the grass wasn’t really any greener in their new positions and that they find their new EHR just as awful as the one I used to be responsible for. Given some of the major shifts going on with value-based care and new reimbursement models, it will be interesting to see if physicians begin shifting alliances or if we start to see even more consolidation among the employed physician ranks.

My other excitement this week was the quarterly provider meeting at my practice. Because of travel conflicts, it’s the first one I’ve attended. Given some of the news that was announced, I was glad to be there in person so I could see my colleagues’ faces. Effective immediately, we are opting out of the Meaningful Use incentive program. There was actually applause and a couple of high-fives. This weekend the EHR will be modified to disable all the extra screens that were added so we could check all the boxes that ended up not being all that relevant to our model of care. The providers were ecstatic to say the least.

The practice owners are extremely process-oriented and determined that the changes to the system will remove literally hundreds of thousands of clicks for users over the next year. I admire their dedication to detail and their gutsiness in deciding to just say no. Our patient volumes have grown dramatically since I started working with this group and it’s fair to say that the revenue from additional patients we’ll be able to accommodate if we can work more efficiently will more than cover any penalties. Having been in the EHR driver’s seat for so many years, it’s been very interesting to work with them as an end-user.

They asked me to stay after for a few minutes. I’m the most part-time of all the physicians and work the fewest hours each month, but had previously volunteered to work some of the less-desirable shifts to allow the full-time staff to have more time with their families. I suspected that they were going to ask me to pick up a couple of extra shifts over the holidays since I had mentioned to the COO that I’m not traveling this month. What I did not suspect, however, was that they would offer me a leadership position in the organization.

I would be going back to formal CMIO duties with a bit more operational authority than I’ve had in the past. I’d also be spending dedicated clinical time at one of our expansion locations, which the organization plans to use as a pilot site for new initiatives and for vetting workflow changes. Our workflow is already pretty serious as far as quality, efficiency, and patient satisfaction are concerned so I’m very flattered by their belief that I could help take it to the next level. I have to say that the idea of being able to return to a CMIO position without dealing with Meaningful Use or hospital politics is seriously tempting.

Although I’ve enjoyed doing more consulting this year and have learned a tremendous amount, the travel quickly becomes less than fun. Based on what I’m being offered, they’ve done an outstanding job of figuring out what makes me tick and what I might find compelling enough to give up my frequent flyer status. They know me well enough to not expect a quick decision on such a weighty matter and I’m sure we’ll have additional discussions over the next few weeks. A wise man once told me that you should spend 10 percent of your time looking for your next gig. Sometimes I guess your next gig might just fall in your lap, though.

What’s your dream job? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/30/15

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/23/15

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Dr. Jayne Goes to AMIA-Wednesday

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What’s your favorite conference? Email me.

Email Dr. Jayne.

Dr. Jayne Goes to AMIA–Tuesday

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

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

Presenter Brian Dixon shared a couple of interesting vignettes:

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Dr. Jayne Goes to AMIA–Monday

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.