EPtalk by Dr. Jayne 7/9/15

Lots of chatter about the NYSE crash in both the IT and physician spheres today. Despite assurances by the US Department of Homeland Security that hacking was not a factor, conspiracy theories are running rampant. Couple the apparent technology failure with the financial crisis in Greece and a stock market slide in China and people are feeling unsettled. Physicians are starting to fear hackers as much as they fear inquiries by Medicare Recovery Audit Contractors.

I’m closely following the #DataIndependenceDay movement and Mr. H’s efforts to get his health records. I wrote in May about a friend who had knee surgery. She has requested her records to no avail, although she did get a refund check from the hospital. A call to the patient accounting department failed to yield an explanation. Since the amount she paid upfront for the surgery was actually less than what her insurance carrier identified as the patient responsibility amount, the refund doesn’t make much sense.

We’ve been having a good time reviewing the various “explanation of benefits” notices during our biweekly girls’ night in (kind of like girls’ night out, but without the need for one of us to be the designated driver). If the accuracy of her medical records is anything like the accuracy of the billing documentation, she’s in real trouble. She’s been overbilled twice, both from the initial injury. The first time was for an upfront physical therapy co-pay when the provider was contracted to deliver services with no patient responsibility. The second time was for radiology services through the emergency department. When she called to protest the bill, they claimed they had no knowledge of her insurance information even though both the hospital and the contracted emergency physicians seemed to be able to figure out how to bill her insurance carrier.

The most surprising part of the billing situation is that some of her providers have failed to submit bills at all despite it being some time since services were provided. I guess they’ve either never heard of a timely filing deadline or they really don’t need the money. In addition to being unable to get her medical records, she has also found it impossible to get itemized bills from any of the providers. Although her insurance statements list line item charges and adjustments, there are no CPT codes or descriptions to use in trying to figure out exactly what procedures were performed.

So far the winner of the billing game is the physical therapy provider, who submits bills every other week and then immediately bills the patient after receiving their electronic remittance advice. Usually she receives the bill for the patient portion within a day or two of receiving her insurance explanation of benefits. The bill has detailed explanations of the services provided. They offer online bill payment with a no-nonsense interface that gets the job done in seconds. It’s clear that they have their revenue cycle under tight control. Then again, I’d have it under control too if I was only being paid 10-15 percent of the amount I was billing.

Back to the data independence movement. The initiative is not just about patients having access to their data, but for families to be able to participate and collaborate where needed. Another way that families really need to participate and collaborate is advance care planning. Medicare recently announced plans to make such counseling a covered service starting January 1. Whether it’s billable or not, physician counseling on end-of-life issues can be helpful, especially in the context of a long-term physician-patient relationship. Often physicians are too rushed to include the discussion in routine office visits.

There is a large amount of data on the tremendous cost of end-of-life care. Often procedures are done that not only fail to prolong life, but may actually increase suffering. There have been multiple articles on how physicians die compared to the general public. I created my own advance directive at the end of my intern year after watching bad things happen to otherwise healthy young people.

I’d like to encourage everyone to consider talking to their family members about how they would want to receive care in the event of a catastrophic injury or a terminal illness. After the discussion, it’s important to get those wishes documented and provide copies to the appropriate people.

Do you have an advance directive or health care power of attorney? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/6/15

During my travels, I’ve been catching up on my journals. Given my current clinical work, I read both primary care and emergency medicine journals, and then there are the informatics articles that appear across a number of specialties.

I was amused by an editorial about cystic fibrosis in the June 15 edition of American Family Physician. It states, “The continuity and closeness that a family physician has with these patients has the potential to be a stabilizing and encouraging force in assisting with compliance and disease prevention, enabling patients with CF to maximize their quality and quantity of life.”

One of the main complaints I hear from primary care physicians across the country is an increasing lack of continuity. Patients are forced to change insurance when their company decides to update plans, or their providers may be dropped from insurance panels due to cost or quality profiling. Generally speaking, most primary care physicians I know entered the field because they wanted to have longstanding relationships with patients and wanted to help those patients live longer, healthier lives. Considering the average physician compensation across specialties, they certainly didn’t get into it for the money.

Because of my IT work, I’ve spent the last several years practicing in non-continuity settings such as urgent care or the emergency department. Although I occasionally work as a locum tenens in primary care practices, in those situations I usually see acute visits or overflow patients that can’t be accommodated by the other physicians in the practice. Not every practice has the luxury of bring in a locum when a physician is on vacation or leave, however. Many of them end up referring patients to local urgent care centers or walk-in clinics in order to address their needs.

Capacity isn’t just a problem when providers are out. In many of the practices I encounter, the physicians are carrying patient panels that are much larger than they should be to deliver quality care. This results in patients being directed to urgent care centers more often than they should, as well as patients electively choosing the urgent care route due to access and convenience issues. This in turn can drive up the cost of care and lead to increasing fragmentation. Physicians are carrying larger panels not only due to decreases in the primary care workforce, but also in attempts to tweak their payer mix to ultimately bring in more revenue.

Although we can celebrate interoperability and the portability of our health information as a way to smooth this fragmented care, that’s only part of the answer. There is a certain element of quality provided by being able to see a physician who knows you well over time. Merely having more pieces of information doesn’t always give physicians the information they need to provide the best care for their patients.

As the population ages and the burden of chronic disease increases, patients become more complicated. With the technology boom, we’ve seen an increase in the options available to manage patients and this also drives up the complexity of care. Complicated patients with complicated problems require more time and thought to manage. I can’t imagine how personalized medicine is going to play into the mix. We can throw layers and layers of technology at the problem, but that approach seems to frequently create additional problems.

In some situations, new therapies lead to the need for increasingly personal conversations with patients about whether a treatment is right for them and what the various costs and benefits might be. Additionally, we don’t have long-term studies on some of these treatments, so we’re trying to predict risk with our patients without adequate data.

In one of my journals, there was a write-up about a new diabetes medication that has a unique mechanism of action. This may be perceived by many patients as new and improved, but there is no long-term data on the morbidity or mortality benefits of the drug. In one study, it was shown to be equally effective as traditional therapies. My translation of “equally effective” is “no better than,” but there’s quite a different emotional response depending on which words you use.

Although the medication is newly approved and heavily marketed, it comes at a cost. A one-month course of treatment costs $335 compared to the “equally effective” older drug which costs $4 per month. It also is associated with higher risk of urinary tract infections and bladder cancer. Having that conversation with a patient you know well and who trusts your advice is very different than with a patient with whom you don’t have an established relationship. It’s hard to provide culturally competent care (one of the new markers of quality) when there’s not adequate time to develop rapport or resources to form an assistive care team.

The newer models of care delivery include Patient-Centered Medical Homes and other structures designed to deliver care in our increasingly value-based models. We’re offering physicians reimbursement for care coordination and increased payments for higher quality. However, it creates a chicken-or-egg cycle where you have to have more staff to form and train a care team to get more money, which you need in order to have more staff, etc. It’s easy for those of us in the IT and policy trenches to think that physicians should just cut their pay to hire staff. Although that might work in a physician-owned practice, it certainly doesn’t work in employed situations.

Regardless of employment status, new medical school graduates are coming out with record debt – another reason not to choose primary care. Most of the new physicians in my community are entering practice with over $300,000 in student loans. Even at a 30-year repayment it’s like having an extra mortgage payment (or two). Many of those new grads opt for employed positions because they can’t take the financial risks required to open their own practices (assuming someone would even loan them the money to do so with that kind of debt). They wind up in a different kind of bind where their hospitals or employing health systems control staffing and expenditures and often create barriers to developing effective care structures.

I know by this point some readers are wondering what this has to do with healthcare IT and why it’s in HIStalk. In the field, I see many practices where work is being shifted up to providers rather than down to support staff due to increasingly complex systems. A recent engagement involving multiple EHRs revealed clinical reconciliation processes that were so confusing that physicians were reluctant to have anyone else perform the task. Even as an advocate for work redistribution, I agreed with them. I saw two different patient portals in use, both of which had serious usability issues and one that had some potential patient safety issues. Although they may have performed well in some kind of laboratory testing event, they were not meeting the needs in the complex realities of the average office.

Vendors need to have clinicians on staff as well as a network of client and non-client physicians to test new products and proposed changes to products. This also goes to other types of users – clinical, financial, etc. We need to see technology vetted in more real-world environments if we expect to be able to revolutionize how care is delivered. We need vendors to be more nimble and use best practices to translate emerging federal and payer requirements to viable code. We need processes and procedures (both vendor and governmental) that allow product delivery in enough time for practices to implement upgrades and features without the rush and chaos we currently see.

Having better systems, processes, and workflows will help mitigate what sometimes feels like an assault on our nation’s caregivers. It might even convince some physicians who might otherwise be motivated to leave or curtail their practices to consider staying. Ultimately, it might even result in better care.

What are your thoughts about the future of medicine? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/29/15

I agree with Mr. H that this is a slow time of year for healthcare IT news. Not only is it a slow time for news, but it seems to be a slow time for overall productivity as well.

I’m working with a client right now that is having a hard time getting anything done. Their teams are extremely lean and most staff operate without a backup, so vacations have a significant impact. Additionally, it feels like when we have the right people in place from the client side, there is a good likelihood that someone will be out from the vendor side.

I did some work a couple of years ago that involved a Swedish vendor. We were up against an extremely tight timeline because we had been warned that the entire company (literally) would be on vacation for four weeks during the summer. I remember thinking they must be terribly progressive, some kind of Scandinavian high-tech outlier going to extremes to keep their staff happy. After a little digging, we determined it wasn’t that unusual at all – since the late 1970s, Sweden has mandated five weeks of vacation for their workers. Many take the majority of them in the summer.

There are a variety of reasons that approach wouldn’t get very far in the United States. In addition to the political and economic factors opposing it, think about the planning needed to pull it off. Even for a small company, it would involve a great deal of strategic planning to ensure that the time off is factored into all projects. It would also require that projects are actually executed on time so that there are no last-minute pushes into the vacation.

In digging into the economic factors, though, I wonder if the return on investment for something like that might be real. If you look at the lost productivity encountered at a hospital like my current client, it’s significant. Workers are continually coming to the office late or leaving early for a variety of issues: traffic patterns are different with children out of school; childcare situations may be less predictable during the summer months; and tourism picks up in the city, resulting in parking and other logistical issues. We’re also seeing more people working from home to keep an eye on their children, resulting in a greater percentage of online meetings with barking dogs, background noise, and the occasional yelling dad who forgets to use the mute button.

I was looking for information on countries with more liberal vacation policies and came across this great Washington Post summary. It discusses the work of Swedish environmental psychologist Terry Hartig, who notes that those returning from a relaxing vacation tend to return to the office relaxed. I see more and more people “vacationing” with their smartphones, laptops, and piles of documents. Not only are they not enjoying their time away, but I’ve also seen feelings of guilt for those back in the office who feel bad for having to contact them. For those staffers who manage to avoid calling in for meetings, there are productivity-sapping discussions when their colleagues discuss the Facebook posts of those who are soaking up the sun.

Hartig’s research looked at prescriptions for anti-depressant drugs in Sweden over more than a decade. When people vacationed simultaneously, there were fewer prescriptions. The article (from 2014) lists the annual cost of depression at $23 billion a year in the US, so we can add that into the ROI calculation. Hartig also notes that Europeans spend less on healthcare and live longer than Americans – and have 20 to 30 vacation days a year. US companies seem to be cutting back on vacation unless it’s contractually mandated.

A couple of years ago, my health system did a “realignment” of vacation and sick time policies. They essentially declared that ours were too generous and out of line with other employers in our metropolitan area. We had previously been allotted seven corporate holidays and two personal holidays. The personal holidays were originally intended to allow employees to have time off for those holidays that were not corporately-declared, such as Christmas Eve, New Year’s Eve, Columbus Day, Presidents Day, Martin Luther King Day, Veterans Day, etc. if they were important to the employee. The HR people found out that no one else offered anything like that, so the personal days were cut.

That began a race to the bottom that ended with not only the elimination of the personal holidays, but all personal days in general. They also reduced the ability to carry over vacation days from year to year and eliminated the existing vacation buy-back program. They announced the new carry over rules during the last two months of the year. Many departments were getting ready for a major system migration after the first of the year and vacations weren’t being approved, resulting in many more employees who had to lose it rather than use it. Managers were given virtually no flexibility to accommodate their employees. The end result felt a lot like theft.

The Washington Post piece also notes that “the US is the only advanced economy with no national vacation policy (unless you count Suriname, Nepal, and Guyana).” Nearly 25 percent of workers have no paid vacation at all with those who do have vacation averaging 10-14 days a year. When I left my CMIO role, the vacation policies were a total patchwork. Employed physicians in direct patient care were allotted 15 vacation days and five continuing medical education (CME) days for a total of 20 days plus the corporate holidays. Administrative physicians had the same number of vacation days and holidays, but were allocated no CME days. I suppose that means that once you are an administrator you either lack the capacity to learn or the organization assumes you already know everything.

Anyone less than a manager title only got 10 vacation days, regardless of seniority. Even the sick-time policy was confusing. Hourly employees could take their time in one-hour increments but salaried employees had to take it in four-hour blocks. Although they told us that as salaried employees we had the ability to take an hour off here and there without formally requesting it, there was a lot of pressure to make up any time out of the office. The net result was that very few salaried employees were actually able to take advantage of their sick time unless they were seriously ill.

Losing vacation and sick days is fairly common, with the article mentioning an estimated 577 million unused days each year which equates to “$67 billion in lost travel spending and 1.2 million jobs.” Adding that to the ROI, I’m starting to wonder if we can afford to NOT take more vacation. It also mentions some interesting political facts:

• In 1910, William Howard Taft proposed giving American workers two to three months of paid vacation each year.
• John Muir recommended compulsory vacationing as better for the country than compulsory schooling.
• The 1938 Congress proposed the 40-hour work week, a minimum wage, and two weeks paid vacation.

I’m taking several vacations this summer, mostly to make up for the lack of them during the last several years. I also have the luxury of being my own boss right now, so it’s much easier than before to schedule a vacation. It’s a bit harder to execute, though, since I’m a corporation of one. Even when clients are understanding and know I will be out of the office, it takes a conscious effort to disconnect. Checking my phone is tempting but it usually results in at least half an hour of work, so I try not to do it at all.

I’m staging all my projects for the next couple of weeks in preparation for some wilderness adventures. I can’t wait to be not only out of the office but in a place that literally has no cell towers or electricity. It also has no running water, but I’m not exactly looking forward to that. I’m sure some of my fellow travelers will be bringing solar chargers or Biolite stoves, but I’m not even taking anything with a USB port.

What’s your strategy for disconnecting when you’re out of the office? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/25/15

I’ve been on the road fairly often over the last month. Most of my trips have been to work with small or mid-size provider groups for ICD-10 training. The sheer amount of misinformation floating around the physician lounges across the country appears to be staggering.

At the site I visited today, the physician leaders were actually cringing at some of the questions their providers were asking. I’m sure they thought they had already done a fairly good job educating their providers, but it just goes to show that you can never have enough training. It reminded me a bit of when our residents used to teach a sex education class at the local middle school and kids had the opportunity to ask anonymous (and often myth-laden) questions on slips of paper. We saw some doozies, but this was even more fun because very educated people were asking these wild questions out loud and in front of their peers.

Most of the questions revolved around creative ways to avoid ICD-10 or the lack of need to learn it since it has so many codes it might as well be impossible. It’s hard to convince people that it’s not going away when we’ve had unexpected delays before. It’s also hard to keep them from acting out of fear or panic because they haven’t done anything to prepare for the last several years despite plenty of advance warning. I’m hoping that the fact that their organizations paid good money to bring in an honest to goodness physician to deliver their training will help add a reality check.

Despite the fear and resistance, most of them have done just fine during our structured practice sessions. The fact that they’re using EHRs is going to make the transition pretty seamless, unlike having to use pocket reference cards or laminated cheat sheets.

One of my clients made me smile as their planning document kept going back and forth in email. They wanted me to train onsite at their clinics and were trying to figure out the best way to block schedules and ensure adequate time with the care teams as I crisscrossed the city. When the last document arrived, it was named “Copy of copy of copy of final schedule working copy version8.” I’m glad that explaining document versioning was out of scope for this engagement because I probably couldn’t have done it with a straight face. I give them full credit for trying, however.

Since I had six flights this week, I honed my personal ICD-10 skills:

• H91.23 – Sudden hearing loss of bilateral ears due to having your music playing so loud I could hear it through your headphones like I was wearing them myself.
• G47.62 – Sleep-related leg cramps for the passenger across the aisle.
• S37.20xA – Injury of bladder, initial encounter for the passengers consuming a mammoth cup of coffee prior to takeoff, then being foiled by a persistent “fasten seat belt” sign.
• R45.82 – Worry, for the kindly older woman next to me who kept waking me up to see if I wanted a drink, pretzels, or crackers

Unfortunately, I couldn’t find a code for “personal psychotic reaction due to child playing games on iPad without headphones.” so if anyone locates it, please let me know. I heard from a fellow road warrior that there is a restaurant that allows you to relive the glory days of flying as you dine aboard a replica Pan Am 747. I’m thinking it might be time to find a client in Los Angeles so I can check it out.

Mr. H mentioned earlier this week about his LinkedIn pet peeves. Although he focused on problems with user profile pictures, I wanted to throw in my two cents. If you’re going to try to connect with me, I am more likely to ignore you if you use the stock “I’d like to connect with you on LinkedIn” greeting. Even if we just met in passing or you’re a friend of a friend, at least add a personal comment that lets me know you’re not an anonymous “medical researcher” or a medical student from halfway around the world just looking to connect with MDs.

From Jimmy the Greek: “Re: patient recording colonoscopy. Please tell me this is at least as good as a Weird News Andy piece.” Yes, yes it is. A Virginia man receives $500K after recording his physician’s inappropriate comments during a colonoscopy. Although I don’t in any way condone the physician behavior, I wonder why the patient had his phone during the procedure. At most of the facilities where I’ve worked, patients who are being sedated have to put their personal belongings in a locker during procedures. Even if you’re not sedated, I doubt they’d let you take your phone to the GI lab. I’d hope that clinicians would be professional at all times, but this should be a lesson for our colleagues with borderline (or over the line) behavior.

My nephews like to play Mad Libs, the word game where you one player asks for a list of nouns, adverbs, and adjectives then reads back a funny story populated with the words. I received a spam email the other day that must have come from the creators of Mad Libs. Rather than parts of speech, though, it was populated with random, techy-sounding words strung together to form the name of the company and its services. Anyone asking for “thought leadership content” cracks me up, as did the suggestion that the sender had met me at a party at my home in a state where I’ve never lived. Nice try, but no go.

What’s your most entertaining variety of spam? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/22/15

A reader commented on last week’s Curbside Consult asking about effective leadership teams:

I would love to hear about effective leadership teams and how they become that way. I am not part of our organization’s leadership, but occasionally interact with them and also hear info from people who more frequently interact with them), and it just seems that the more layers we add – VP, SVP, EVP – the more work is created without true hierarchy and responsibility. We don’t even have a clear IT leader. Is it our VP of IT? Our Chief Innovation Officer, who replaced our Chief Information Officer, but she seems to have limited interest in core IT functions? Our new EVP of “peripheral” services like IT, Finance, Pharmacy, etc.? God only knows. And yet even with an expanded leadership “team,” they all give the impression of having too much on their plate to concentrate at the issue at hand or even, yes, show up for meetings (much less on time!)

There are plenty of books out there about building effective leadership teams. Although they may have good information from an academic standpoint, it’s often hard to put those theories into practice, especially in an environment as chaotic as healthcare.

Most of my early experience in leadership was not on the IT side but rather the operational side of an employed medical group. As I moved through the ranks to CMIO, I was exposed to a lot of different leadership structures within my own health system and was a member of several highly functional teams. Unfortunately, I was also a member of several highly dysfunctional teams. Through interacting with other customers sharing our core vendors I’ve been exposed to even more teams all across the spectrum. Those experiences have given me a lot to consider in answering the question.

Now that I’m in consulting, I’ve had to put together my own methodology for helping people move in the right direction. There’s no one answer for how to get a team to be effective, but there are some key characteristics that have to be present.

First, the group has to communicate effectively to lead effectively. Although some people are naturally strong communicators, most aren’t. In order to drive people in the right direction, I’m a huge fan of applying a great deal of structure regarding communication. All of my clients have to sit through a communication skills for leaders class with me and do a communication matrix exercise where the team decides and documents how they’re going to communicate, at what points in the project/initiative, with what methodology, to what audience, and by whom. Once they put pen to paper, I ride herd on them to make sure they’re sticking with the program. A successful team will realize that they don’t need a consultant to keep them in line and will take on the tasks themselves. I continue to prod them a little to make sure it’s sustainable.

Communication isn’t just how they report things out — it’s how they document things day to day and operate when they’re communicating (for example, in meetings). Do they have written (and time-boxed) agendas before the meeting? Does someone facilitate the meeting, allowing people to participate without worrying about minutes or timekeeping? Does someone take good minutes and get them out the same day? Are meetings halted when key people are missing rather than wasting everyone’s time because topics will have to be revisited with the appropriate people in the room? Are there ground rules for meetings to make sure everyone plays nice with the other kids? Making sure the answer to all those questions is “yes” helps a leadership team become more effective.

Second, effective teams have buy-in to their project. Ideally the team has been together since the project’s inception, participating in charter creation, writing a mission statement, etc. That’s usually not the case for most organizations, where people come and go or restructuring seems like its own constant. Teams that actually understand and agree to try to deliver the mission do much better than those with only a loose understanding. For people who don’t natively buy-in, an organization needs strategies to either coach them to arrive at that point or employ incentives (or penalties) to elicit the desired behavior.

Even people who may not agree with a given mission tend to be motivated by financial or other incentives. Consider Meaningful Use: whether it was the carrot or the stick, it sure got a lot of physicians who didn’t natively give a hoot about EHRs to actually install them in their practices and start using them. In working with end users, recognition and small rewards (giveaways, raffling off gift cards, etc.) can make a huge difference in aligning people’s actions with the end goals. Teams that either have buy-in or are otherwise motivated tend to show up on time and ready to participate.

Third, effective teams have to have clear leadership. I sympathize with your comment that the more leadership layers that are present, the less effective the leadership is. I recently worked with an organization that suffered from what I can only call “title bloat.” Their VP level people were what would have been considered directors at best in my former health system. Did I mention they had assistant VPs, associate VPs, VPs, senior VPs, executive VPs, system VPs, and more? Many of the titles had no discernible meaning, but were used as ways to try to elevate people or reward performance without giving raises. It led to an arms race where they had to keep promoting others to keep parity among the ranks.

Regardless of what people are called, someone has to be in charge. There has to be, in the words of one of my favorite executives of all time, a “single neck to choke.” That person should come into the office every day asking, “What’s at risk today, this week, this month” and address the issues when his or her team answers the questions. In shared initiatives, there have to be clear leaders for operational, technical, and clinical pillars. For those types of shared structures, I like to add additional necks to choke in the form of a steering committee that meets regularly and addresses a standard list of project metrics (budget, timeline, risks and mitigation strategies, etc.) People always ask me who is best to own a project. Operations? IT? Clinical leadership? I’ve seen them all work, provided the structures are in place to ensure accountability. I’d rather have a well-organized leader from an “underdog” part of the organization than a disorganized alpha dog.

The leader has to have skin in the game. They should feel personally responsible if their project is not meeting expectations. The right person will have this quality intrinsically. Others can be motivated (again, think bonus goals or incentives) to put it on the line. The leader also has to have dedicated time and resources to lead the project. In a stakeholder assessment I did recently, the designated IT leader was overseeing hospital revenue cycle and ambulatory EHR implementations, both at the same time. The projects were headquartered on opposite sides of town and both were billed as “highest priority” for the health system. The sheer logistics made it almost impossible for her to be hands-on in the way needed for success because she always seemed to be driving to one location or another for a meeting, while taking another meeting in the car. It was no surprise that both projects were failing.

In my opinion, these three elements are key. When they’re not well defined or executed, things can very quickly fall apart. Of course there are dozens of other “essential” facets of effective teams, but these are the ones I see malfunctioning the most often. Sometimes they’re easy to fix and sometimes you scratch your head figuring out how in the world you’re going to patch things together enough to get the job done. Sometimes it takes an outsider to figure out which person is the square peg in the round hole and how to rearrange them. Sometimes it takes a major project failure to get people to wake up and pay attention. I’d be interested to hear what others think.

Have an opinion on what it takes to build an effective team? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/18/15

Some days I have a love/hate relationship with social media. There are simply too many things to read and not enough time in the day, especially while I’m trying to grow my consulting business and regain my sanity after years in the non-profit health system universe. It was with great dread that I read Mr. H’s comment on Twitter upping its character limit from 140 to 10,000. I have a hard time keeping up with the current twitterverse, where people are forced to parse their thoughts. I can’t imagine what things will become. I know I had to think more along the lines of Haiku than Soliloquy when posting and that was a challenge. We’ll have to see how it flows once the change becomes real.

Crushed by alligator: W58.03XA

One of my clients is arriving at the ICD-10 dance a little late. Although they thought they had been preparing, they lost some key resources and really aren’t sure where they stand. I would bet that they’re fairly representative of small-ish physician owned practices across the country. They aren’t large enough to have dedicated resources, so ICD-10 became “other duties as assigned” for members of the practice. Once those resources moved on, they were in a bind.

I have to give them full credit, though, for realizing that they have an issue and reaching out for help. My first task was to go through the former employees’ computer files (which thankfully the office kept copies of) and identify any ICD-10 preparedness work or documentation that already existed. There was actually a decent amount of material – especially vendor documentation, a couple of partially completed assessment matrixes, and a library of vendor contacts.

I reached out to their EHR vendor and found that they were already offering an ongoing series of webinars. It’s a specialty-specific EHR that I hadn’t worked with previously, so I signed up. At first, I was skeptical because the webinar started late (normally a black mark in my book). However, my opinion started to turn when I realized that they had already placed ICD-10 under the hood of the application almost a year ago. Since it’s a hosted product, the client just has to open a support ticket to get it turned on. Whenever they’re ready, the client can start with dual coding workflows.

The conversion will occur by payer, and based on an effective date of 10/1, so it doesn’t hurt anyone to go ahead and get ICD-10 going. Once the switched is flipped, providers will see an extra column in their diagnosis grid that will hold the ICD-10 codes. Additionally, when selecting an assessment, they’ll be prompted for laterality (right, left, bilateral, unspecified) on applicable diagnoses before they can make their final selections. That all looked pretty good.

I wasn’t impressed, however, by how the providers have to modify their custom lists for past medical history and assessments to associate ICD-10 codes. This provider mapping has to be done through the practice management system. Although they have embedded crosswalks to assist, it doesn’t look like the mapping process shows the native ICD-10 descriptions but rather just the ICD-9 ones. For me as a physician, it would be difficult to trust the mapping without being able to see the native description. Additionally, when walking through the provider mapping process, some diagnoses didn’t appear to have bilateral as a choice even though right, left, and unspecified were present.

They offered interactive question and answer time after the formal presentation. The attendees were pretty quiet, despite there being a number of them dialed in. It was difficult to tell whether they had no questions because they were: a) deer in the headlights; b) confident in the workflow; or c) tuned out and just attending the webinar because someone told them to. The vendor did provide a document with frequently asked questions that was pretty solid, explaining the testing processes they’ve used and their plans for handling billing should something go dramatically wrong on October 1.

I found it interesting that in the FAQ they admitted that they had to use third-party development resources to help meet the timeline. Additionally, they said that their clearinghouse is positioned to provide additional support should there be any issues with claims submission. They also explained in the document that they’ve been using SNOMED coding all along and that is the intermediary by which they are going to transition the ICD codes. The FAQ document also made it clear that they anticipate there may be some downstream issues with payers having “varying levels of preparedness for the deadline.”

Having come from the client-server, self-hosted world, I appreciated the fact that the vendor has done significant claims testing that individual customers do not have to repeat. The vendor uses a single clearinghouse, so I’m sure that made the testing a bit easier than it might have been. I feel pretty confident this client will be OK from a technology standpoint, but am planning some face-to-face provider education as well as structured practice sessions in their test environment. I’m already looking for funny scenarios to break up the monotony of training and found this one today: Z63.1: Problems in relationships with in-laws.

What’s your favorite new ICD-10 code? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/15/15

As a free-range CMIO, organizations often hire me to do work that they should be able to do themselves. Sometimes there are valid reasons why they can’t, such as the unexpected departure of a key employee. More often, though, it’s due to lack of organizational structure or even outright chaos.

I was working with a group in the latter position this week, putting together a plan to try to get them back on their feet. It’s a mid-sized group of employed physicians associated with a mid-sized hospital. They were initially referred to me by one of their physicians after we met at a conference.

I knew I would be in for an interesting time after the first discovery call. I usually set up a meeting or two to figure out who the key players are and why they think they need assistance. The calls usually reveal that why they think they need my help is not actually why they need my help. More often than not, they think there’s a problem with their software, or that they have problems with individual physicians refusing to get with the EHR program. When we start to talk about the specific concerns, it tends to show that they have problems with communication, resource allocation and prioritization, or perhaps strategic planning. If I’m lucky, it might be a project management issue.

This time it was all of the above. The first time we tried to do a discovery call, only one of five client attendees bothered to show up. The second time, we had several “leaders” (and I use that term loosely) attend, but two of them had no idea why they were on the call or why the organization was seeking outside help. We spent the first half of the call with one of their internal IT resources trying to explain to them who I was and why they had contacted me. Ideally that would be done before we all get on a call together, but then again if they had their act together, they wouldn’t need my help.

We talked about their key concern of “we’re not going to get Meaningful Use” money and did a quick exercise to determine root cause. I love techniques like the Five Whys for their simplicity. The premise is that you can get to the heart of an issue by asking why something occurred, then following each answer with another “why” question. Usually after three to five repetitions, it becomes clear what the real problem is. People are often astonished when you start identifying the real reasons behind their situation. Of course, there are a lot of other formal methodologies you can use to do a true root cause analysis, but when there are “soft” issues at play, the Five Whys is usually enough.

We quickly identified some major issues contributing to their lack of MU confidence. Their EHR is poorly configured and overly customized. When physicians complain about the workflow, there’s no routine analysis. Instead, the IT team just adds fields and checkboxes to the EHR because they perceive they’ve been given a mandate to “make them happy.”

The operations team, on the other hand, feels that IT coddles the physicians and that the customization interferes with their ability to control the providers. The finance team thinks the whole thing is too expensive and the consultants they’re using to customize the system are laughing all the way to the bank.

I’ve been working with them for a couple of months to put together a proposal and actually get them to approve it. Through that process, I was able to identify that they have some pathological corporate policies that certainly aren’t helping things. One major issue is their email retention policy – all emails delete after 45 days unless they’re manually archived. I don’t know about you, but I certainly don’t have time to go through my emails on a regular basis and manually archive things on that kind of cycle. My former employer had a six-month retention policy, which was reasonable – after six months, you know whether something is archive-worthy (and they actually had a class in how to best manage folders and filtering to make the retention policy easier). These folks just leave their employees hanging.

Inability to manage and retain emails led to a lot of requests to resend documents and repeat conversation threads that we thought were already resolved. It also was instructive in warning me that I needed to dramatically increase the block of time that I was planning to allocate to this client.

Once they accepted the proposal, I was able to do a fair amount of remote work with them while we waited for calendars to open up for our first onsite visit. I had requested documents related to their organizational structure, roles and responsibilities, contracts between the client and their EHR vendor, and service level agreements between IT and their internal customers. Although it took weeks to get some of the documentation, eventually most of it turned up.

What surprised me (but probably shouldn’t have) was the lack of awareness of some parties regarding their own documentation. Interestingly, no one could actually produce the policy about the 45-day email retention standard. Needless to say, unless they can validate why they want to allow that to contribute to their dysfunction, I’m going to push to lengthen it.

This week was my first time at their offices. I had scheduled a number of one-on-one interviews with identified members of their leadership. Usually I walk through an interviewee’s understanding of the EHR initiative and its purpose, what they think is in it for them, what they hope it will accomplish, etc. For the first few interviews, I felt like I should be charging behavioral health CPT codes because the leadership interviews turned into therapy sessions. I felt like I was in junior high school again, but instead of dealing with cliques and mean girls, I was dealing with organizational silos and power-hungry players with grossly inflated titles.

Of course, most of them want me to just jump right in and “fix the EHR.” Having been in this game for a fair length of time, I know that without putting the right leadership structures in place and making sure we have functional processes to sustain any changes to EHR content and workflow, we might just worsen the chaos and make the physicians even less happy. Once we identify who the decision-makers will be and what the strategic goals are (besides just “get that MU money”), we’ll be able to really figure out how to solve the problem.

I wasn’t able to finish all the interviews last week (of course, many “emergencies” prevented people from attending, but they wouldn’t tell me what those urgent problems were) so I do have some phone interviews to finish this week. At least I won’t have to hand out tissues since we won’t be in the same room. I also don’t have to worry as much about maintaining my poker face when the stories of one department slighting another get petty or silly. Once the interviews are complete, I’ll deliver a formal assessment and recommendation and we’ll see how it is received.

Having done this more than once, I know they’ll go through some of the stages of grief (particularly denial, anger, and bargaining) before we can arrive at a real plan to move forward. They have some strong physicians who seem to be buying what I’m trying to sell. They’re not ‘titled’ leaders, but rather informal ones, so I’m hoping they’ll be able to help drum up some grassroots support. The titled leaders will be a bit of a challenge, but I’m hopeful that the burning platform of MU will help move them in the right direction.

What is your current stage of grief? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/11/15

Only a couple of days remain to submit comments to CMS on the proposed modifications to Meaningful Use. Comments are due on June 15. Be sure to have them in by 11:59 p.m. if you’re submitting electronically. If you opt for mail, courier, or hand delivery, they need to be there by 5 p.m. I wonder just how many people submit them by hand? I’ve been watching episodes of “The West Wing” on Netflix and recently viewed one where they put a campaign volunteer in a chicken suit to heckle the opponent. I think it would be great to hand deliver comments dressed in ironically themed costumes.

In other news, CMS released the Medicare Shared Savings Program Accountable Care Organization final rule last week. It addresses beneficiary assignment methodology as well as beneficiary protection during data sharing. The rule also looks at measurement benchmarking and adjustments based on an organization’s previous performance. I’m still torn on whether I am on board with the whole ACO concept. I understand that we need to generate savings for Medicare and deliver more quality care to patients, but it seems overly complex.

In my market, the ACOs are all over each other and it’s confusing for patients, who may not be motivated to seek care in the way that the ACO wants them to. Some may not even realize they’re part of an ACO. Many of us who have insurance through our employers receive premium discounts for healthy behaviors. How about something similar for the Medicare set? Let’s split the savings between Medicare and the patients when diseases are managed through lifestyle interventions rather than drugs or surgery. I bet that would drive the needle in the right direction.

With the tagline “It’s time to rebuild medical education from the ground up,” the AMA launches an initiative called Accelerating Change in Medical Education. They’re accepting proposals for the ChangeMedEd 2015 conference in October. Additionally, a new policy statement calls for medical students to experience hands-on use of EHRs during training. I like the idea of actually teaching future physicians how to use EHRs well rather than just throwing them out on the wards and hoping for the best as many programs still do. Using an EHR well in the patient exam room is a learnable skill. Not everyone takes to it easily, but being able to interact well with patients while documenting and accessing information is a key skill that many end users still lack.

I hope that while they’re “rebuilding medical education,” they push for courses in the other key areas that none of us realized were part of the practice of medicine:

• Quasi-Mandates 101: Managing participation in federal and payer programs while keeping your sanity. (Prerequisite is “Zen Breathing 101: Skills to avoid strangling people who say this isn’t mandatory and that physicians have choices.)
• Open Wallet 101: Understanding all the outlays required to practice medicine. Includes coverage of AMA’s stranglehold on CPT code licensing as well as discussion of state licensing, DEA, state controlled substance permits, medical staff dues, professional liability coverage, specialty board fees, maintenance of certification, and more.
• Administralian 200: Learn how to speak fluent buzzword and translate what you are hearing from administrators. (Co-enrollment in Hospital Administrator language lab required.)
• IT Support Practicum: Learn how to work through help desk blockades and the magic words to getting administrative privileges so that you can install useful medical apps on your personal device.
• Medical Review Practicum: Learn how to navigate payer phone trees and multi-level case reviews to ensure your patient receives the care he or she needs.

Most of my professional friends know I’m pretty happy in my new role as a free-range CMIO, but that doesn’t stop them from sending potential opportunities my way. Some are serious and some are hilarious. They also send clippings form sites like Glassdoor with reviews of potential employers. One I received today wins the prize. It was from a hospitality employee at a major teaching hospital. “Pros: great benefits, discounts on meals, yearly bonuses. Cons: you have to interact with a lot of sick people at work.”

I’ve always been a sucker for Vespa scooters. After today, though, I know that if I decide to move to fewer than four wheels, it will have to be in one of these. Thanks to the intrepid reader who sent it, making my day. I’m sure I can get a matching helmet to complete the ensemble.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/8/15

I was visiting some friends this weekend and we drove past a niche primary care clinic. It advertised “Healthcare for Guys!” which certainly caught my eye. Although the location I saw was next to Costco, a quick Web search revealed that they apparently also have a location next to a home improvement store. I’m always interested in new models of care and thought I’d find out a little bit more. Unfortunately, their website was pretty sparse without even a listing of their physicians or the fact that they now have multiple locations. Their Facebook page had multiple posts with grammar errors and typos. Not exactly a vote of confidence, but a great example of why physicians need to pay attention to their social media presence and webpages.

On the flight home, I noticed that the ever-present SkyMall catalog was missing — apparently it’s gone digital-only. After some procrastination (check out the automated pill dispenser above), I was forced to read journals instead. An article in the Annals of Family Medicine caught my eye: “Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians.” The study set out to assess “the feasibility and acceptability” of some of the care coordination objectives in the proposed Meaningful Use rule for Stage 3. Specifically, they looked at referrals, transfer of care, clinical summaries, and patient dashboards.

Researchers surveyed primary care practices that had been recognized as patient-centered medical homes (by the National Committee for Quality Assurance) in addition to participating in Meaningful Use. They also surveyed community health centers with patient-centered medical home recognition. The survey looked not only whether the sites had implemented the proposed objectives, but also at whether the practice thought those objectives were important. The results were similar to anecdotal comments I’ve heard in the field. While 78 percent of the physicians thought it was important to be notified of hospital discharges, only 48 percent were using IT systems. Conversely, while 77 percent of practices were providing clinical summaries to patients, only 48 percent of them considered providing summaries to be “very important.”

Similar to what we know about vaccine delivery (namely that non-physicians do a better job of following protocols and ensuring vaccination), the study found that care coordination was more often done using IT systems when a non-physician was responsible. The practice’s “capacity for systemic change” was also positively associated with using health IT for care coordination as was being in a non-urban area. The study concludes that “health IT capabilities are not currently aligned with clinicians’ priorities” and that “many practices will need financial and technical assistance for health IT to enhance care coordination.”

Those aren’t earth-shaking conclusions for anyone who has been in the trenches during the Meaningful Use era. While those practices that had already transformed care coordination prior to MU will continue to do so, those arriving later to the dance are struggling. It’s hard to identify dedicated resources to manage patient panels without negatively impacting the bottom line of practices already on thin margins. Although there is the promise of future money for demonstrable outcomes, you have to demonstrate quality to get the money. It’s a somewhat perverse chicken-egg-chicken loop.

I also wasn’t surprised by the fact that the survey only had a 35 percent response rate. Additionally, the study found that the most commonly implemented care coordination processes were not those with the most IT involvement. Respondents cited the top barriers as time, money, and IT systems. There were several other interesting data points from the practice demographic data: approximately one-third of clinicians were concerned about practice financial health; more than three-quarters of practices received help improving care coordination; and referral tracking was less than 100 percent. My former risk/compliance department would have a field day with the latter statistic since everyone was expected to track 100 percent of referrals 100 percent of the time.

Now that we’re getting a critical mass of providers involved using IT systems, we need more surveys such as this to determine where physician priorities really are and whether we can align systems to support those clinical priorities rather than trying to drive clinicians based on what systems will support. Interestingly, the next article I read discussed the idea that payment reform isn’t the only factor turning medicine on its ear. The NPR headline caught my eye: “A Top Medical School Revamps Requirements To Lure English Majors.”

Having been a non-science major myself, I support approaches like this aimed at bringing more diversity into the field. Some of the problems we’re trying to solve are extremely complex with a high number of psychosocial factors. It’s going to take more than biochemists and fruit fly-counting biology majors to help solve them. There were a decent number of non-traditional majors in my entering medical school class, but it certainly wasn’t the norm.

What was your undergraduate major? Would you do it again or is it just good for cocktail party discussions? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/4/15

Pharmaceutical companies are major users of direct-to-consumer advertising. Although we see a lot of EHR vendors advertising in medical journals and at conferences, I haven’t seen a lot of direct mailings to non-administrative physicians. This week at my clinical office, I received a direct-to-physician mailing from Imprivata regarding electronic prescribing of controlled substances (EPCS). It was actually a nice piece – educational with respect to Meaningful Use requirements and the current status of EPCS.

Rather than relying on MU-related scare tactics, it appealed to the concepts of streamlining physician workflow and reducing prescription fraud and abuse. Enclosures explained the DEA ruling in detail and laid out strategies for planning a successful implementation. They did, of course, market their solution, but it was tastefully done. I also appreciated the fact that the entire packet was devoid of flashy marketing distractions. Maybe I’m getting more boring with age, but it’s nice to see something straightforward.

Health Datapalooza took place this week in Washington, DC. The agenda listed sessions on personalized medicine, patient-reported outcomes as quality indicators, data privacy and security, and advancing technology. I’d be interested in hearing from readers who attended. What were the best sessions? Anything earth-shaking?

The May-June issue of the Journal of the American Board of Family Medicine surprised me with a special issue including multiple healthcare IT articles. One reviewed existing studies on physician use of scribes, concluding that scribes may improve clinician satisfaction and productivity. The researchers were only able to find five studies done between 2000 and 2014, so the validity of the results is limited. Another discussed the notion that “primary care researchers are uniquely positioned to inform the evidence-based design and use of technology.” It suggests leveraging existing research programs and methodologies from human factors engineering, which sounds like a great idea. A third examined how physicians use previous visit notes to prepare for an upcoming visit, suggesting that the note output of EHRs needs an overhaul to reduce cognitive load.

A friend shared Atul Gawande’s recent piece titled “Overkill,” which discusses continued recommendations for unnecessary tests and treatments. These not only drive up the cost of healthcare, but can lead to additional testing, which often leads to a spiral of waste. It also leads to overdiagnosis, which creates stress for patients and can also lead to additional unnecessary treatment. Theoretically our EHR systems should help us avoid these pitfalls through the use of clinical decision support and better availability of patient data at the point of care. However, until we spend time educating the populace that there are risks to “doing too much,” we won’t be able to take action on the information before us.

Gawande cites specific examples, stating, “We’ve tripled the number of thyroid cancers we detect and remove in the United States, but we haven’t reduced the death rate at all.” It’s not just the United States facing this issue – South Korea is seeing similar problems. I often hear patients talking about the nation having the most advanced technology in the world and the best procedures, so it’s challenging to help them understand that often less is indeed more.

We’re putting steps in place to encourage physicians to proceed thoughtfully and avoid unnecessary expenditures, but I haven’t seen the level of national programming needed to bring patients around to this new way of thinking. Choosing Wisely presents evidence-based lists of tests and procedures to reconsider, but I don’t see them being used on the front lines of care. Patients often don’t want to rely on a physician’s education and clinical judgment; they want hard proof and this leads to testing. The relentless pursuit of higher patient satisfaction scores doesn’t make it easy to say no to patients, either.

It will be interesting to see how the healthcare landscape shifts over the next five to 10 years. Billions of dollars in Meaningful Use funds haven’t shifted the needle as much as we’d hoped, so it might be time to try new strategies.

How can we make the most of the next decade? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/1/15

I had lunch this week with some former colleagues. One of the topics of discussion was the 21st Century Cures initiative that was approved by the House Energy and Commerce Committee in May. Supporters such as Representative Frank Pallone state that it “will ensure that innovative treatments are getting to those who need them most, giving real hope to patients and their families.”

For those of you who may not have seen the non-IT details, the bill has significant goals:

• Reauthorize National Institutes of Health (NIH) funding through FY2018
• Establish an innovation fund at NIH
• Require strategic planning and greater accountability at NIH
• Increase funding for pediatric research
• Require sharing of data generated through NIH-funded research
• Standardize patient information across trials housed in ClinicalTrials.gov
• Establish a public-private Council for 21st Century Cures to “accelerate the discovery, development, and delivery of innovative cures, treatments, and preventive measures”
• Increase patient-focused drug development
• Require the FDA to issue guidance on precision medicine
• Streamline policy to facilitate development of new antibacterial and antifungal agents
• Formalize vaccine recommendation processes
• Modify FDA review requirements for certain categories of drugs and devices

Most of us have heard about the language on ensuring interoperability and “holding individuals responsible for blocking or otherwise inhibiting the flow of patient information throughout our healthcare system.” There is also a section on expanding telehealth under Medicare.

As a primary care physician, I also liked the section addressing issues where Medicare beneficiaries can’t get certain services covered because care is delivered in the home setting. My favorite part, though, is Medicare site-of-service price transparency. I hope all the health systems doing so-called “provider-based billing” take note of this. It’s going to be harder to trick patients into paying exorbitant facility fees if this makes it through. Rebranding free-standing physician offices as hospital departments as a thinly-veiled cash grab is one of the more despicable practices I see among hospitals and health systems.

The Senate is working on its own version of the bill, so it remains to be seen whether all of this passes, and if it does, how much the individual sections are modified. Funding research and cutting edge therapies is important, as is dealing with various Medicare oddities that complicate care delivery. In talking with my colleagues, however, we all balk a little at the call-out for precision medicine. Although it’s an interesting concept, is it really going to be pivotal for the majority of patients?

I’m a huge fan of public health. Basic sanitation and preventive measures have made a tremendous difference in quality of life for people around the world. However, I’d like to see more discussion (and also funding) of the basic health services that many people either cannot access or lack understanding of their value. It is still difficult to get insurance companies to pay for nutrition counseling or sessions with a registered dietician except for certain disease states. We can try to get patients to self-pay for these services, but it’s a difficult proposition when some are already paying large premiums for minimal coverage.

I’d like to have the time and resources to try to convince patients of the return on investment for these interventions (both in quality of life and lower health costs), but it’s hard to make headway during a 10-minute office visit. Watching Congress debate legislation that impacts rare diseases and drug development is difficult when one realizes how much work is still yet to be done on diseases that have 19th and 20th century cures already. A good number of the diseases on which we spend the most can be markedly improved (if not cured) through behavioral and lifestyle interventions, but these are the most difficult to implement. It’s much easier to take a pill for many Americans.

I’m not sure what primary care will look like in the next century. I can’t wait for the next generation to be able to scan patients with a Tricorder and synthesize antidotes and treatments Star Trek style. That seems such a long way away, though, when we’ve yet to figure out how to implement some of the basics such as universal vaccination, healthy eating habits, and regular exercise.

Looking back through the Bill’s history, I did see a small step that actually will make an immediate difference. At the same time the House of Representatives Energy and Commerce Health Subcommittee was hearing about 21st Century Cures, they were also considering HR 1321, the Microbead-Free Waters Act of 2015. It caught my eye because I’ve been aware of the microbead problem for a while, especially the fact that the US lags other countries in banning them. I must say, this Act is probably the shortest piece of legislation I’ve seen in a long time – a grand total of two pages and 14 numbered lines. If only Meaningful Use was that simple.

What’s your favorite Act of Congress? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/28/15

Even though I’m not ready to jump into another CMIO position at the moment, I still keep up with job postings and am watching a couple of positions to see how long they take to fill. I know the health systems involved more deeply than I’d like to admit. It will be interesting to see who is brave enough (or naïve enough or desperate enough) to sign up for those kinds of adventures. I’ve subscribed to a couple of job sites and today’s email brought some laughs under the banner of “great new jobs found for you this week.”

They included: utility location technician, Uber driver, business analyst at Emdeon, inside sales rep at Thermo Fisher Scientific, data entry clerk, patient experience officer, chief technology officer, and my favorite – Deerpark Barn Supervisor at The Biltmore. When I hit that last one, I noticed that all the jobs were in Asheville, NC. Although it’s a beautiful city and I’ve had some fun times with good friends there, I’m wondering if my profile has been hacked.

Speaking of job hunting, I’ve received several recruiter mailings this year and find it curious that they have all mentioned what EHR system is used at the site. Having used many systems, I’m not sure having one vendor over another would really make or break an opportunity for me. I’d rather have a well-implemented version of a low-key system than a poorly managed version of one of the industry darlings. Even in the cloud or on standardized MU-ready versions, clients still seem to have enough configuration and workflow options to get themselves into trouble.

I started a consulting project this week training ICD-10 for a local group of independent providers. It’s been a lot of fun working with end users who aren’t used to having a clinical informaticist around. With their focus on clinical care, they haven’t been PowerPointed to death and actually seem excited about learning something from my traveling road show. I’m just doing introductory content now then will circle back in a month or so with actual workflow training on their EHR system.

We’ll see how enthusiastic they remain after we get into the gorier parts of the workflow. I knew it really clicked with at least one student, who sent a piece from MSN entitled “The Strangest Ways Americans Die in all 50 States.” She asked whether the “cause of death” information would be more specific once ICD-10 is live. I hope so, because some states have amazingly general categories listed such as “water, air and space, and other and unspecified transport accidents” in Alaska and “legal intervention” in Nevada.

I received a handful of “thanks for stopping by our booth at HIMSS” messages this week, mostly from booths I don’t remember visiting. I’m pretty meticulous about taking notes while I’m crawling the exhibit hall and none of them were on my list, either. I’m attributing it to a HIMSS technology glitch rather than faulty memory. Nonetheless, if I want to buy mounts for my flat screen displays, I know where to go.

The National Healthcare Innovation Summit takes place next month in Chicago. An advertisement for it asks. “How will you innovate healthcare this year?” Most of my CMIO friends aren’t going to be doing any innovation. It looks like 2015 is about catch-up and ICD-10 preparation. Especially with Meaningful Use Stage 3 howling at our door, I don’t foresee vendors doing a lot of innovation, either.

I hadn’t realized that Minnesota passed legislation in 2007 that required all healthcare providers to implement a certified EHR by January 1, 2015 and to connect to a state-approved HIE. I came across a blurb this week that the legislature has approved an omnibus bill containing an exemption for cash practices and solo practitioners. I’d be interested to hear from Minnesota readers who have an opinion on the situation.

One of my favorite shoe enthusiasts brought these to my attention. Controlled by a smart phone app, they change colors and patterns to match the wearer’s needs or possibly just her mood.

In a related link, we’re introduced to motion-capture ballet slippers constructed from Arduino components and conductive thread. I forwarded it to my nephews in the hopes that they might need a project to keep them busy this summer. Maybe we can combine the two technologies to put together a graphical representation of what really happens on the HIStalkapalooza dance floor.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/14/15

First of all, I want to say thank you to all the readers who sent warm wishes after Monday’s Curbside Consult. Quite a few people shared their own stories of leaving positions they had been in for a long time. It’s encouraging to hear from people who have been there. Right now it’s nice to not be in overdrive for a change.

I also had questions from readers about my new perspective having used multiple different systems and having worked in some different provider environments. Here’s a bit of Q&A for those readers:

Are most EHRs universally disliked? Yes, but to different degrees. I don’t think the users dislike the EHR so much as they dislike the changes to their workflow. Although it’s popular to call for more disruption in the industry, physicians don’t like that their way of life has been disrupted. When you actually ask about the EHR system itself, some of the complaints are pretty small in the grand scheme of things. As a seasoned observer, I’d say 80 percent of the time there are unresolved operational issues rather than software issues. I see a lot of physicians blaming EHR for increased work when it’s really that the implementation didn’t redistribute work to the right people at the right point in the care cycle. I also see a lot of poorly configured systems and lack of knowledge on how to improve them. Most providers have only used one EHR (or maybe one in the office and one in the hospital) so they don’t have much of a frame of reference.

Are most EPs grumbling about all the CQM, PQRS, and MU hurdles? Yes, yes, a thousand times yes. Previously with PQRS, many providers had staff that did that behind the scenes with claims submission and now they’ve got it in their faces at the point of care. Some systems have CQM alerts that actively fire in the provider’s way and the measures don’t always match with their clinical priorities, so it causes frustration. Some systems handle alerts more gracefully than others. I was in a pediatric practice recently that was so tired of answering “the Ebola questions” that I thought they were going to go mad. The data-driven reason to ask about Ebola in a US-based suburban private practice is miniscule, but they’re on a subsidized software platform from their local mega-hospital, so they are stuck with the workflow. Providers are tired of MU and the attestation numbers reflect that. Specialty providers are significantly more exhausted by the MU CQMs because they don’t match practice priorities.

What about ICD-10? Lots of fatigue here and the delays didn’t help. Although large organizations seem to be doing a good job of being prepared, I’m not seeing enough grassroots training for end users. I’m also seeing some systems that have limitations regarding dual coding. Although having a seamless switch from one ICD to another on October 1 sounds slick, providers want to ramp up slowly and feel that working in a test environment is a waste of time or double work. Systems also vary on how well they will prompt users to enter all the information required for the more granular codes. Some are adding required fields and others are adding optional fields. My gut feeling is that it’s going to be messier than it needs to be, especially since we’ve had so long to plan.

Have EPs just given up on all these programs? The bloom is definitely off the rose. At the beginning of MU, it was clear that $44K was only a down payment on what it really costs to transform a practice, but a lot of people were seduced by the money or frightened by the future penalties. Some non-participants figured out along the way that they could see one or two more patients a day and more than make up for any penalties and they seem fairly happy with their decision. Others are just figuring that out now and feel pretty bitter.

I also received many recommendations for National Parks, including a plea not to overlook the state parks. I totally agree after visiting an obscure-sounding state park in Florida last year that was absolutely lovely and completely off the beaten path. Most of my previous National Park experience was on a Griswold-style family pilgrimage. There’s nothing like hitting the Grand Canyon, Sequoia, Yosemite, the Black Canyon, Mesa Verde, Bryce Canyon, and a host of other notable places in about a month’s time span. I didn’t fully appreciate it at the time, but do remember my mother being ready to throttle my adolescent self at the Glen Canyon National Recreation Area. Although no one was harmed during the trip, there were a lot of crazy stories.

For those interested in reader recommendations, here’s the score card. Bryce Canyon is leading Arches three to two with strong recommendations on Volcanoes, Grand Canyon, and Zion. Special mention goes to Yellowstone (which Weird News Andy calls “the king, queen, and court jester of National Parks”) and to Mammoth Cave, which I hear is breathtaking but also has almost 80 miles of trails that never get any use because everyone is underground. I also hear Glacier National Park is getting ready to emerge from winter and I haven’t yet packed away my fleece jackets. Plus I could hit the Black Hills on the way.

Do you prefer “Find a Car Bingo” or “The Alphabet Game” for your in-car entertainment? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/11/15

Jayne Becomes “Available to the Workforce”

Unfortunately, George Clooney didn’t arrive on my doorstep to give me a pink slip as his character did so many times in “Up in the Air.” Instead, resigning from my hospital position was fairly anticlimactic.

If you missed my previous post, here’s the short version. My hospital is migrating to a single platform EHR and I’ve been on the fence about taking a role on the new project vs. doing something else. I made my decision quite some time ago, but have been procrastinating actually writing about it. Readers have been asking whether I am opting for “fight or flight,” so I’m finally ready to let the cat out of the bag.

I ultimately decided not to apply for a position in the new organization, primarily because of the way the transition was being handled. Not only for leadership, but for my staff. There were so many consultants in the mix that it wasn’t clear who was making the decisions or what the eventual structure would be. I couldn’t even tell who I might report to or who my boss would be in six months.

Although it would have been tempting to jump into the fray and find something to make my own, I didn’t feel it was tenable. Apparently I wasn’t the only one thinking the same way – several of our best managers opted not to make the jump either.

I could have stayed in my old role and helped turn the lights off on the old systems. I realized quickly, though, that my team was being gutted, not only by movement of key resources to the new project, but also by the departures of those who felt sticking around would be risky. There were no guarantees of employment in 18 months after the legacy systems shut down, so people grabbed opportunities as they came by. The prospect of trying to continue to roll out new physicians and support our existing users with an inexperienced staff didn’t excite me.

Although I’ve resigned from jobs before, this was my first time resigning from one at this level. Once my decision was made, the next concern was what would happen once I handed over my letter. Would they walk me out or would I work out my notice period? I really wasn’t sure which way they would go and I wasn’t about to poll my colleagues. I’ve seen it happen both ways. On one hand, I didn’t see them with a reason to walk me out – I’ve been a loyal employee and a highly visible leader. On the other hand, I had access to all kinds of sensitive information, including upcoming physician acquisitions, strategic planning, and financial data.

I couldn’t imagine having someone else pack up my things if they did show me the door. Even in our increasingly digital world, there’s a certain amount of “stuff” that accumulates over 10 years. While I was debating my decision, I did a fair amount of multitasking as I sorted files during conference calls and took home a laptop bag full of personal belongings here and there. I couldn’t take much off the shelves, though, since I didn’t want it to be obvious what might be going on.

The weekend before I was ready to hand over the letter, I came in on Saturday and took all my personal belongings except the medical textbooks and the diplomas hanging on the wall. I figured HR could box those up and ship them, or if I had the dubious honor of doing the “pack your things while we watch” routine, there would be no question of what was mine vs. company property. It was probably an overkill approach, but you never know how it’s going to turn out when you’re dealing with a corporation.

It’s not like I was leaving to go work for a competitor. I may have been the first executive who actually resigned to “pursue other opportunities” for real rather than as a euphemism for being terminated. Still, I was pretty nervous when I headed to meet my boss for our weekly one-on-one meeting with my letter tucked in a manila envelope.

I knew he wouldn’t be surprised, but actually delivering it was another thing. He opened our meeting with his usual, “What’s on your list for today?” as expected, so I prepared to hand it over. Unfortunately, I was more nervous than I thought and my attempt to gracefully slide the letter across the table ended up being more flippant than intended. An image of an air hockey game popped into my head and I have no idea what my facial expression was, so he may have thought I’d finally gone off the deep end.

He was actually pretty cool about the whole thing since we had been talking about my need to make a decision for some time and he was aware I had decided not to move to the new system team. I sensed a little disappointment as he said he hoped I’d stay to “hold things together” but understood the decision.

The only real suspense was waiting for the answer after asking him what happens next. Apparently the topic of executive departures had been covered as part of project planning for the new system and I was on the “OK to stay” list. I have to say I was a little disappointed on some level at not being shown the door since having an extra month of paid vacation would have been nice.

I had timed my notice so that I would depart with the other team members, thinking that would minimize the disruption since there would already be activities in place to reassign work, reorganize teams, and create new reporting structures. It turned out to be a good decision since I had a natural support structure of people to talk to as we went through the process. Even when leaving is voluntary, it’s still difficult, and even more so when you don’t necessarily have something you’re headed to.

While they would be flying off to training after their last week on the team, I was headed towards a bit of a sabbatical while I burned through a decade of accumulated vacation and comp time. The last day was a bit teary all around, but overall the final month went better than expected.

I’m not going to say how long I’ve been away from the hospital – Dr. Jayne’s timeline is fairly fluid and sometimes I don’t publish what I write until weeks or months after it happens to preserve anonymity and make sure it doesn’t come back at me. I know readers will ask what I’ve been up to. I didn’t want to relocate for another CMIO position, so it’s been an interesting combination of clinical work (both local and locum tenens) with a sprinkling of healthcare consulting. I’ve worked with nearly a dozen different EHRs, which gives me a perspective that I didn’t have before. I’ve been able to travel to cities I’d not normally visit and have had access to a stunning variety of office and health system dysfunction. Locum tenens work is not for the faint of heart – often the positions are opened to locums because they’re virtually non-fillable by traditional candidates.

My plan was to lay low for at least six months while I figured out what to do with the rest of my life, but already some opportunities are on the horizon. One came knocking after I updated my LinkedIn profile – from an organization that had been interested in me for some time but thought I would never leave Big Health System. Another is an organization that is looking to hire their first physician IT expert.

I’m not going to jump into anything just yet, but it’s nice to feel wanted. In the mean time, I’ll be adding stamps to my National Park Passport, collecting multiple state medical licenses, and seeing whether the grass is any greener on the EHRs used by other Eligible Providers. Please remember to be kind to drivers with out-of-state plates because one of them just might be me.

Have a National Park recommendation? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/7/15

I’ve received quite a bit of reader mail this week, mostly in response to two recent pieces. One discussed people who wear the same thing to work every day. One software engineer talked about a very relaxed work environment where he wears a uniform of jeans and a collared shirt. In summer, they’re allowed to wear shorts and sandals. Although he’d prefer a t-shirt, he agrees the collared shirt is “more appropriate.”

The sandals issue is always a tricky one. I’ve been in offices where this has been allowed and have seen everything from a nicely manicured foot in a dressy sandal to platform flip flops that could cause a serious workplace injury. If you’re going to allow sandals, it’s hard to legislate what kind. Are Keen water shoes OK? What about Birkenstocks? Tevas? Flip flops? How much of the foot has to be covered? What about sandals and black dress socks like my grandfather used to wear? It’s a slippery slope for sure.

I’ve also received a significant number of emails on my recent trip to the hospital with a friend. Mr. H suggested I have my friend request a copy of her medical record to see what it costs, how long it takes to be delivered, and what it contains. It might be an interesting exercise, but I can tell you that two months later she still hasn’t received a bill from the hospital where she was initially treated. You’d think that with many of their patients being vacation-related injuries they’d be more vigilant about timely billing than say a small community hospital. I’ve also asked to take a tour of her Explanation of Benefits statements and any bills she gets since I always find them interesting. She did show me a recent statement from her PCP which actually detailed charges that were more than two years old and had been settled months ago. The current statement was for a $25 vaccine coinsurance, yet they had printed out every service and payment since 2013. The bill wasn’t even in date order. As a professional, I could barely figure it out.

Some of the reader comments have patient stories that are truly heart (or gut) wrenching:

A reader passes out after standing quickly at a restaurant. She is taken to a hospital while she is out, and when she realizes what is going on, starts to worry about the ramifications of her high-deductible health plan. Her workup is unremarkable. Two hours later, she is presented with a patient balance and asked how she’d like to pay it. She requests an itemized bill and copies of her records, which the hospital can’t produce unless she returns another day to request them or has a physician request them on her behalf. My favorite quote from her account: “I smile again, and I realize that I am fake-smiling so she won’t think I’m ‘that girl’… The thought that I would fake-smile at any other person in the world that just handed me a bill for $1,000 without telling me what it was for and ask me for my credit card is absurd.” My own observation is this: If a restaurant can provide an itemized point of sale bill for a party of 20, why can’t the ED give an itemization for a single patient?

An out-of-town patient visits a community hospital emergency department after his health plan triage nurse suspects kidney stones. This is confirmed via bedside ultrasound, which also finds kidney cysts. He is told to follow up with a urologist when he returns home, but forgets to ask for a copy of the ultrasound. Before flying home, he leaves a letter with a family member to take to the hospital to request the records. Radiology agrees to make a copy, but when the relative returns to pick it, up she leaves empty handed, being told that radiology doesn’t manage ED ultrasounds. Medical records doesn’t have it, either. The ED administrator doesn’t know how to get it and has to ask others, which delays the process for a day or two. The return call states that the request has to be notarized (which had not been required by radiology) but no one really knows how to copy the ultrasound or print pictures. A reply is promised, but never comes. The kicker: the hospital advertises point of care ultrasound as the first bullet point on its ED website.

A patient goes for a complex procedure that requires two different surgeons. Neither specialty uses the hospital EHR for outpatient notes. The post-op nurse provides discharge directions that conflict what the surgeons told the patient regarding home medications, requiring clarification with the physicians. The medication list includes every medication the patient has taken in the last three years and has not been reconciled despite the patient handing an updated medication list to both surgeons and multiple pre-op personnel. Discharge instructions were cut and pasted, not only from two different sets of physician instructions, but also from a previous procedure during a different hospital stay. They also contradicted each other. “At the end of the day – I was saved because I am an experienced and knowledgeable healthcare consumer. However, it takes a lot of energy, stress, and worry.”

I appreciate the reader comment that says I’m probably one of the 0.01 percent of physicians that have the interest and patience to write up the experience. He or she goes on to say, “For any hospital executive, she’s just provided a service that a consultant would charge $50K for (if you catch them on a cheap day) – lay out in plain view the issues that make modern medicine intolerable for the average consumer. And things were not that different in the pre-EHR era.” That’s more truth to that than most of us care to admit. A good percentage of EHR implementations don’t address underlying workflow issues or organizational culture. They just threw tools at it.

One reader summed it up: “We have a long way to go.” I agree completely. Some of these things are not rocket science – they’re basic processes that could be handled through checklists and protocols. However, maybe we should go to the rocket science approach. After all, if we can put a man on the moon, we should be able to figure this out.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/4/15

Jayne Goes to the Hospital

I’ve enjoyed reading the posts this week from our patient advocate HIMSS attendees. They all have interesting stories to tell from the patient perspective.

Recently I took off my doctor coat and became a patient advocate as I accompanied a coworker through her knee reconstruction process. Although she didn’t have it done at my hospital, she had it done at one that is part of a large multi-state health system that advertises its relentless focus on quality. It was eye-opening to see behind the curtain at someone else’s facility and to look at what goes on in a typical patient’s experience.

Her journey started after an ill-fated adventure vacation when she called me for an orthopedic recommendation. Since we work together, I asked why she didn’t go with one of the surgeons we know well. Her answer – privacy concerns – didn’t surprise me. She was able to get an appointment the day after returning home and was immediately scheduled for an MRI. Unfortunately, her surgeon’s office didn’t tell her she needed to schedule an appointment to receive the results, so she ended up calling a couple of days after the MRI only to be told she’d have to come in the following week.

That’s the kind of patient aggravation that’s totally avoidable. I had previously referred hundreds of patients to this particular practice as a primary care doc and never had that kind of complaint before. I did some digging with colleagues, and it turns out the practice was recently acquired by a health system that requires them to use a centralized scheduling service. Apparently the ball gets dropped a lot. It didn’t make me confident since I had referred her, but at that point, what can you do?

After receiving her results, she was scheduled for surgery at a hospital across town. I asked her why she selected it since the surgeon operates at multiple places. Her response this time did surprise me: that’s the first choice they gave her and she really didn’t consider other options. It just goes to show that no matter how much we think patients agonize over quality scores and other factors, sometimes they really don’t care.

Since she’s single, she asked if I would go with her and stay at her place the night after the procedure until she was sure she could get around the house. I agreed and we spent the night before sharing a bottle of wine and laughing about being young, sassy, and having your own personal notarized advance directive. After years of hospital work, she said she wasn’t crossing the threshold without it.

As we were leaving the house the next morning, the hospital called asking if she could come any earlier. Not likely since her scheduled arrival time was in 25 minutes and the hospital was 20 minutes away. It kind of surprised me that they’d bother calling patients to come early if it was likely that they’d already be on their way. That should have been a harbinger of the adventures we were about to have.

We arrived on time, only to find the parking lot where she was told we should park to be marked with “no surgery center parking” signs. Twice around the block and several one-way streets later, we made it to a parking garage.

The surgery center lobby was vacant except for patients and a sign-in kiosk. She registered and it took more than 15 minutes for anyone to call her up. So much for the need to arrive early!

The first question she was asked was whether she had traveled to West Africa in the last 21 days. The second was whether she was ready to pay her estimated patient portion in advance since she’d get a discount if she paid pre-op. Once her credit card was swiped, she was handed a laminated HIPAA and consent document (which had to be 8-point font) and told to “sign the signature pad when you’re ready.” There’s no way patients who are already nervous about a surgery are going to actually sit there and read it. I wonder if it would even hold up under legal scrutiny given the way it was presented.

By this point, I was totally taking notes on my phone since I knew a blog entry was likely to come out of this. The registrar asked if I’d like to receive text updates during the surgery, which I thought would be interesting to see how it worked.

With the paperwork done, we headed back to the outpatient surgery holding area. After being specifically told to keep her undergarments on (a fact which will become pertinent later, I promise), she changed into her low-fashion hospital gown and revealed the fact that she had marked her opposite knee with “NO!!!” in Sharpie. The nurse immediately jumped on this and belittled her, saying that she shouldn’t have done that because it would be confusing to the OR staff. Making a patient feel bad because they have a genuine (although humorously stated) concern about the risks of wrong-site surgery should never happen. She finished the intake process (after asking again about West Africa but never about the advance directive) and scurried off.

Luckily the anesthesiologist was a little more sensitive, kindly explaining that they have never had a wrong-site case at the facility and describing the multi-step process that they have in place to prevent it. The surgeon would meet with the patient, review the consent, sign the correct knee with “YES” and his initials, and this would be witnessed by patient and staff before the patient received any medications. They would repeat the process once the patient was anesthetized and before the surgeon started the procedure.

He was reassuring, but also stated we’d need to remove the “NO!!!” so it wouldn’t confuse the OR team. She agreed, but I wondered if the OR team couldn’t tell the difference between YES/initials and NO!!! that there might not be other issues at play.

We joked about the buffalo plaid sheets on the outpatient surgery gurneys. Our hospital has plain white, so we were snapping pictures. A second nurse came in and asked if the first nurse had finished the intake process. Um, I don’t know, since I don’t know what your intake process is. Wasn’t it in the chart? Apparently it wasn’t.

The second nurse finally logged in to see what had been charted, then proceeded to ask my friend specifically what the first nurse had done: Did she listen to your lungs? Did she use lidocaine when she started the IV? I pasted my best quizzical look on my face to see if she’d notice, but she was too busy charting another professional’s work to pick up on it. After copious clicking had gone on, the first nurse returned, asking “Oh, are you doing my charting?” and the second nurse admitted to it. I wonder what values she charted and whose login was used?

Shortly after that, the OR holding area called for my friend, so they got ready to wheel her off. The problem was the surgeon hadn’t come by yet. The nurses also realized they hadn’t completed some of the pre-op orders, but didn’t want to mess up the schedule, so off they went. I was given the option of carrying her bag of clothing with me or putting it in a locker – of course I chose the locker. I walked with her to the doors of the OR holding area and crossed my fingers that they would write on the correct knee.

The hospital has the same waiting room for the inpatient and outpatient surgery areas, but there was no one at the desk. I selected a seat close to an electrical outlet and started catching up on some work. A few minutes later, I received a text that she was “now in the operating room.” A few minutes after that, a staffer in scrubs and a cover gown arrived and asked for the “Jane Doe Family” and I raised my hand. She walked over and handed me a clear Ziploc bag stating “she forgot to take off her underpants” in a loud stage whisper. Luckily the rest of the room couldn’t hear her over the Shark vacuum infomercial that was playing on the communal TV, but I know my friend would have been horrified.

As she left, a hospital volunteer arrived to staff the desk and explained the monitor they have on the wall that shows the patients’ initials and a color-coded bar that says where they are in the grand scheme of things – pre-op, OR, procedure in progress, procedure complete, recovery, post-op, etc. I liked the idea and I liked even better the family member that interrupted, asking for the remote control. They found an episode of “Gunsmoke,” which was much more appropriate for this particular waiting room demographic.

I received a “procedure has started” text and set my timer so I could plan the rest of my afternoon. I was able to accomplish a massive email cleanup with very few distractions from Marshal Matt Dillon, then took a break for lunch.

The cafeteria was chock full of motivational posters for staff as well as banners celebrating their “Top 10 Hospital” recognition from an organization I had never heard of. Regardless, it was nicer than my own hospital and the food was better, so I gave the experience a 10 myself. I continued to receive “the procedure is still in progress” texts every hour or so. Once I returned to the waiting room, I also received hourly updates from the waiting room volunteer who actually said, “She’s still in surgery – whoop de do, I know” at least twice. It has to be boring saying the same thing all day and she was sweet, but nevertheless I doubt the hospital would appreciate it.

Once I received the “patient is now in recovery” text, I found a good stopping point and packed up my laptop. The surgeon came out (wearing rubber rain galoshes with his scrubs, which was a new one for me) and went through her surgical photos with me. I have to say, the innards of her knee looked pretty ragged in the “before” photos and much more glamorous in the “after” shots. He told me she’d be “going home on crutches” and that he’d leave a script for pain medication.

I knew he was straight out of fellowship, but he looked even younger than expected. Despite feeling old, I figured that being proficient in the latest and greatest techniques outweighed any concerns about duration of practice – I wasn’t even aware the procedure she was having existed before she told me about it.

The volunteer stepped away and asked that someone answer the phone if it rang. It did, and I was told to “go back to the outpatient holding area.” I went back to the outpatient surgery lobby and it was closed with a sign directing me to the front desk. I figured going to the front desk would be more hassle than finding my way to the holding area, and made it there after only two wrong turns. My friend was in a holding bay and awake, so I stepped to the bedside and immediately received a look of annoyance from the nurse. “She just got here. We’re not ready for you yet.” I apologized and told her that I had been instructed to come up and backed away. They didn’t tell me where to go, so I just stood there feeling stupid.

Once I was allowed back at the bedside, my friend was still pretty doped up. The staff offered the ubiquitous eight-ounce can of Sierra Mist and her choice of Cheez-Its or pretzels. Another nurse yelled, “We’ve been out of Cheez-Its for months,” which set the stage for our tour through the post-op process. The staff printed her discharge instructions and went through them with me, explaining that she had received two nerve blocks in her leg and they would last for at least 18 to 24 hours. That was news to both of us! I started wondering how I was going to get her out of the car and into the house since managing stairs, a tall lanky athlete, and a dead leg might be quite the trick.

As we went through the instructions, we found several conflicts on dressing changes and showering. I had questioned the “leave dressing on until showering” and “shower after seven days,” which resulted in a call to the OR to clarify with the surgeon, who had started his next case. Next was a search for the prescription, which the nurses assumed I had been given in the waiting room. A call to the OR revealed the surgeon had taken it with him. Last, there were no instructions for how often and how long to use the high-tech ice water therapy machine he had ordered for her (which incidentally insurance didn’t cover, but we have enough mutual friends with sports injuries to scrape one up from someone with better coverage). Yet another call to the OR. I can only hope that as a young surgeon, he’ll learn to double check things or develop a process, because three calls to the OR to clarify orders is too many. On the other hand, maybe his hospital’s $200 million EHR might have an order set?

Since she had been drinking fluids, eating solids, and not feeling nauseated, the nurses announced she could get dressed and go home. That was when my radar went up. In my post-op universe on the other side of town, we want to have a patient complete some critical functions (such as emptying the bladder) after they’ve had general anesthesia and a bladder catheter. I didn’t consider three pretzel sticks to be “eating solids” and my friend was still pretty dopey, not to mention completely unable to move or even feel her leg. I asked about the crutches since the surgeon said she’d be going home on crutches and they said he didn’t order any. I gave the quizzical look again and she said that even if they had an order, they couldn’t dispense them because it was after 4:30 p.m. and the physical therapists had gone home, so no one could do crutch training. Then she added that I could rent them at the pharmacy if I wanted them.

I reminded the nurse that my friend had zero control of her leg and I had no idea how I was going to get her out of the car and into the house. What did they suggest? Another nurse chimed in and said, “I don’t think crutches are a good idea anyway. They’re not stable. She really needs a walker.” I asked if we had an order for that. She said no, but they had a walker she could try. I suggested that maybe we try the walker on the way to the bathroom since she hadn’t been yet.

She barely made it the 20 feet to the bathroom since her toes were dragging and she had to lift the leg from the hip to get it to swing through as she advanced the walker. I couldn’t believe that as a facility that does this every day, they had no plan for this. I guess maybe all the other patients bring their own crutches or walker. I took the opportunity while she was in the bathroom to start calling septuagenarian relatives who have had knee replacements to see if anyone had a walker I could pick up on the way home. I was grateful for success on the first attempt.

While she was in the bathroom, she figured out that she was missing some clothing she had been wearing pre-op. She asked where it was and was not amused by my answer that they brought them to me in the waiting room. I dug them out of my laptop bag while we strategized on getting her dressed. She wasn’t keen on having the nurses assist, so I helped her wrestle the dead leg (with its huge bulky dressing and rigid brace) into her clothes. While the bay curtain was closed, we overheard the nurses buzzing around since someone had taken their specialty wheelchair that is set up for a patient with their leg locked in an extended position. One never wants to hear, “We’ll just have to rig something” when you’re being discharged from the hospital.

Being out of the hospital gown (and also free of mind-fuzzing medications) must have been empowering because my friend started to let the staff know how much she was not amused by the discharge process, the multiple order conflicts and omissions, and the apparent lack of a plan for what is likely a common set of events. A supervisor stepped in and I slipped away to get the car, knowing she could handle herself. I pulled into the circular drive as instructed and discovered it was full of cars left for the valet but not addressed. I had to double-park in the traffic lane and go back in, where I found the nursing supervisor offering her best service recovery tactic. It involved (no kidding) a “XYZ Hospital” mug with a can of soup, tied up with cellophane and a bow. I actually laughed out loud at this point.

Soup in hand, our patient announced she was ready to go and the supervisor wheeled her out, taking a route which required me to manually open two doors on the way so she could wheel the patient through. I guess there is no way to take a patient out in a wheelchair that either uses automatic doors or assumes the family will be there to open them. What if I was out waiting with the car? It’s a small thing, but if there’s anything that the events of the day proved, the small things count.

Our patient immediately became nauseated upon trying to get into the car, resulting in a frantic run by the nurse. Luckily we avoided any actual vomiting, but I guess it’s something the family should be ready to handle.

We headed into the sunset to pick up the walker, drop off the prescriptions (couldn’t she have been given the script at the pre-op appointment when she scheduled the surgery?) and wrestle the dead leg into the house. Luckily she’s an athlete and was able to do some kind of parallel bars lift and twist maneuver to handle the steps, but I worried about her banging the dead leg around. She made it to the sofa and we fired up the ice therapy machine. I ran out to pick up her prescriptions and provisions. Three bags of ice, 90 Percocet, two Red Box flicks, and a medium pizza later, we were stocked.

The night passed uneventfully, although I couldn’t resist snapping photos of her wearing compression stockings with her walker. Some day when we’re of “Golden Girls” age, we’ll look back and have a lot of laughs. The dead leg started waking up after 8 a.m. the next morning but it was more than 24 hours before she could really move it. I violated the post-op orders and changed her dressing the next day since they had three battlefield dressings on there. It was so thick I didn’t think the ice therapy was making it anywhere near her knee. and once she was no longer numb, it was confirmed.

After two days. she ditched the walker for crutches (borrowed from the high school basketball player up the street) and started physical therapy a few days after that. Her overall prognosis looks great and I have successfully resisted the urge to ask her if I can examine what has got to be a seriously rock solid knee. It will be a while before she’s wearing stilettos again, although if there’s anyone who could manage them on crutches it would be her.

I still wonder though what other people do in these situations. Do they really leave a grapefruit-sized dressing on for seven days? Or do they just call the office? Do they bring their own crutches to surgery? Do they know to ask for the post-op prescriptions in advance? Do they know to bring something for possible carsickness? Are they savvy enough to take off all their clothes even when told to leave some of them on?

I wasn’t the patient, but for a healthcare system that increasingly demands quality, the whole process was certainly something. The next time I am asked to review post-op order sets or pre-op protocols, I’m going to look at them with a new perspective.

What’s your patient-side story? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/30/15

One of the hot topics in the physician lounge this week was the provision in the recently-signed SGR bill that ends the use of Social Security numbers on Medicare cards. Medicare is authorized to spend $320 million over four years to make the change. The first $50 million is in the 2016 budget. Other interesting facts in the article: more than 4,500 people enroll in Medicare every day; total enrollment is projected at 74 million by 2025; and the push to end use of the SSN in healthcare has been going on for more than a decade. Other than the number being “randomly generated,” there aren’t many specifics about how patients will be enumerated moving forward. Based on how providers have been assigned UPINs and now NPI numbers, it’s not likely to be quick. Additionally, vendors will have to update systems to handle the new numbers.

Another hot topic was the recent CMS report that half of the professionals eligible for the PQRS program didn’t participate in 2013 and are therefore subject to penalties this year. More than 98 percent of those being penalized didn’t even try to participate. In my book when half the candidates don’t even try, that makes a statement that either they’re not interested or have other priorities. Unfortunately it has fallen on deaf ears as the move to new payment models continues. Very few industries have the “pay-for-quality” construct like we now have in healthcare. I recently had to deal with a legal matter involving a law firm that was not exactly with the program. Too bad they weren’t on a pay-for-performance plan because they’d likely be looking for a new line of work.

JAMA online offers a nice profile of our new Surgeon General, Vivek Murthy. It feels a little odd to have people in my generation filling major roles. At 37 years old, however, he is not the youngest to hold the post – he mentioned to the interviewer that the first two appointees (by Ulysses S. Grant and Rutherford B. Hayes) were younger. Like Murthy, I remember first hearing about the Surgeon General when C. Everett Koop held the post. Seeing him on TV was probably my first view of public health. Murthy is a fan of social media and digital platforms, and I have to say I’m somewhat jealous of his public service announcement with Elmo. If Sesame Street is ever looking for an average family physician, I hope they look me up.

The AMA continues to nauseate me with their congratulatory focus on the SGR bill. AMA President Robert Wah cites “Five ways health care will look different in the post-SGR era.” Number four is that health outcomes will be improved and he names the idea of Medicare payments for care management of chronic disease patients as the reason. The devil is in the details – our practice investigated using the new Chronic Care Management codes that went into effect in January. The fact that the patient has to consent and agree to pay a 20 percent coinsurance is a huge barrier. Patients are reluctant to put their nickel down on something that feels unproven, especially if they are on a fixed income. Additionally, it’s first-come, first-served, so if other specialists charge it before the PCP does, they win.

I got a chuckle while reading Mr. H’s news feature mentioning a new referral management software vendor named Fibroblast. For those of you who may not have had to sit in the dark through dozens of hours of histology slides on carousels in medical school, a fibroblast is a connective tissue cell. It also does a lot in wound healing. If there is anything that the completely dysfunctional healthcare referral process needs, it’s something to help heal it. Good luck to Fibroblast in their work.

From Eager Reader: “Re: Dr. Jayne, I enjoyed your fashion commentary from HIMSS, especially since I couldn’t be there this year. What do you think of this article about people who wear the same thing every day?” I have to admit, I wear a modified “same thing every day” wardrobe myself. It’s kind of like Garanimals for adults, only without the matching labels that allowed even the most fashion-challenged to put together a workable outfit. When I was a kid, as long as you had the lion-tagged pants with the lion-tagged shirt, you were good to go. I’m pretty sure my brother had the outfit above, but I remember him wearing it with a wide white belt. Although the article cited Steve Jobs, Mark Zuckerberg, and Albert Einstein as devotees of simple dressing, there might be another famous fan in the wings. The parent company of Garanimals is now owned by Berkshire Hathaway. I’m going to start the Warren Buffett style watch in the morning.

What’s your favorite work uniform? Email me.

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