Curbside Consult with Dr. Jayne 9/21/15

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

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

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

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

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

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

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

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

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

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

What do you think about Theranos? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/17/15

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

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

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

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

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

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

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

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

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

Have you opted out of Meaningful Use? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/14/15

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/10/15

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/3/15

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

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

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

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

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

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

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

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

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

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

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

How do other physician readers keep up? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/31/15

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

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

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

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

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

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

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

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

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

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

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

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

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

How do you deal with delinquent charts? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/27/15

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/20/15

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

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

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

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

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

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

In thinking through the event there were several potential causes:

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/17/15

Dr. Jayne Does Downtime

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How do you handle a system outage? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/13/15

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/10/15

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

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

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

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

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

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

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

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

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

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

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

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

Have you hugged a vendor lately? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/6/15

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/3/15

I spent most of this weekend doing something that I really enjoy. Most physicians dread it, IT people tolerate it, and vendors may or may not love it (depending on whether they’re getting paid for it.) I won’t keep you guessing on the riddle of what I was doing – I was running a client’s upgrade project. As a CMIO, I picked up a lot of skills I never dreamed I’d have. It’s fulfilling to use them to help clients who are struggling or who want to take on something that’s bigger than they’re used to handling.

This wasn’t just any upgrade – the client wanted to install new hardware, upgrade the operating system, and upgrade the EHR/billing system all in the same weekend. There are varying opinions on whether that combination of tasks should be done at the same time. Does it make it too hard to troubleshoot? Does it create too much stress for the team? Is it just a bad idea?

Ideally most of us would prefer not to have to do all of these things at once, but unfortunately this client’s parent organization backed them into a corner from a timeline perspective, so we had to make it work. They realized the need to have some project management support so they could focus on other things they needed to complete prior to the upgrade. I was happy to agree, although somewhat nervous about the whole idea.

The client is one that I’ve been working with for some time. Even before I left my full-time CMIO gig, I had done some side consulting work and was therefore familiar with the team’s abilities and work ethic. I knew they had a strong leader – one of those “the buck stops here” types – who wasn’t afraid to roll up her sleeves and get dirty if needed. They also had a proven track record for solid communication and problem-solving. Upgrades of this magnitude aren’t without issues and I strongly suspected that with those factors in place that we would be successful.

The other asset of this team is its culture. They’ve embraced the idea that it’s OK to ask questions even if it seems to be challenging the status quo or questioning someone’s expertise. All the members seem genuinely motivated to deliver a quality product whether that product is software, connectivity, training, or support. They also have relatively thick skins and don’t take things personally, which is my favorite part of working with them. Sometimes the role of the consultant is to turn over every rock and make sure there isn’t anything hiding under it, even if it makes people uncomfortable. I appreciate being able to do my job without any hurt feelings or drama.

This team also has a strong record of aggressive project management, detailed planning, and constant refinement. They’ve done many individual upgrades over the last half-decade and have continually modified their plans to make sure that every detail has been attended to and that they have planned for a variety of contingencies. When they decided they wanted to try this plan, they already had proven methodologies for doing each of the component parts and it was fairly easy to figure out how we could fit them together.

When they first presented their plan, I was impressed. They had data on each of the last several upgrades they had done, including the elapsed time for various steps and a log of what didn’t go as planned as well as the modifications they identified for the future. They also had worked with the various vendors involved to identify potential timelines and to determine whether the combined project was even possible. A review of their documentation showed that the planning was sound, so the next step was to perform a tabletop exercise and walk through all the moving parts to identify any other potential gotchas.

This was several months ago, but I still remember how they walked through it all, talking through each step and verbalizing the handoffs. Several team members also added specific comments on their steps, such as, “… and now I’m going to stop process A, because we know that if we just pause it we’ll have a problem. Process A is now stopped. Clear for the handoff to the DBA.” It was overkill from anything I’d ever seen, but it let me know that they knew their stuff and were ready to tackle something larger. It did feel a little bit though like being in mission control for a spaceship launch, however.

Over the last several months, they’ve performed each upgrade separately in a test environment except for the hardware piece. Although they experienced some performance issues, they were within the expected realm considering that their test servers were several years older than their production servers. They started training end users several weeks ago and ensured that not only did the users demonstrate mastery of the content, but of the support process and troubleshooting steps and downtimes procedures that would be needed if something didn’t go as expected.

Our final test came about a month ago when they received their new hardware and did a complete dry run. There were a couple of glitches, but nothing that couldn’t be addressed. All training was complete the week before last and they’ve been in a code freeze, so all that was left was to review the downtime plan and train a couple of stragglers.

Most of my work with this client has been remote (I do so love working in my fuzzy slippers), but I wanted to be on site for the go-live. They’re in a city that has a lot to offer and I headed to town on Thursday to spend time with friends as well as to make sure I was in position if anything unexpected happened. When we took the system down on Friday evening and the clock started ticking, I admit it was a little bit of an adrenaline rush. I wasn’t prepared for what was next though – this is the most anxious I’ve ever been on an upgrade project. It wasn’t necessarily because I was worried, but because it was so quiet. I’m used to getting phone calls here and there with questions about sticky situations and I wasn’t hearing anything from this client.

When we reached our first pre-scheduled checkpoint call, everything was under control and they were even a little bit ahead on the timeline. I’m not used to working with a team that is this capable and organized and found myself having to come up with strategies to just mentally let it roll. The friends I was staying with have a pool, so I spent the better part of the weekend contemplating the mysteries of various kinds of rafts and floats while waiting for my next checkpoint call.

Everything finished early Sunday morning and we were able to get some end users on the system for quick testing before we released it to the urgent care locations that were just getting ready to open. I have to admit, with all the pool time this is the most relaxed I’ve ever been going into post-live support. The urgent cares represent only 10 percent of the typical user load, however, so Monday morning might be a different story.

We’re as ready as we can be – issue tracking processes are in place, people know where they need to be, the communication plan has been reviewed, and I’ve ordered enough food into the command center to feed an army. Every practice site will get a personal visit from someone on the team at some point during the day, whether there are issues or not. And every visit will be accompanied by a snack basket. Maybe it’s because of my roots (don’t ever go visiting without a covered dish, seriously) but I believe in letting the users know that we care how they are doing and wanted to bring a little something to brighten up the day.

It’s now Sunday evening and the daily close process is running. The nightly backup will kick off soon and I hope everyone is settling in for a good night’s sleep. I’ll let you know later in the week how it goes. Despite its magnitude, this has been a lot of fun.

What’s your favorite kind of IT fun? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/30/15

I received a fat envelope in the mail today. Unfortunately it was from my former employer’s credential verification service, reminding me of the need to renew my medical staff privileges. I thought it was odd since I resigned my appointment when I quit, but a call to the medical staff office confirmed they never received my letter. In keeping with the digital age (even if it doesn’t comply with the medical staff bylaws) they let me resign via email and confirmed receipt. This is the first time I’ve been without hospital privileges since finishing residency and it feels a little odd.

Speaking of receipts, my new pet peeve: Outlook users who have their accounts set up to request a “read receipt” for every email they send, regardless of its importance. One of my consulting clients gave me a corporate email account and my inbox is plagued by two analysts with this behavior who also engage in extreme carbon copying. You can bet our next discussion of their communication policy will include these elements.

Another pet peeve: sales teams who use physician directories to try to drum up business from people they think might have money. “I called your office earlier and spoke with Katherine, but wanted to follow up with you via email about our event.” Interestingly, I’ve never worked with anyone named Katherine and haven’t had an office for months. I’m not sure I’d trust someone to manage complex affairs like asset protection and financial advice if they can’t manage the truth.

From Cardinal Fan: “Re: BJC HealthCare experienced a system-wide computer outage lasting over 20 hours across more than a dozen facilities. It wasn’t just the clinical systems – everything was down including email. Corporate mouthpieces celebrated our contingency planning, but things were far from smooth. Emergency departments went on diversion and transfers from other hospitals were impacted. Although there is no official root cause, lots of employees are speculating hackers might be involved.” Local media agree with the lack of smoothness, noting problems with moving patients from the emergency department to patient care floors without a functional bed tracking system. An internal email forwarded to me described “system-wide information systems non-functionality.” I admire their fine use of synonyms to avoid saying “outage” or “downtime.” Definitely a bad week to practice medicine in St. Louis – about four hours into the incident, a 20-inch water main broke outside flagship Barnes-Jewish Hospital, sending water into lower levels of the facility and shorting out electrical equipment. At least one backup generator failed and over 130 patients were evacuated.

Some physicians I was having lunch with earlier in the week were discussing the recent Forbes article about curing “Doctor Dropout.” Young physicians see the stress levels of their teachers and mentors and are selecting careers outside of traditional practice. The piece cites Stanford as having just 65 percent of their students going on to residency training in 2011. That doesn’t surprise me – although it was a few years before 2011, nearly 10 percent of my medical school graduating class elected not to pursue residency training or even physician licensure. Of those who did complete their training, quite a few of us have left the careers we trained for.

The author comments that “trying to combine revenue maximization into a clinical process results in a system best described as a Gordian Knot designed by Rube Goldberg. Common sense would suggest that adding yet more complexity (e.g. new payer reporting requirements) on top of an already-flawed model is a recipe for disaster.” That about sums it up.

In case you were getting bored waiting for the Meaningful Use final rule, CMS released proposed rules addressing long term care facilities. The nation’s 15,000 nursing facilities would be required to send care summaries when patients are transferred. I’m disappointed that they’re not requiring electronic transactions in the same formats required of the rest of us. Instead, they’re just proposing a set of information to be communicated. Problems with transcription errors and inaccuracies were cited as why the rest of us need to exchange data electronically with prescribed formats, but I guess CMS thinks nursing homes don’t need to be held to the same standard. The actual language states:

Transfers or Discharge: We propose to require not only that a transfer or discharge be documented in the clinical record, but also that specific information, such as history of present illness, reason for transfer and past medical/surgical history, be exchanged with the receiving provider or facility when a resident is transferred. We are not proposing to require a specific form, format, or methodology for this communication.

I can’t believe that not even a problem list, a medication list, or an allergy list made the cut. At least when they’re done torturing eligible providers and hospitals, CMS will have plenty to work on with other facilities.

What do you think about the proposed rule for nursing facilities? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/27/15

There are many reasons to use consultants. Sometimes an organization needs an expert resource that they don’t have on staff or don’t have time to develop. Sometimes they need staff augmentation for a critical project. Sometimes they need an outside opinion to validate their goals and the plan to achieve them.

At least in my current consulting practice, however, most of the organizations I’m working with just need a consultant to save them from themselves.

Healthcare has always been a fairly dysfunctional business. The emphasis on shifting models of care and the relentless pursuit of technical tools has added stress to an already challenged system. Although a couple of my clients were referred to work with me early when things started heading in the wrong direction, my newest client waited until they hit rock bottom. I’m never one to shirk a challenge (particularly during the slow summer months when other clients don’t want to do much because too many key staffers are on vacation) but this one is a doozy.

This client was referred by one of my existing clients, who I had worked with on creating policies and procedures for Meaningful Use-related workflows and making sure that they had solid workflows prior to their reporting period. They had been a dream to work with. I knew that the physician owner had a brother who was also a physician, but in a different specialty.

Scope of practice not withstanding, the two practices couldn’t be different. My existing customer was a dream to work with. The new client called me incessantly demanding we set up an initial call. He apparently didn’t listen to my outbound greeting which explained that I was on vacation and would not be returning any calls until a certain date.

One of the benefits of working for yourself is being able to set your rates however you feel is appropriate. From the tone of this physician’s calls (increasingly desperate), I suspected he would be in my top billing tier. I also knew before even talking to him that if I did decide to take him on as a customer, it would be for an extremely limited engagement.

When we finally were able to have an initial discovery call, he had calmed down quite a bit and our discussion was entirely reasonable. We discussed the services he was requesting and what an engagement would look like.

His situation is not unusual. He is an independent physician who accepted subsidies from a health system to implement the EHR they were offering. Now he has decided to move off that platform and needs assistance with selecting a new system and actually making the transition.

One red flag, though, is that he wants to leave the hospital’s EHR system due to “philosophical differences,” which can mean a variety of things when you’re a high-profile surgeon. As far as finding a replacement, he’s already been largely swayed by a couple of vendors who should be easy to work with. I’m always happy to take any complications out of the mix.

Despite his desperation in trying to contact me initially, he had no problem dragging his feet when it was time to execute our consulting agreement. My standard contract is pretty simple – less than two pages – and spells out exactly what will be done and on what timeframe. He wanted to argue about the duration of the engagement (as a rule, I never do more than a six-month engagement the first time I work with a client) and didn’t seem to understand that in this situation, the consultant has the power. I don’t have to work for him and don’t have to agree to his terms.

He eventually figured that out and agreed to my proposal, so we jumped right in to his system selection problem. If I thought my contract negotiation with him was a challenge, I can’t imagine what it’s going to be like for him to execute a software agreement. I haven’t worked with either of his top choices (both are specialty-specific offerings) so am not able to give him much guidance in how best to work with them.

He’s still trying to decide and hasn’t been very receptive to my advice on how to weigh the pros and cons of different vendors and features. He refuses to use checklists or document his thoughts immediately after demos. When he can’t remember what he saw or what he thought about it, he just demands another demo, which results in a lot of schedule juggling. I’m fortunate to have a retired project manager I can throw at the problem so we can start to document for him and reduce the overall craziness.

In the mean time, we’re working to clean up the data in his existing system and create a plan to extract the data he wants to load into his new system. A good chunk of his documentation was dictated and he still has the original text files, so those will hopefully be easy to add to the new system. It’s the first time I’ve ever been grateful to not have very much discrete data.

He also didn’t attest for Meaningful Use yet, so I’m grateful to not have to deal with archiving that data for audits or dealing with how to synchronize his reporting period with the migration to the new system. I’ve got a young informaticist working with me who is excited about dealing with what data there is, so that is off my plate as well.

It’s a little strange to be delegating this work when I’m used to doing so much of it myself. It was one thing to delegate when I was a CMIO and working for a large health system, but it’s another thing to delegate when your name is on the door and it’s your company. Right now, though, my main function is to “handle” the customer and make sure we meet his needs. I’m OK with that. I’m not sure the people assisting with his engagement feel the same way, but we’ll have to see how things unfold. If nothing else, it’s putting experience under our collective belts.

How do you handle difficult customers? Email me.

Email Dr. Jayne.

EPtalk by Dr Jayne 7/23/15

This week has been chaotic. It’s amazing how being out of the swing of things even for a couple of weeks can interfere with our habits and processes. I thought I had this week’s EPtalk nearly written and saved it out to the cloud, only to now be unable to find it (along with another presentation I was working on). A keyword search wasn’t helpful nor were some of the other tricks I tried, so those thoughts will have to wait until they turn up which will hopefully be before next week.

Luckily the presentation is for something several weeks out, so I have time to rebuild it if I can’t find it. I’m also traveling and my laptop’s wireless has been on the fritz, which might have played a role in the mystery of the missing documents. At one point today I was working at a blazing fast 512 kbps, which I haven’t seen in a long time. There’s nothing quite like cloud storage gone wrong.

I’ve also been tunneling through more than a thousand emails that came in while I was away. Many are related to social media and things like LinkedIn, so shame on me for not having adequate filters set up to prevent it my inbox from being an overwhelming mess. I’m grateful for the legitimate mail from readers that keeps me soldiering on.

From Commanding Officer: “You wrote about an ICD-10 code for the psychotic reaction you were going to have when kids were playing games on your flight without headphones. My recommendations are:

• R45.4 Irritability and anger
• F63.81 Explosive disorder, intermittent; Aggressive episodes frequently result in physical or verbal assaults or property destruction (for example, road rage). The individual may report feeling tension prior to the episode, immediately followed by relief.”

I agree with the reader’s suggestion of leaning towards the road rage code. Although we occasionally hear about airline passengers behaving badly, the more I fly the more I continue to be amazed that there are not even more incidents occurring.

From Jimmy the Greek: “With the number of conference calls I’m sure you’ve been on in your career, I thought you’d get a kick out of this quote of the day. A coworker actually said, ‘That’s impossible for us to do, because we’ve never done it before.’ I resisted the urge to ask how she managed to get out of her cave.” Hearing stories like that always makes me feel better about the places I’ve worked. No matter how bad you think it is, the grass isn’t always greener elsewhere. The fact that this comment is from a technology professional at a company known for communications solutions makes it all the funnier.

As for summer adventures, several readers have written to share theirs: hiking, camping, and a safari were included on the list. At least three readers plan to spend time at scout camps with their children. One reader noted that although it was great to unplug, it was not so great to have to spend two whole days reading emails after returning to work. Another travels every year to a working ranch in Montana that I have to say looks pretty incredible.

From High Adventure: “I’ve enjoyed several treks to places with minimal cell phone coverage and what was there, was enough to get the occasional text message or phone call out to family to let them know we’re safe. Not enough to download email or anything like that. As an IT professional who deals with the daily deluge of electronic communications, I find these trips refreshing. But, I’ll confess, you need to learn how to unplug and let go of the work. It’s not easy but you have to trust your team and co-workers to do the right thing. As a leader, if you can’t trust them to do that, you’ve failed in one of your key jobs.” I remember reading a blog piece attributed to Jonathan Bush where he talked about taking a month off for summer vacation with his family. He cited the need to let his team have the experience of managing without him as one of the reasons for taking an extended vacation. That’s great when leaders have seasoned teams below them, but as a consultant, I see a fair number of dysfunctional teams where that would never be an option.

Speaking of vacation, several readers responded to my piece about vacations in modern business culture. One mentioned that his company, Lexmark, went to an unlimited vacation policy in 2013.  One reader suggested SCUBA as a great vacation since cell phones don’t function well underwater. Another offered tips for vacationing as a corporation of one:

I also have my own solo business as does my twin sister in the legal field. When one of us is going to be seriously out of touch, we cover each other’s voice and emails just scanning for “must do now” things and sending reassuring messages to those who can wait until the owner gets back. We also have a deal that the person vacationing knows that the other will contact them if something comes up but that they are supposed to relax and not check since they have a proxy on duty who is filtering. You do have to trust the person you partner with (and I know it is harder to get closer than an identical twin) but perhaps something like this would be helpful to you.

That’s a great story. My brother is also an independent business person, but given his entrepreneurial tendencies, he’d probably charge me for the coverage. Luckily right now my file of consulting clients is small enough that I was able to tell everyone my plans in advance and most know me well enough that even if anything urgent came up I’d be able to turn it pretty quickly on my return. I’m sure it won’t be that way forever and I appreciate the idea.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/20/15

Mr. H mentioned that I was away last week. I had the pleasure of spending it on a wilderness adventure and was able to seriously unplug for the first time in a long while. Being forced to make do with what you remembered to pack and what your companions are carrying definitely casts a different light on the idea of accomplishments. I wasn’t away very long before I had some experiences that made me question how important some of the things we all worry about on a daily basis really are in the grand scheme of things.

My active clients and my practice knew I was going to be away and to not expect any responses to email until today. Although our group had a solar charger with us, most of us were pretty serious about putting our technology away on day one. Being able to wake up without the blinking light on my phone was priceless. I went from a world of worrying about hundreds of minute details to a world where the key worries were having enough water, making fire, having adequate food, and staying dry were the real priorities (and not always necessarily in that order).

Teamwork has an entirely new meaning when you are depending on each other to share the load (literally) and look out for each other. Being in the backwoods means getting creative with solutions when you don’t have ready access to everything you wish you had. I administered some fairly primitive medical treatments – fortunately the standard of care doesn’t apply when you’re many miles from nowhere. Everyone made it home with all their limbs and most of their senses of humor, so I guess my wilderness first aid skills were OK. It was certainly nice to be in a world where I didn’t have to worry about documentation, although I did have to have my companions do a “sanity check” on my plan of care since my mind was trying to operate in a Level I trauma center while my patient was sitting on the ground in the dirt.

The best thing was being away from federal (and other) mandates. When your main directives are “Leave No Trace” and to not do anything stupid or that might get you dead, it’s a lot more simple. None of my fellow hikers were in healthcare and only one was in IT, so we didn’t get sucked into beef sessions about work or coworkers. I’ve spent the last decade and a half using the better part of my waking hours to deal with unhappy physicians, poorly functioning technology, and whether my employers were sane. It was nice to just worry instead about how far I could push myself mentally and physically and whether my feet were staying dry and happy.

I learned that I’d rather deal with venomous spiders and reptiles any day than with RAC audits and PQRS calculations. I also learned that having the right kind of supplies turn up at the right time makes all the difference (and indeed what I would do for a Klondike Bar, when presented with one that had been delivered in dry ice following three days with the heat index well over 100F). I shared my tent with a fascinating spider – do you know how long it takes her to eat a fly? I do. I also shared my path with a flock of wild turkeys (not the liquid kind), mosquitoes the size of hang gliders, and what one of my trail mates insists was a chupacabra (personally I think it was a raccoon).

I think the best part of the experience was being mostly without the need to keep track of time. You wake up when the sun comes up and go to bed when you feel like it. There are no double-booked meetings or back-to-back conference calls. You rest when you’re tired and pick up again when you’re ready. You have the luxury of watching spiders build webs because you don’t have anything else pressing to do.

Coming back to civilization was initially a rude awakening. The first person I encountered at the airport was a twenty-something man using voice-to-text for messaging his best friend about why the friend’s girlfriend was bad news. I got to hear all the gory details and doubt he even thought that everyone around could hear. (By the way friend – it’s going to backfire. Your friend needs to figure it out on his own.)

Civilization did redeem itself, however, when I discovered I was sharing my flight home with the BYU Ballroom Dance Company. They were extremely courteous travelers as well as being classily dressed. I almost thought I had fallen into a 1960s air travel dream with the men in crested navy blazers and the women in matching tangerine travel dresses. I found it amusing that although the ladies’ jewelry matched, they all had their own choice of shoes.

Nearly 70 miles of hiking later, I’m back in the saddle with quite a few emails and a couple of conference calls. It’s hard to be back, but I’m interested to see how my new perspective influences my day-to-day work. I’m exhausted but invigorated. I’ve already started planning next summer’s wilderness adventure and it’s great to have something to look forward to.

What’s your next adventure? Email me.

Email Dr. Jayne.