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.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/27/15

CMIOs Gone Wild

One of the challenges of being anonymous is missing out on get-togethers at HIMSS. Sometimes vendors invite me to participate in events as myself, but other times the invitations come to Dr. Jayne. Even though most of them promise to either maintain my anonymity or allow me to register under whatever name I choose, attending such invitations has risk. Plus, I generally don’t attend events that I didn’t get invited to as my “real” self (or at least couldn’t tag along as someone else’s +1).

Although I trust Lorre and Mr. H to protect my identity, I had mixed feelings about attending the HIStalk CMIO lunch at HIMSS. I was excited about meeting other CMIOs outside the settings where we normally cluster in the wild – symposia, conferences, and of course the AMIA Clinical Informatics board review course. I get together with other CMIOs in my health system at least quarterly.

But it’s different when you have the opportunity to talk to people from other parts of the country that may be facing challenges that haven’t hit your market yet. It’s also different when you get a group of CMIOs who face the same pressures every day and they’re put in a relatively “safe place” where they can speak their minds.

My original plan was to cruise by, see who was at the table, and drop in if feasible. Most of the time though the table was packed and Lorre reported that they had to swipe chairs from the McKesson table because more people kept arriving. She was gracious enough to take notes on some of the discussion so that I could attend vicariously, as well as some pictures.

I thought about running the photos, but then I remembered my own hospital’s rules about vendor interactions and I certainly don’t want to get anyone in trouble by calling them out. I’ll keep the attendees anonymous, but here are the group demographics:

• University hospital or major health system – 4
• Physician group or IPA – 2
• Government or public health – 3
• Industry or vendor – 6
• Other – 2 (multiple roles, consulting, etc.)

Since women in technology leadership has been a hot topic on HIStalk lately, I’ll give the breakdown: two were women, the rest were men. There were more vendors than I had expected, but several were either notable personalities or had been CMIOs in a previous position.

Although I had given Lorre some conversation starters in case the group was quiet, from her notes, it sounded like the discussion did just fine on its own. Hot topics included:

• Patient portals. What strategies are CMIOs using to increase patient portal use? Most agreed it needs to be more valuable to the patient to get them to engage. One mentioned that at Duke the only way to pay a bill is through the portal. Others agreed that the ability to schedule appointments was key. There are different strategies to gradually add the appointment piece to the portal since physicians are sometimes reluctant to allow patients to self-schedule. Appointment cancellation is also important. The topic of no-shows came up and the general thought was that if patients are willing to go online to schedule, they’re typically willing to go online to cancel.
• Physicians opting out of MU. Several felt that MU is not useful. One commented that, “There are no opt-outs in malpractice.” Another commented that the penalties aren’t high enough to force providers to engage – some have done the math and if they can see one more patient a day and do less work, that’s more economically favorable even with the penalty.
• Board certification. CMIOs discussed fellowships vs. on-the-job training. Many would not choose to spend time in a fellowship if it was required. There was discussion about Maintenance of Certification and the fact that the American Board of Preventive Medicine has not certified enough relevant content for Clinical Informatics. One CMIO is going to take a dive medicine trip because those credits count and she gets to SCUBA dive.
• Various CMIO challenges. New problems seem to crop up daily. One physician found that lab analysts were rounding the numbers for lab values rather than displaying them as they were reported from the analyzer machines. Another cited the difficulty getting clinical photos into the EHR and the problem of physicians taking photos on their iPhones and sending them around. They also noted the problem of dealing with operational issues that are uncovered by an EHR implementation. For example, labor and delivery nurses that could no longer “preorder” for physicians before the patient was admitted. Since there weren’t any formal standing orders, the nurses were ordering on paper what they knew the physicians would want. When they couldn’t do it in EHR, it became an issue, requiring discussion of their scope of practice.
• Documentation was a hot topic. Attendees felt that what EHRs are putting out isn’t clinical documentation — rather it’s all about billing documentation. They’d like to ask CMS whether clinical documentation should be required to support clinical decisions rather than billing decisions. Evidence-based documentation is necessary and needs to be pertinent. CDS should be a major part of documentation, but it needs to be filtered to the situation and actionable. Context is key. Alerts should be standardized. Use of documentation templates and order sets is increasing. One site is using Lean Six Sigma principles and Kaizen events to create disease specific clinical note templates to help communicate information to help nurses and social workers with post-discharge care. We need to better identify what parts of the documentation need to be discrete. What is the important information? What is the minimum needed?
• Global healthcare models are being examined. One attendee recently visited hospitals in Japan. He liked their clinical pathways, where grids are used for each day of the treatment plan. Each role had guidelines on what should be documented.
• Interoperability. FHIR was discussed as was the use of SNOMED and LOINC. What will the next standard be? There are still problems between systems. We need to broaden interoperability for problems like visual diagnostics. Providers should be able to take a photo and send to dermatologists behind the scenes for decision support. Another wants to be able to take a photo and have it count for documentation and billing/coding bullet points – rather than describe the rash inadequately, put a picture in the chart. But CMS doesn’t allow providers to do that.
• Retail healthcare was mentioned. Some CMIOs are having interactions, receiving referrals, and being part of the feedback loop. One mentioned his experience with a specific retail clinic, saying that working with them was “as complex as working with the Department of Defense.”
• HIPAA Omnibus Rule requirements were discussed. If patients declare they are paying cash, the encounter data can’t be reported to payers. How are various vendors handling this? Some are suggesting providers use a “shadow chart” for the protected content. Others are just starting to discuss tagging the data. There is concern that allowing patients to choose which portions of the chart can be shared will interrupt care and cause possible misdiagnosis if physicians don’t have all the information.

Although I’ve mostly summarized from Lorre’s outstanding notes, one of the quotes caught my eye. I’m not sure who said it, but, “The CMIO is the face of dysfunction” might just be my new mantra. We (or our respective EHRs) certainly get blamed for everything. We’re also expected to figure out how to solve it without hurting anyone’s feelings while helping the operational, clinical, and technical teams play nicely together.

Based on the number and caliber of attendees who stuck around for a fairly long time during a very busy HIMSS week, it sounds like they found the event valuable. I hope Mr. H will consider doing it again in Las Vegas.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/23/15

It was only a couple of weeks ago that I was lamenting a slow health IT news cycle. Now I’m up to my eyeballs in things I want to write about.

The physician lounge is buzzing about the Medicare Access and CHIP Reauthorization Act of 2015, also called the “SGR bill” or “Doc Fix” bill. Unfortunately, most of them didn’t read beyond the AMA headline — “Medicare payment formula bites the dust” — to see what is really heading their way. Although they won’t be threatened frequently with Medicare payment cuts, the entire Medicare payment game is changing. For those who participate, there will be annual payment increases of 0.5 percent through 2019 and then a variety of other changes.

Although that’s certainly better than a cut, it doesn’t even keep up with inflation. Physicians can’t ask their suppliers to limit their price increases to 0.5 percent. Many hospitals and health systems that only offered employees that level of salary increase would see feet moving towards the door. AMA leadership is lauding it as historic legislation that “finally brings an end to an era of uncertainty for Medicare beneficiaries and their physicians.” Based on the discussion around the physician lunch table, anyone who thinks this is going to end uncertainty about physicians and Medicare might be confused.

I have to admit I haven’t read the whole thing, but rather several strategic digests and quite a few chest-thumping press releases. Colleagues who are savvier about the actual contents of the legislation are appropriately skeptical. Those that were considering a departure from Medicare haven’t changed course, and today, additional physicians were jumping into the discussion. Although Medicare’s quality reporting programs should be streamlined, many physicians still are not on board with pay for quality if physicians will continue to be graded on outcomes beyond their control.

Although the new payment models are voluntary, I can see employed physician organizations immediately heading in that direction. Administrative bloat will increase as teams are hired to review and comply with what will undoubtedly be reams of new CMS requirements and regulations. While physicians around the table were initially applauding the end of MU as we know it, the room became quiet when the detail-oriented ones pointed out its replacements. The more unified incentive program will be based on quality metrics, resource and cost utilization, practice improvement, and also Meaningful Use. Physicians in the so-called “Alternative Payment Models” will also have to continue using certified EHR technology, so vendors aren’t off the hook either.

Physicians are particularly leery of metrics that include untested patient satisfaction or engagement metrics. A piece in The Atlantic this week addresses the issue. My favorite quote: “Patients can be very satisfied and be dead an hour later.” It cites research by a professor at the University of California-Davis that concluded the physicians may be reluctant to have difficult conversations with patients due to fears of lower patient satisfaction scores. There’s not a tremendous amount of data looking at patient satisfaction scores compared to morbidity and mortality data. We all know of patients who continue to go to physicians that we know have horrendous disciplinary records and poor clinical skills, yet when a change is suggested, they profess happiness with their care.

I’m encouraged that legislators included some level of protection so that plaintiff’s attorneys can’t use Medicare quality data to support a standard of care, but there are plenty of other organizations collecting and analyzing the data and where no such protections exist. As CMS goes, so go the commercial payers and eventually we’ll all find ourselves dealing with all kinds of different flavors of payment schemes from the large health insurance companies.

Interoperability is also a key feature of the legislation. HHS will have to figure out how to measure whether national priorities are being met and determine how providers will be evaluated. This means additional rulemaking and additional burdens on providers and vendors. As specified in the title, the bill also extends the Children’s Health Insurance Program (CHIP) as well as community health center funding for another two years.

The good news is that the bill didn’t include anything delaying ICD-10, so those of us making plans can get on with it. I had a good laugh reading an AMA fluff piece on prepping for ICD-10. “Spend your time in the month ahead identifying the changes you need to make in your practice for ICD-10. For example, you’ll need to update your systems, forms, and work flow processes.” Just a couple of small things you can do in your spare time, right? The next sentence was even better. “Pull together a group of all staff members involving coding, billing, claims processing, revenue management, and clinical documentation, then figure out each task necessary to bring your practice in line with the new code set.” That’s pretty much everyone in a typical physician practice. If practices are just figuring out what they need to do now, they’re way behind and oversimplification doesn’t help things.

The bill also includes provisions on competitive bidding; Medicare face-to-face documentation requirements; chronic care management services; funding for the National Quality Forum; and requirements that Medicare Administrative Contractors establish “improper payment and outreach education” programs. It also includes a section on what happens to monies recovered by Medicare Recovery Audit Contractors. The Secretary of Health and Human Services is required to use that money for alternative payment model incentives, additional Medicare Administrative Contractor functions, reducing payment errors, prior authorization for repetitive scheduled non-emergency ambulance trips, and improving chiropractic documentation.

You never know what you’re going to find in a piece of legislation this size, which illustrates the old adage about the devil being in the details.

What’s your take on this recent legislation? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/20/15

HIMSS Wrap-up and Final Fashion Commentary

I’m still recovering from HIMSS. Apparently there was a lot of craziness at the hospital while I was gone, but I’m grateful to my second in command who handled all the issues. That lets me know that they’ll be in good hands down the road.

I’ve been going through my notes and arranging follow up with a handful of vendors that caught my eye. I’ve also been sorting through the scads of business cards I collected and am trying to remember who I met at which events. The week was quite a whirlwind.

From Bright Lights, Big City: “Re: my boots. As requested, here’s a better picture. They are one of my favorite pairs of boots (my blue suede ones are killer too). Thanks for the compliment on HIStalk. I was totally flattered. The House of Blues was so much fun!” Mr. H and Lorre outdid themselves with the event. Although I wasn’t an official shoe judge, after discovering these boots I’m thinking that next year we need a “Jayne wishes she had my shoes” sash to hand out. I’m also thrilled that she responded to my plea for a photo of the boots. It’s fun to connect with readers, even if it’s just email. It also lets us know you’re actually keeping up with HIStalk, unlike the two guys at the bar at the House of Blues who had never heard of Mr. H or Dr. Jayne.

Although Nordic’s Drew Madden won our official shoe contest, a reader emailed a picture of this pair of blue suede shoes that he snapped at the NextGen party. I’m thinking they could be a contender next year. Drew also sported an inlaid wood tie clip and I’m thinking we need to add some additional categories for best accessories.

I’m declaring HIMSS 2015 to be “The Year of the Sock.” I saw more fetching hosiery this year than ever before. Special mention goes to Colin at the Patient IO booth. The socks were kind of a teal/aqua color with several accent colors below the shoe line, and coordinated perfectly with his bow tie and pocket square. His described his companies app as being “like Legos for patient engagement,” which drew my attention when I was fading partway through the exhibit hall.

Speaking of bow ties and pocket squares, the Aventura team had it going on all week long with different combinations every day. The ties, pocket squares, sweaters, Converse sneakers, and strappy sandals spotted at the booth were perfectly matched to their specific shade of orange, as were their giveaway candies. I didn’t know you could Pantone match M&Ms, but they just might have done it. I heard they also had cufflinks that honored their owl mascot, but I missed them.

After my final lap around the show floor, it was time to head to the airport. I chuckled at the seat sign which promised no extra charge for payment by credit card since I was charged a processing fee every time I used an actual taxi. Usually I’m just changing planes at Midway and hurrying to another gate, but this time I had time to stop for lunch and more hydration at Harry Caray’s. I was people-watching when a vendor rep I haven’t seen in a while stepped up to the host stand. I waved him over and we caught up over a burger. He’s starting a new venture soon and I can’t wait to hear more about it.

The other bonus of arriving at Midway early was being able to help welcome in an Honor Flight group from Kansas that was changing planes in Chicago. Honor Flight sends veterans to Washington, DC to visit their respective war memorials. This looked to be largely a group of World War II veterans. Travelers stopped and lined up a good way down the terminal, applauding as each veteran deplaned. The applause followed them down the concourse as they passed different gate areas. Many of their family members and escorts were moved to tears and I was as well. This generation sacrificed so much and being able to thank some of them really put the week in perspective.

My flight home had multiple vendor reps still in booth attire, including scrubs. Everyone appeared tired and I almost had to use my doctor skills when a passenger nearly dropped her bag on our row while trying to get it in the overhead bin. “Heavier than I thought” almost caused a head injury, which makes no sense on an airline that checks bags for free. Based on the backpack (carry-on number three for her), she was a HIMSS attendee. Maybe a first timer – HIMSS is the one event I take my expandable suitcase to, because you never know what you might bring back. Thank goodness the folks at Medicomp agreed to ship the six gallons of popcorn I won playing Quipstar. As a reminder for those of you who are not road warriors: If you can’t lift it, it’s not a carry-on.

The in-flight Wi-Fi allowed me to file most of my expense report before landing and I also had a chance to get caught up on email. One of my readers had reminded me on Monday that running would be my sanctuary this week. It had me wondering how many steps are in a HIMSS. Although I didn’t participate in the BYOD wellness challenge, I can state with confidence that it’s at least 65,000. I don’t know exactly because I didn’t wear my Garmin to HIStalkapalooza, so all that dancing didn’t get captured. I’m not sure on mileage since the data from the Garmin (29.2 mi) doesn’t match Garmin Connect (50.4 mi). I’m more inclined to believe the wrist unit, but I’m glad Garmin isn’t building healthcare software.

How many steps were in your HIMSS? Email me.

Email Dr. Jayne.

Dr. Jayne at HIMSS 4/16/15

I’m home but still playing catch-up with my HIMSS experiencing. As I was triaging my inbox, I found a gem about a new patient engagement product. It wasn’t a great release and didn’t even mention the vendor showing it at HIMSS. Who sends dry press releases during HIMSS and doesn’t even mention the conference? I’m sure the visibility on this one was pretty low.

The highlight of my day Tuesday was running into a good friend while waiting for the show to open. His cup caught my eye and we had a nice catch-up until heading into the fray. The show floor was pretty busy. The creepiest booth was in the Interoperability Showcase, where one of the hospital displays had two people sitting in a hospital bed together. One was wearing a baseball cap and looked totally bored. The same display area also had a guy walking around in a hospital gown with a sign around his neck, pushing what looked like a vital signs monitor machine. Very strange.

I saw HIStalk sponsor signs at Sunquest and Santa Rosa as well as at Healthfinch, where I had a great demo from Debbie. Healthfinch is one of what feels like only a handful of products that actually makes physicians’ lives easier, so I salute them. I stopped by the Enovate booth to see if they had anything new – we use their pediatric computer carts and they’re super cute. I was hoping they’d have a new animal offering this year and they promised to send some literature.

Venturing back into the bowels of the hall to the HX360 area, there were quite a few empty booths. One of my colleagues joked about creating a fake wireframe and sitting at their booth just so we could have a rest. We did use their chairs while I caught up on email. My goal was to check out MediVu, who had emailed me about their startup. Although their message said they had “no fancy giveaways or fancy parties to invite you to,” they were warm and welcoming as I chatted with CEO Robert Baldwin about their product’s dynamic icons. They did offer me some mints in a test tube, so they passed the southern hospitality test as well. I like to follow startups – I’m still following one that I first saw at HIMSS in 2011. They haven’t made the big time, but they’re still at it.

McCormick Place failed the southern hospitality test, with overflowing trash cans and recycle bins. They also committed the “here’s a trash can but no corresponding recycle bin” faux pas, which makes me crazy. It’s not like they’ve never hosted a convention before, you know?

They did, however, have an actual working pay phone near the lower-level restrooms, so that’s something.

I spotted these shoes in the 900 aisle. Although they’re attractive, I think the gentleman she was talking to made a more responsible shoe choice.

I tried several times to connect with specific vendor reps as I roamed the aisles. My success rate was zero for three –people had stepped out of their booths and the response of those left behind was highly variable. IMO (Intelligent Medical Objects) gets the prize for best response. First they asked if I would like them to try to find the person or whether they could help me, then offered refreshments while they looked for him. The second two vendors will remain anonymous to protect the guilty – one didn’t bother to ask what I wanted, saying, “He’s out of the booth, but I can help you,” which wasn’t true since I was just there to see pictures of his new baby and catch up. The third just said, “I have no idea where he went, but it was a while ago” and left it at that. Vendors take note: you should have a plan for this because I bet it happens a lot. Other “booth teams behaving badly” included the guys from Intel, who were leaning on the door of the Medicomp booth and preventing people from getting in or out.

Humetrix had surfing rubber ducks at their booth.

I headed to the HIMSS Bistro in the afternoon to stalk the CMIO lunch. This sign on the sky bridge reminded me of the need to proofread. It looked like the CMIO group was having a great discussion, but I was a little disappointed by the small number of women at the table, one of whom was Lorre. She has promised to send me her notes from the discussion – I bet it was a good one and would have loved to attend if there was any way to stay anonymous.

Epic had their traditional quirky art. I really like this guy, though – I would totally buy him. Insight Enterprises had a life-sized “Operation” game in their booth, but I couldn’t get a picture of it because of the crowd around it. I visited with my good friends at RemitDATA for a few minutes. They helped talk me off the ledge after I was accosted by aggressive vendor reps on the way there. One was stepping into the aisle, randomly shoving literature at people in complete disregard to their “no thank you” or corresponding lack of interest in their product. Another actually grabbed my hand and tried to pull me into the booth. When I told a colleague about it, he also commented on the aggressive nature of some of the reps, saying, “It was like they were on an attack vector.”

After that, it was time to head back to the hotel and change for the evening’s parties. The bus to the hotel was much faster this time, but still with the same people rushing the front as soon as it stopped. I got ready quickly and the cute boots I brought sat unused as I knew I wasn’t going to make it through the night without serious pain. I cabbed it over to the New Media Meetup at Gino’s East with a friend. The Chicago-style pizza was the perfect way to fuel before a big list of events, but I was bummed that I didn’t have a paint pen to add my “Dr. Jayne was here” to the walls.

From there it was off to the “HIMSSandHers” networking event, sponsored by XX in Health and Edifecs. They generously donated $5 to Bright Pink for everyone who tweeted a pic from their event. Do you like my selfie? There were several other parties that night including Nordic and NextGen. I caught up some friends at the end at Tavern on Rush, where I was confused by the fact that they have a pair of sparkly Louboutin heels in a rotating Plexiglas box behind their bar. I’m sure there’s a story there.

By the end of the night, I was ready for a trip to the spa as this bakery display advertised, but alas there was still more HIMSS ahead of me. Next up: I’ll post my HIMSS wrap-up after the weekend.

Dr. Jayne at HIMSS 4/15/15

I’m way behind on my writing, mostly due to the overwhelming nature of the exhibit hall coupled with entirely too many social events. I had decided to walk to McCormick Place Monday morning but abandoned my quest after the first half mile due to the drizzle. I was joined on the bus by two women who joked about the window curtains, saying that if they were rock stars they’d close them and kick back. If they were rock stars they’d have couches and tables rather than the flimsy cup holder that turned my bottle of Diet Coke into an ankle-seeking missile.

They joined me in rolling our eyes at the people on the bus who jumped up and rushed the front as soon as the bus stopped. I’m not sure what happened to waiting until those in front of you exit, but that wasn’t the only bus ride where that happened. I had been trying to time my arrival to the opening of the exhibit hall, but was early since I decided to catch the shuttle at the Hilton. I picked up some breakfast and was nibbling a sandwich and juggling my stuff. I want to offer a profound thank you to the gentleman who gave me his chair and proved that manners still exist.

Shortly after that, I saw a tweet from Jessica Kahn that highlighted images of women at HIMSS with the hashtag #overit. Sex definitely still sells, as proved by a vendor event I attended that featured scantily-clad Go-Go dancers. I did overhear several attendees comment that they thought there were fewer “booth babes” than in previous years. The wildest thing I remember seeing was in 2011 when one vendor had contortionists on stage in their booth. As a clinician, it was fascinating, but still not appropriate.

I did make it to a couple of sessions, but none of them had anything earth shattering. Monday’s agenda was aggressive and included hitting several booths before making my way to play Quipstar at the Medicomp Systems booth. The amount of work that goes into putting together a full-scale working game show set is huge. Their backstage area hosts a variety of technology that keeps the game up and running. I’m not sure how many trucks it takes to haul it, but the infrastructure of their two-story booth is pretty impressive.

My performance as a contestant, however, was not impressive. Despite winning the double-points bonus question, I finished second and will be taking home six gallons of popcorn, which I’m sure my staff will enjoy. The real prize was their donation of $1,000 to Wings of Hope. Nominated for the 2011 Nobel Peace Prize, they set up field bases in developing nations. The bases help build clinics and schools, and establish air ambulance service for rural areas. As a non-sectarian, non-political organization, they can often work in areas that will not accept other charities. They also operate a Medical Relief and Air Transport Program in the US that flies children for medical treatment free of charge.

I returned to Quipstar later in the day to escort Jonathan Bush to the booth. He played for the St. Boniface Haiti Foundation against former ONC Deputy National Coordinator Jacob Reider. St. Boniface Haiti Foundation helps bring healthcare, education, and community development to the people of Haiti. The highlight of the round was seeing them take a selfie together. The contest was also full of entries for my “things I thought I’d never hear at HIMSS” list, but they were throwing them out too fast for me to jot them all down. Dr. Reider won the round, earning $300 cash which he added to the Medicomp donation to Engeye, which is dedicated to improving health and education in Uganda.

Later I stopped by the Dell booth to put together some cute headbands for Brooke’s Blossoms. They will go to pediatric cancer patients. We always like hearing about HIMSS events that benefit others, so if you have pictures or write-ups, feel free to share them. I wanted to hit several other booths, but was struggling mightily with the floor plan, mostly due to confusing booth numbering and crazily staggered aisles.

I left the exhibit hall early to get ready for HIStalkapalooza and was glad that I did since the bus ride to my hotel involved nearly 45 minutes of bumper-to-bumper traffic. Luckily the taxi to the House of Blues was much quicker. I had the opportunity to chat with my Secret Crush, David Dieterich, who was admiring my escort’s crushed velvet jacket. Although my crush initially bought my cover story, I’m pretty sure he figured out my secret identity.

The third floor at the House of Blues was the place to be for dinner, with minimal buffet and bar lines. I snagged a front row seat to enjoy the music while having dinner with a couple of friends. Although I couldn’t experience the sponsor opera boxes because I didn’t have a wristband, they looked cool. After dinner, it was time to grab some pecan pie and head to the dance floor for the HISsies.

As an avid baker, I enjoyed Judy Faulkner’s comments about liking to bake pies. She said she was reluctant to put the pie in Jonathan Bush’s face because it would be an insult to the pie. BTW, apple is her favorite. Once the HISsies were over and the pie was abused, Party on the Moon took the stage. They were even better than I remembered and I hope we can make them a permanent fixture. I overheard several hysterical comments throughout the night, including one attendee’s remark that the lead singer looked like the love child of Farzad Mostashari and Usher.

I admired many footwear choices, lamenting the fact that I just can’t do stilettos anymore. I wish I could have gotten a better picture of the red boots above — they were phenomenal. If the owner sees this, please send me a picture and description for my wish list. I could probably tolerate those for a couple of hours. Since I listened to my Shoe Advisor’s pronouncement that “wedges win every time,” I was able to stay on the dance floor until the bitter end, then hit two after-parties before collapsing at The Palmer House.

A reader shared a pic of the Athena Cloud Party, describing it as “insane.” I’m wondering if Jonathan Bush had any comments to make about HIStalkapalooza? I know there were plenty of other events Monday night – send your best pics and a description and I’ll run them next week.

Dr. Jayne at HIMSS 4/13/15

I made it to Chicago despite an extremely turbulent flight, opting to take an earlier route to Midway instead of O’Hare. The taxi queue was epic and made me long for the organization of Las Vegas. I did run into several friends in line, although none we headed to the same hotel. Although I’m usually annoyed when my taxi driver talks on the phone while driving, this one was lecturing his high school daughter on her GPA and the importance of getting into a good college, so I just relaxed and enjoyed the ride.

Besides catching up on new products and doing research, the main reason I come to HIMSS is to catch up with colleagues. It’s nice to be able to chat in person and the event brings so many people together. A friend who has missed the last couple of HIMSS conferences met me and we enjoyed the long walk to the convention center for registration. Other than a few sprinkles, the weather was gorgeous. The only thing that could have been better would be if Google Maps had not been providing walking directions that felt like we had been bar-hopping first.

While waiting outside the opening reception, I ran into a CMO friend that I hadn’t seen in several years and we talked about her new work with the VA system. Our employed specialty physicians provide a lot of care to veterans outside the VA clinics, so we talked about some strategies for making sure all the information is shared not only within the VA but with the community physicians who deliver increasing amounts of care for veterans.

The reception opened a bit early and there were plenty of bars and buffets set up. The band was named The Fat Babies and was playing to the backdrop of scenes from The Untouchables on the video screens above and behind them. I haven’t seen it in years and the younger Kevin Costner and Sean Connery reminded me that I’m not getting any younger either. I’ve officially been in healthcare IT for more than a decade. Had you asked me at the start whether I’d be doing it full time, I’d have thought you were crazy.

The reception brought some interesting characters my way. Since I was there early enough to grab a table, I made a good target for solo attendees looking for a place to set their drinks while they ate. People aren’t afraid to just introduce themselves and start talking, and my wing-man got to see me almost choke when one of the random people started talking to us about absolutely ridiculous things. Despite the titles on his badge, he had only a loose grasp of some of the key concepts in health IT, so we educated him on the Direct protocol and how physicians need to incorporate received data into patient charts – not just leave it in some email box. I had to leave my wing-man after the reception, but he promises to share many stories about other characters on our upcoming stroll through the exhibit hall.

After the reception, we headed towards the river with a stop at Rebar at Trump Tower. It has a beautiful view and apparently also was hosting a get together for Healthfinch, so we enjoyed seeing celebrities come and go. After a quick dinner we headed to the Divurgent/Experis reception at Roof on the Wit. I was traveling with a pack of party animals who decided to have a contest to see how many people each knew. The competition was stiff and I was quickly reminded that even though I’ve been around a while, I’m but a young pup when it comes to networking. I did run into Nordic’s Drew Madden who showed off what must be the year’s hot accessory – snazzy socks. He informed me that he brought a special pair of shoes for HIStalkapalooza.

On the way to catching my beauty rest, I happened upon the Aventura team at the Palmer House bar. I didn’t make it to the HIStalk sponsor reception (it’s a little tricky to do that and remain anonymous) but they promised a pair was waiting at their booth. I’m excited and think I’ll sport them at Quipstar rather than the sparkly numbers I brought.

EPtalk by Dr. Jayne 4/10/15

For those readers attending HIMSS who might want to check out my shoes, you can catch me at the Medicomp Booth (# 2318) on Monday afternoon. This year’s celebrity contestants include Jacob Reider, Lyle Berkowitz, and Ross Martin. Medicomp will again be making donations to our favorite charities and I’m honored to have been invited back. They offered bodyguards to protect my anonymity as well as a swanky backstage green room, which should make for a fun afternoon.

After I get my game show on, I’ll be heading over to the Meditech booth for the official launch of their Web Ambulatory product. Quite a few legacy vendors seem to be trying to embrace the cloud, so I’m eager to see their take on it. Plus they’ve promised champagne, although I wonder if they’ll be sneaking in the good stuff given the typical trade show restrictions on food and beverage service. I spent a fair amount of time sorting through press releases and booth invites today (nearly all of them via email) and can report that misspellings of HIMMS are leading HIPPA 3 to 2. I’m definitely not putting those organizations on the priority list.

I received the final instructions for the HIMSS Wellness Challenge. It will be measured in steps taken on Monday and Wednesday and in distance walked for Tuesday. Entrants must be present at the Connected Patient Learning Gallery to win – times are 5:30 for Monday and Tuesday and 3:30 for Wednesday. Those times border on my social schedule, so I think I’ll have to take a pass. If you decide to hang in there, the prizes are $300 gift cards.

Our leadership is hoping that CMS uses HIMSS as the prime time to release the rule making official a 90-day reporting period for 2015 Meaningful Use. Regardless of when it happens, I suspect that quite a few organizations will be planning to attest as late as possible so that they maximize their timeframe for upgrades and workflow changes they might need to be successful. We’re historically conservative and planned for full-year reporting, so our monthly status reports continue to be amusing reads as providers have decided they don’t need to be compliant just yet.

I had a brief trip in the Wayback Machine this week when our newly-acquired community hospital started including me on its email distribution list. Apparently they can’t convince their physicians to actually use electronic charting, so they’re going to pilot scanning hand-written progress notes starting next week. They reminded physicians to “change the dial on the charts to yellow which will alert the staff to scan the note.” It’s been so long since I actually used a paper chart, I had forgotten about the colored dials and sliders we used to let unit secretaries know we had written orders.

On Monday, CMS opened the Dispute Period for Open Payments. Drug and medical device makers are required to report payments made to physicians and teaching hospitals and physicians have the opportunity to review the data for accuracy. The review period is open for 45 days. Although I have all the logins, I discovered reviewing the data isn’t as easy as it sounds. Physicians have to register for both the CMS Enterprise Portal and the Open Payments system. Enterprise Portal accounts are locked if there is no activity for 60 days and deactivate at 180 days. Based on other demands for our time, I doubt that too many physicians will be personally reviewing their data. Maybe CMS could try sending us our data using DIRECT addresses.

Earlier this week, Mr. H mentioned the ECRI Institute list of top patient safety concerns. Of course health IT-related issues are hot topics, but I was surprised to see managing patient violence as number three. Our hospital was on lockdown multiple times last fall and it’s always unsettling, but the high-profile events aren’t the ones I’m most worried about. I’ve been threatened several times by patient family members. I suspect some of our outlying physicians may have firearms at their offices despite our official ban.

What are you doing to keep your staff and patients safe? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/6/15

The run-up to HIMSS is typically packed with marketing, but this year has been incredibly slow. As I scanned the Monday Morning Update, this ad from First Databank caught my eye. I’m pretty sure no one in their right mind would electively join a Meaningful Use club (unless they had some sadomasochistic tendencies), but it was catchy and smart. In fact, so catchy and smart that I might borrow their “varsity” idea. We typically have a theme for each year’s major EHR upgrade and I’m liking the idea of awarding varsity letters to our next class of super users.

There are only four more postal days until I board the plane for Chicago, so if vendors were going to try to reach CMIOs by snail mail, they’d better already have their marketing pieces on the way. There are usually several pieces that arrive the week after HIMSS and I hope their senders at least got a bargain when they chose PR firms that wouldn’t get the message out on time. My administrative assistant is getting seriously depressed at the lack of entertaining pieces – usually he enjoys making fun of the poker chips and other items, but there hasn’t been anything interesting this year.

The weekend email did bring a heartfelt apology from Nordic President Drew Madden, who heard about my dis-invitation from their HIMSS event. It sounds like they’re still working on right-sizing given their venue and have been able to expand capacity. Being part of the HIStalk team, I certainly understand how crazy it can be to find your event turning into the hot ticket. If I can figure out how to re-RSVP and stay anonymous I’ll certainly give it a go. I appreciate the personal contact and his kind words.

Speaking of HIMSS events, I’ve finally locked in my wardrobe for HIStalkapalooza. I’m really a jeans and boots girl at heart, but do love dressing up. It looks like the Chicago weather is going to be fairly cooperative and I’ve got plenty of other casual-dressy events, so this year’s red carpet look is going to be decidedly formal. I was completely outdone by Lorre, last year so it’s time to catch up. I’m still waffling between two different pairs of stunning shoes and will be wearing them around the house this week in the hopes that I’ll be able to decide. There’s nothing that can make you feel classier than folding laundry in heels and pearls. Eat your heart out, June Cleaver.

There are very few people from my day job who will be attending HIMSS, so I have a long list of booths to try to visit. A friend of mine recently clued me in to Humetrix, which offers several different smartphone apps. Their iBlueButton offering allows patients to store, aggregate, and share personal health data. SOS QR allows patients to create a record of emergency health information and then generate a QR code that can be displayed on their phone’s lock screen. First responders or healthcare providers can use the code to access critical health information during an emergency. A premium version allows patients to send out SOS messages to their emergency contacts.

Although it seems like these would be good for older patients or those with complex health needs, for young active patients who might wind up with a concussion or sports injury, it’s a great idea as well. It took me all of three minutes to create my record and there’s a certain peace of mind knowing that if I get loopy during my next half marathon, someone might have access to better data than what I illegibly scribbled on the back of my race number bib. Humetrix announced their Tensio app at the Consumer Electronics Show and they’ll have it at HIMSS. I’m looking forward to seeing how they use HealthKit data to engage patients for disease management.

The annual HIStalk guide to HIMSS is out and lists sponsor booth numbers as well as blurbs about swag and other giveaways. Several sponsors are donating to charities if you stop by, so be sure to visit AirStrip, Divurgent, and Orion. The Guide is also a great way to plan your route for complimentary drinks and snacks (cocktails at Billian’s, coffee at First Databank, scones at MedData, smoothies at PatientKeeper, and of course candy at PerfectServe). HCS Health Care Software, Inc. is hosting “a night of baseball, beer, and burgers” near Wrigley Field – check out the Guide to see what else you might be missing.

What’s your HIMSS15 exhibit hall battle plan? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/2/15

I’ve been struggling to get through the Meaningful Use Stage 3 proposed rule, but finally reached the end. I’m not sure how much of it I’ve retained, although I did take good notes.

I also skimmed the certification document to get an idea of new things my vendors may be offering. A couple of them struck me as interesting additions: the family health history pedigree; expanded social, psychological, and behavioral data; and consolidated care plans. CIO John Halamka, MD and Micky Tripathi posted an excellent analysis last week that should be required reading for all hospital and software vendor executives.

My favorite section of their write-up (appropriately subtitled “The Ugly”) encapsulates my frustration as a primary care physician:

If a clinician has 12 minutes to see a patient, be empathetic, document the entire visit with sufficient granularity to justify an ICD-10 code, achieve 140 quality measures, never commit malpractice, and broadly communicate among the care team, it’s not clear how the provider has time to perform a “clinical information reconciliation” that includes not only medications and allergies, but also problem lists 80 percent of the time. Maybe we need to reduce patient volumes to 10 per day? Maybe we need more scribes or team-based care? And who is going to pay for all that increased effort in an era with declining reimbursements / payment reform?

Most of my primary care peers could deliver truly excellent care if I we only saw 10 patients per day. However, primary care physicians in my organization are expected to perform at a certain percentile based on MGMA data. The majority are seeing 30-35 patients daily, yet revenues are still declining. They’re also working longer hours with increased burnout. One of my favorite colleagues just “retired” from practice at the tender age of 48 and will be doing part-time urgent care instead.

I’m grateful to those who actually selected primary care residencies during the recent National Resident Matching Program process. Over 1,400 fourth-year US medical students selected family medicine and I salute them. To consciously choose this life given current market forces, you are either called to serve or you are a risk-taker. Fortunately, we can benefit from having more of both in the trenches. There were a total of 3,195 positions available and graduates of non-US medical schools will typically fill the remaining slots.

I mentioned last week that I had received some pre-HIMSS mailings with butchered addresses and titles. Not to be biased in reporting only questionable print media, I’ll share that this week I received three emails that fell into the category. When preparing mass communications, first make sure you’re selecting the right field for the last name. I guarantee my real name is not “Dr. O’Day,” so I didn’t read your piece. Second, “Dear Chief Nursing Executive” isn’t going to make CMIOs want to continue reading. Third, don’t call out my mostly-inactive consulting company as needing your services because my “organization is bustling and case managers are overwhelmed with ineffective ways of contacting and tracking patients.” Nothing like serving up an insult to an entity that doesn’t even have contact with patients.

While I’ve got my crankypants on, let’s talk about vendor events at HIMSS. On one end of the spectrum, we have sponsors like Divurgent who offered all HIStalk readers the opportunity to attend their HIMSS event.  On the opposite end, we have Nordic. Their event was advertised in a CHIME bulletin, but after an initial acceptance email, I received a follow up email stating I’m now declined “due to the lack of space and focus on our clients.” I guess the fact that I’m on the IT committee at one hospital who has been a client and on staff at another Epic hospital is moot. I’ll be reporting on other social events instead, but they might want to update their website since it says guests are welcome and suggests forwarding the invite to colleagues.

I always enjoy hearing about sponsors and their philanthropic efforts. NextGen announced its Eighth Annual NextGen Cares Golf Tournament to benefit the Jayne Foundation. The scholarship fund is in memory of former client Dr. John W. Jayne, but for obvious reasons, it caught my eye. Opportunities are available for both golfers and non-golfers, including a cocktail hour and silent auction.

Have a charitable event and want to get the word out? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/30/15

I mentioned that we are having budget meetings this week. One of the hot topics is how we’re going to manage office space and various leases as we reorganize to consolidate onto a single vendor platform. The health system’s goal is to move everyone under the IT umbrella, so we’ll need more space at the mother ship.

We’ll also have to figure out what to do with existing office space leases at our regional campuses and how to transition people from one location to another in a timely fashion. Certain functions such as desktop support and provisioning will continue to be somewhat regional, so there’s going to be some delicate negotiating while we figure out which spaces to keep and which to let go.

I hadn’t given much thought to the new space they’ll be outfitting for the project. The last time I was involved in a significant office move was seven or eight years ago and we were going into a largely completed space. The biggest thing we had to decide was which staffers would be placed into which rows of cubes.

Late last week, I had the dubious pleasure of attending a half-day session to discuss design and construction of the upcoming office build-outs. Given some of the complaints we’ve gotten about the open office design at some of our newer facilities, I thought the topic might be contentious, but I had no idea just how much.

One faction came to the meeting armed with copies of a recent article in The New Yorker called “The Open-Office Trap.” It details the perils of the open office, citing examples of reduced productivity and higher levels of employee stress. Reports have also chronicled higher use of sick days and reduced cognitive performance. One study from Cornell University found that workers exposed to typical open-office noise had higher levels of the stress hormones that are typically associated with the fight-or-flight response. Another from Finland looked at whether younger employees did better with the open office platform and concluded that although they might seem to, there are trade-offs.

As we started the meeting, another attendee hastily emailed links to the Washington Post piece on the topic. The author mentions employees who have difficulty with the transition the open office paradigm and laments the lack of huddle rooms to be used when private conversations are required.

I know that the first time I had to transition from a private office to a cube, I had a hard time adapting. As a newly-minted medical director, I was given a “supercube,” which was essentially double sized with a small table for meetings. It was on a main thoroughfare in cubeland however, which seemed to invite people to plop around the table for impromptu conversations.

I was often interrupted with requests to borrow my chairs or by people just saying hello on the way to the bathroom, icemaker, elevator, or coffee pot. It was also difficult to have confidential conversations about physician behavior, especially since we didn’t have enough smaller meeting rooms. This led me to hide out in a poorly-lighted and recently-vacated office in the basement near hospital engineering, at least until that space was reassigned. The experience definitely strengthened my support for allowing staff to work from home.

Halfway through today’s already-rowdy meeting, another colleague emailed around a piece entitled “Open-Plan Workspaces Are the Work of Satan.” The meeting quickly spiraled out of control after that since it’s hard to take Formica samples and color swatches seriously after someone has invoked the Prince of Darkness. The design and construction team had brought along an intern and I’m sure she found the meeting to be highly educational, just not in the way it was originally intended.

I’m just glad I kept a low enough profile to avoid being volunteered for the subcommittee that will meet again to “continue the dialogue.” I’ve spent the last two months fretting about the future of my team and of my own career and it didn’t even occur to me that serious choices needed to be made on whether we want an aquatic color scheme or one that is desert-inspired or how many “rolling-wall” whiteboards we might need to order. I’m glad there are people that care and are thinking about these things, but at this point it feels frivolous.

The positions for our new clinical project were posted last week. It’s hard to watch my highly-qualified staff fret over whether they’ll be chosen. They’ve heard that they have to take a personality test and that there may be a preference for younger workers without “bad habits” gleaned from working with other vendors and systems.

I’m not part of the hiring decisions at all, but I certainly hope we don’t shoot ourselves in the foot by throwing away all the non-software knowledge we have amassed regarding how to effectively serve our physicians and their practices. In the mean time, I’ll have to amuse myself by running the betting pool on aquatic vs. desert color schemes.

What do you think about open offices? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/26/15

I read with interest Mr. H’s summary of Chicago’s April weather over the last several years. One of my friends was in Chicago this week and posted pics of snow. Right now I’m still planning a ball gown for this year’s Histalkapalooza, so I’m crossing my fingers against rain, snow, sleet, hail, and slush. I do have an opera length coat at the ready, but I am not looking forward to figuring out how to pack it all. The fact that I’m thinking about HIMSS planning right now underscores the fact that I’m procrastinating the continued reading of the Meaningful Use Stage 3 documents that were released last Friday.

I’ve only received a couple of pre-meeting mailers, but there have been a couple of ads in healthcare IT publications that caught my eye. Sponsor ChartMaxx is giving away some Chicago pizzeria gift baskets in their “Grab a Slice of the Windy City” promotion. Winners could receive a gift basket and pizzas delivered to their home – sign me up for that one. The two mailers I did receive both mentioned Apple Watches, but I’m not an iPhone girl, so they didn’t engage me. Additionally, one had my title wrong and another botched the address. It never ceases to amaze me when a mail merge goes awry or that people don’t proof things before they go out.

Speaking of proofreading, I wonder if 1-800-Contacts realizes that their most recent mailing provides a possible time-travel option for customers? Although it was mailed earlier this month, it invited me to place an order through January 2013. I guess it’s not just conference marketers who can’t get it straight, but I’m wondering if I can call and see if they’ll honor their 2013 pricing.

Procrastinating on the Meaningful Use documents also means catching up on journals this week. I’ve been doing a better job of keeping the pile on my entryway table to a minimum, but still am not current. A blurb about using Fitbit devices to predict recovery from back surgery caught my eye, however. Researchers at Northwestern University, New York University, and the University of California-San Francisco are looking at patient activity four weeks prior to a procedure and six months after. Preliminary data shows that patients not only reach their pre-procedure activity level after about a month, but continue to increase to levels that weren’t possible prior to surgery. Although they’re only looking at a subset of spine surgery procedures, I like the idea of capturing that data to model real-world results.

I’m glad I went through the journal pile because nestled in the back pages of American Family Physician was a “Patient Oriented Evidence that Matters” (POEM) segment answering the question of whether computerized decision support systems linked to EHRs improve patient outcomes. The ‘not really’ response cites a recent meta-analysis and I’m glad I read the original article. It was a little less pessimistic than the “bottom line” summary provided in the POEM. I printed a couple of copies of the actual paper to keep on my desk because I’m sure someone will bring the summary in next week as support for why we should not have an EHR. I’ll be ready when they do because at this point EHRs are not going away, but I do love a good medical literature spitting match.

Going back to January in the stack, I also found reference to an editorial in the Annals of Family Medicine that talks about allowing medical students to use EHRs so that they’ll be ready for later phases of training such as residency. Our students get a lot of experience with EHRs in our academic hospitals, but very little when they’re on their community-based rotations. The barriers cited by our sponsoring physicians include licensing issues with EHR vendors, lack of dedicated training for students, inability to separate student documentation from rendering physician documentation, and the transient nature of clinical rotations. Most of these were echoed in the editorial, which also mentions the need for students to learn how to manage populations using registries and other analytic components of EHRs.

I’ll be interested to see how the current generation of medical school and residency grads use EHRs after completing their training. In many parts of the country, we’re to the point where students may not even be exposed to paper charts. In my area, even our community free clinics are using EHRs. I’d love to do a study of new physician interactions with patients in an EHR-enabled exam room vs. physicians who transitioned from paper charts.

Got grant money? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/23/15

Just when I was excited that spring had finally sprung, our friends at CMS and ONC have dumped a load of snow on my proverbial daffodils by releasing the Meaningful Use Stage 3 proposed rule along with the 2015 Edition Health IT Certification Criteria. Although it proposes to “simply the meaningful use program,” I find it hard to believe that the 301-page rule and corresponding 431-page certification criteria can be viewed as simple. As an example, there is a four-and-a-half page glossary of acronyms near the beginning.

Having sat through the first two parts of the trilogy, I know Hollywood would have helped me out by breaking the third installment into two full-length features. Alas, we aren’t that lucky with federal regulations and we’re squeezing it into three parts, much like Shakespeare’s Henry VI. I really did try to get through it, but I think the last five or so years of reading so many regulations have shortened by attention span. I hoped if I delayed into the weekend that Mr. H would read it and provide a pithy digest, but it seems he’s thrown in the towel as well.

Glancing through, they do note that, “Stage 3 of meaningful use is expected to be the final stage” which brings a sigh of relief. However, starting in 2018, all providers would report on the same Stage 3 definition of MU regardless of prior participation. Everyone would be on the same playing field regardless of their start date, which certainly does make things simpler. It makes it nearly impossible, however, for those who have not yet started to play the game.

I liked the proposal on page 15 to remove “topped out” measures, which they believe are “no longer useful in gauging performance, in order to reduce the reporting burden on providers for measures already achieving widespread adoption.” Sorry for the easy “A” grades, folks, you’re going to have to continue to work for it. There will, however, continue to be four categories of exceptions:

• Lack of Internet access or barriers to IT infrastructure
• Time-limited exception for newly practicing EPs or new hospitals
• Unforeseen circumstances such as natural disasters
• Exceptions for EPs with limited interaction with patients or lack of control over EHR availability for those of us practicing at multiple locations

The estimated federal cost to continue the incentive programs between 2017 and 2020 is approximately $3.7 billion. They do mention that “we do not estimate total costs and benefits to the provider industry” because those would be difficult to estimate. We all know that our EHRs cost far more than the $44,000 we might be receiving through Meaningful Use. Additionally, I’m not sure what the neck and back pain that some of us experience after hours at the computer might be worth if we asked for compensation. That’s not to mention the anxiety of dealing with all the virtual I’s that have to be dotted and T’s that have to be crossed to receive the incentive payment and/or avoid a penalty.

Pages 20-23 give a nice overview of the regulatory history and if you’re interested in the definitions they start on page 24. I admit, though, that my concentration started flagging around page 30 and I decided to call it a night. The 60+ patients I saw earlier in the day (will flu season never end?) started to catch up with me as did the glass of Simi cab. I’m going to have to work my way through it over the course of the next week, but I’m still crossing my fingers that the Cliffs Notes version will come out soon.

I feel for the vendors that have to read both the proposed rule and the certification requirement documents to be ready for clients who are going to start asking how vendors plan to handle the requirements before anyone has barely had a chance to digest them. Not to mention, this is still just a proposed rule and subject to public comment and potential revision. Although we don’t expect too many changes based on the historical track record, there still might be a few. I always enjoy reading some of the public comments and I’m sure those will be good for discussion in a few weeks.

I’m still a relative youngster in the medical trenches, but reading the proposed rule did make me nostalgic for the so-called good old days that I barely got to experience in practice. I was already nostalgic after a patient encounter earlier this week, when I had the privilege of caring for one of my medical school professors. He retired the year my class graduated and happened to need care while visiting his grandchildren in my city. When I saw the name come up on my census, I couldn’t help but think of my teacher. I’m sure I was beaming when I walked into the exam room and realized it was indeed him. I’m just thankful his issue didn’t involve his specialty of head and neck so I didn’t feel like I was on the hot seat again.

I do miss the continuity of traditional family medicine, so it was nice to make that kind of connection with a patient. I can’t help but think that my class gave him more than a little heartburn and might have contributed at least a little to his retirement decision back in the day. Luckily his problem was minor, but I have to say that seeing him made not only my day but possibly also my week and my month. I went into medicine to connect with people, but I feel that connection is being lost as the healthcare system evolves. After a bright spot like that, sitting and reading government regulations just makes me sad.

I’m sure lots of other CMIOs, medical directors, and informatics pros will be digesting the regulations this weekend. I’m going to finish unwinding and get ready for a big week of budget meetings and discussion about the further evolution of my team.

I asked last week how others unwind after a long day. Several respondents cited wine or other adult beverages, but an equal number mentioned physical activity as a stress reliever. Swimming, cycling, and horseback riding also made the list. As long as the snow stays away I’ll be out in the garden, marveling at the tender shoots and the promise of things to come. For tonight, however, I’m going to close my eyes and count not sheep, but pages in the Federal Register.

Are you ready for MU3? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/19/15

It was good to get away from my day job last week. I spent my days off seeing patients and intentionally not checking my hospital email account. I’m aggravated at how things are going with our upcoming EHR migration and how my team is being treated, so I thought unplugging would be therapeutic.

Initially we were told that our team would be transitioned to the new project and placed in similar job roles. Our ambulatory group continues to acquire new practices and a small team would remain to continue implementing at those sites as well as to support existing sites. We communicated this to the team and they were comfortable with the approach.

About a month ago, the plan changed. Leadership decided that they want to structure the team more consistent with what the vendor recommends. Now we’re looking for a fairly large number of project managers and plan to hire a completely new training team.

I’m reading between the lines and thinking that perhaps they don’t want people with experience because they’re worried about preconceived notions of how an implementation should look. New trainers will certainly be easier to mold to a new paradigm, but I have serious concerns about throwing away as much cumulative experience as our team has. In addition to being solid trainers, they understand our physician base and how our offices run. The offices trust them and see them as advocates.

Before I left for vacation, our leadership informed the staff of this new plan and essentially told people to get their resumes in order. If they want to move to the new project, they will need to apply for the project manager positions. Most of my team members thrive on the front lines and on working directly with users. If they had wanted to be project managers, there have been quite a few opportunities during the last couple of years. On the other hand, they don’t want to be stuck turning the lights out on a dying project and risk being let go at the end.

Because of flip-flopping by the leadership, the team is nervous and scared. At this point, I don’t know what to tell them. I’m still in limbo regarding my own position. I’ve seen at least half a dozen variations on the proposed clinical leadership structure and none of the positions have jumped out at me as being a good fit for my particular skill set. Like the team, I’ve been told to get my resume in order. Once the positions are posted, I can apply along with the rest of the CMIOs that are being consolidated.

We’ll have three days for internal candidates to apply before the positions are posted externally. It goes without saying that they’re going to hire a new system-wide CMIO who has experience with our new vendor, so at least we’re not all fighting each other for the top job. Postings are supposed to go up next week, but they’ve already been delayed several times, so I’ll be surprised if they are there before HIMSS. Once I see what is available, I’ll make my final decision on whether I’m going to stay or fly the coop.

Most people find uncertainty to be disconcerting. For me, it’s been somewhat liberating because I’ve given up on trying to figure it out. This might be the first time in my life that I haven’t had a plan. I’m starting to understand how my colleagues that fly by the seat of their pants feel every day.

After my week off, I came back to work much more relaxed and ready to see what the next curveball might be. We’ll see how long that lasts, based on the craziness that we’re thrown on a daily basis.

In the mean time, there’s always room for pastry therapy. In honor of St. Patrick’s day I made some outstanding cupcakes that a friend had suggested I make. I just may have found my new favorite buttercream frosting recipe. Slainte!

Email Dr. Jayne.